Incentives, Handoffs, and the Rural Care Gap (With Insight into the $50B Rural Health Transformation Program)

Episode Contents

• 0:00 Introduction to NovaNav
• 0:55 Guest Introduction: Dr. Nizar Wehbi
• 6:11 Biggest Gaps Between Discharge and Full Recovery
• 10:25 Social Determinants and the Case for Navigation Support
• 14:46 CMS Bundled Payments and Outpatient Shift: How Leaders Should Prepare
• 19:15 Process Mapping the Episode of Care and Cross-Team Accountability
• 22:42 Standardizing Patient Management Across Sites and Teams
• 25:30 Policy Opportunities to Improve Patient Experience at the System Level
• 29:38 Fragmentation as a Design Problem and the Role of Incentive Alignment
• 32:48 30-Day Readmission and the Misaligned Incentives Across Post-Acute Facilities
• 35:24 Risk Stratification, Yellow and Red Flag Alerts, and Clinical Escalation
• 36:50 Workforce Shortage, AI, and the 80-20 Principle in Post-Discharge Monitoring
• 41:45 The $50 Billion Rural Health Transformation Program and Infrastructure Investment
• 48:51 Hub-and-Spoke Models, Rural-Urban Connectivity, and Community-Based Recovery
• 51:37 Closing Thoughts and Full Circle on the Process Map

Key Takeaways

Dr. Wehbi breaks down fragmented episode-of-care ownership, misaligned post-acute incentives, and how tiered alert systems can function as a genuine workforce capacity lever. The conversation closes on the Rural Health Transformation Program and why the real opportunity is not self-sufficiency for rural hospitals but connectivity to regional and urban hubs.

Transcript

Welcome to The Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At NovoNav, we focus on making surgery easier for patients and their care teams.

That means clearer communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. Welcome to NovoNav's Surgical Journey.

And today, I'd like to welcome Dr. Wehbi to our podcast. Welcome. Thank you, Lisa.

It's my pleasure. Awesome. It's going to be a fantastic discussion, particularly because of your, you know, your experience across so many different layers of health care. But let me give you an intro so the guests know who you are.

Today on The Surgical Journey, I'm joined by one of the most well-rounded health care leaders we've had on the podcast. Dr. Wehbi is a physician, health policy expert, a health care executive, and as well as he advises companies throughout the country. He also served as North Dakota's state health officer from 2021 to 2024, where he led the state's COVID-19 response and co-led integration of North Dakota's Department of Health and Human Services into a single agency with a $6 billion budget and 2,800 employees.

Wow. And so Dr. Wehbi started his career in clinical medicine and cancer research before moving into hospital strategic planning at Nebraska Medical. So there's probably lots more I could share about you, including I think you were served as a Malcolm Broadridge National Quality Award examiner.

So lots of experience. So we will jump in. Yes, let's do. So first question, what happens, in your opinion or, you know, what you've seen when a patient leaves the hospital, right, and is often, that's where often the system kind of falls apart, or maybe it doesn't necessarily fall apart, maybe it's a little disconnected, right?

Where do you see the biggest gaps in how health systems manage the journey between discharge and actually full recovery? Yeah, yeah. Well, and that is really, thank you for the question, Lisa, because this is a very fundamental question, because if we look at it, the outcomes of procedure or, you know, let's say an operation is always based a lot on what happens before and more importantly, on what happens after that procedure. So one of the things that are, you know, very challenging, especially in our healthcare system, is that we have this kind of fragmentation.

So if you look at the procedure as a journey, including the pre-op operation and then post-op, this journey becomes kind of like fragmented. There isn't really one individual or one team that is an owner of this journey, but it is rather a collection of different providers, different nurses, different surgeons, and different individuals that are involved in this process. And now, of course, everyone recognizes also with the discharge, there are some kind of like, you know, discharge instructions. Many times they could be very challenging to understand or very difficult to follow.

Sometimes patients do not understand it fully, thus they cannot really follow it properly. So is the case also with medication, because, you know, you have a discharge with a certain list of medication and sometimes there is a disconnect with what previous medications or other medications the patient is taking. And of course, more importantly, the data continuum is also fragmented. So if you go, let's say, from the operation or a procedure and then now you are discharged into rehab or maybe back home or whatever, not all the information, not all the data gets transferred.

And there is always that kind of like missing pieces or fragments that fall through the cracks. And that also affects the outcomes and affects, you know, like what really happens to the patient after they discharge. And another point that I think is important is like, we always think in the health care system of the patient's medical needs, but there are also all other aspects of our social system, you know, like whether it's transportation or whether it is food or would this patient, when they go back home, will they be, or do they even have a home? Or can they even climb the stairs or get to where they can live?

Do they have dependable caregiver? So all these, I think, are some of the challenges that face the health care system and more specifically patients once they are discharged from a procedure. So that was such a comprehensive, you know, answer. And I took a bunch of notes because I wanted to comment on a few things.

But I love the, you know, you talked about, you know, just not medical care, but whether or not they have, you know, whether it's food, money for transportation, money for co-pay, but even the economics of maybe going to the primary care afterwards, is that another co-pay or is that, what burden may that be? So we think, well, it's pretty easy to cling teens, right? We want to make sure that the patient gets a primary care appointment, but that patient might have reasons why they can't get to a PCP appointment. And that is very true.

I mean, it is so that the health insurance is one of the major obstacles or challenges and whether it will create yet another burden to the patient if they are going to a PCP, a primary care physician, or whether if they are, you know, doing occupational therapy or physiotherapy or consulting with a rehab facility. And, you know, we always talk about social determinants of health and they are really very critical, very important for the patient to put that patient back in their environment because we all know and studies have shown that the best place, the best way for a patient to recover is within his or her community, within their, you know, family member or caregivers rather than in a facility. Yeah, absolutely. I don't mean to stay on this question long, but you bring up social determinants.

Do you feel like hospitals, and not for any wrongdoing or saying there's another layer of what they have to do, but I wonder if that's even a gap in and of itself or an opportunity for someone to come along and be that arm, you know, that this focuses on the social determinants part of discharge? That is exactly correct because, you know, like in medicine, we are trained to address medical needs, you know, like the illness and the diagnosis and the treatment. Hospitals and healthcare systems are also kind of like focus on all these aspects as well. And with kind of like the lack of time and kind of like high pressure environment, there isn't even the leeway or the ability to start thinking of like, hey, as a patient, do you have a way to get your food?

Do you have a way to go back to your home? Do you have a way to go and buy groceries? Or do you have a caregiver that will help you maybe the first week because you are not supposed to walk around? So all these are really very essential items, and it might be a good practice to have this kind of like additional arm.

It wouldn't be like the surgeons and the physicians and the primary care providers, but kind of like the navigators or community health workers that will go and help the patient to ensure that all these needs are met. Because as we recover from a surgery or an operation, it's not just like the medication that counts or rest. I mean, like we have to have food and sustenance as well as, you know, like someone to take care of the patient if they can't take care of themselves. Yeah, absolutely.

And last comment on that is the, you know, for CMS teams, one of their little known opportunities for hospitals is providing a beneficiary incentive. So where hospitals can do something, you know, whether that's technology or maybe, you know, something along those lines, and it doesn't consider like a, you know, like a kickback or inducement, right? And I think those beneficiary incentives that Medicare allows, I think could be very interesting in this space. Yeah, that's very true.

And then we always kind of like, you know, think of, you know, many times family members are the caregivers, yet there isn't really the support for these caregivers also, whether it's financial support or whether it's even emotional and psychological support. So then they can help the patient to recover and get back to their normal stage. Yes. And so thank you for that.

I know we stayed on there a little bit, but I actually agree that the discharge of full recovery, you know, it's a big part of success. So CMS is moving more procedures to the outpatient setting. And of course, bundle payments is so many have come out, particularly CMS teams. How should healthcare or system leaders be preparing for that policy landscape?

That really does shift the accountability really for them that what happens outside the hospital. How are those CFOs, CLOs, those leaders, you know, how should they be thinking about that? Yeah, I think the best way to start thinking of this kind of like episode of care, for example, is to think of it as a continuum. So, yeah, I mean, the presence within the hospital might be one stage, one box of this process, but then it is important to kind of like have a full it's like process mapping of the whole episode of care, you know, from the patient getting sick, possibly like pre op procedures and then going through the operation and then what goes after they are discharged.

And thinking of it as a kind of a continuum and then like deciding, well, who is responsible for what, who is accountable for each one of these steps, because in order to have full recovery, you have to have this full process map done properly with proper accountability and responsibility. So even if something happens outside the hospital, the hospital, you know, administrators, they also need to think of, well, how do we ensure that this step that happens after discharge is taken care of so then the patient recovers properly? So that's kind of like one fundamental or that's where we can start. And of course, as different accountabilities or responsibilities are assigned, we have to make sure that all our incentives are aligned.

So, of course, everyone wants the patient to recover properly, but then there are different teams, different professionals that take care of that patient at different times. So how do surgeons, primary care physicians, occupational therapy, physiotherapy, as well as, you know, skilled nursing facility or a rehab facility? How do we align all of these so then the patient will be like the center of our attention and everyone is catering for the full recovery of this patient? And of course, you know, the other piece that is a little bit very tricky and very challenging is how to navigate the system for the patient.

Because, you know, from our side as health care professionals or health system leaders, things seem to be clear on our side. But from the patient's perspective, I mean, like going from one facility to the other or from one system to the other and talking with the health insurance company multiple times, and that is overwhelming, especially for a patient who is not feeling well or he's still, you know, under a lot of stress or pressure because of their sickness and not feeling well. Yeah, I love the process mapping because it really does break it down into like, like you said, who's accountable, who's responsible? And you wonder how many people really go through the exercise of like a real detailed process map.

Yeah, yeah, exactly. And then, you know, the fact to the matter is that if let's say take the hospital, for example, the hospital is interacting with the patient for a limited period of time. But in essence, they are not, you know, they are not just kind of like or shouldn't they shouldn't be focusing on a small piece of the patient. We are still working with the patient as a whole as a whole human being.

So we have to kind of like follow the patient throughout this journey through a process map with assigned accountabilities. So on that note, how important do you think education is? And what I mean by that is you as a physician and as a policy leader, executive, you know about the like you said, the episodes and you understand, you know, that continuum of care. Sometimes, though, a lot of people who have the day to day responsibility don't know that, right?

So I've had conversations with just, you know, people on the patient jury that really want to explain, you know, the 30 day post-op responsibility that things shift a little bit in their own mind. And I always have thought like, how much does the most employees really know about like bundle payments? And what that would impact the outcomes if the people on the front lines knew. That's where my observation is.

Yeah. And that's, you know, a very correct observation because, you know, like we probably we were kind of like trained to kind of focus on where the problem is. So almost all these providers that interact with the patient, they are laser focused on whatever, you know, whether it's kind of like the illness or the disease or the diagnosis or the, you know, helping him or her, you know, recuperate. But we need to step back a couple steps back in order to see the whole picture.

And sometimes because we are really very busy and we are trained to kind of just focus on the problem, we lose the full picture. And that's where kind of like some education or maybe providing some flexibility in time that will allow the individual or the provider to step back and see that full picture. I'll give you an example, like if you are starting to do this process map and you include the surgeons and the anesthesiologists and occupational therapists and the nurses and the rehab professionals, bring them all together to the same room to work on the same process map. And this by itself will allow them a better perspective to see that, yeah, I see the patient or interact with the patient in this little box.

But hey, look at all this process map. Look at all this journey. Yeah, yeah. No, I love that.

Sorry. Go ahead. Yeah. Oh, no, no.

I mean, talking about journey, I thought, well, you know, it's much like, you know, if you are going on a journey and then like, OK, you ride the train, but then there is a whole a lot of things happening before you ride the train and after you ride the train. And unless you come and bring all these individuals together as a team based approach, then you realize that, oh, well, you know, you walked and then you took a cab and then you rode the train and then you left the train and left the station and went to another mode of transportation. And then this will create this whole full picture of this whole journey. Yes.

That's a great example. Thank you. So you talked a little bit about this, but I don't know if you want to add maybe a little bit more to it. But when a health system tries to standardize how patients are managed before and after procedure across sites and teams, you know, what makes that work and what makes it break down?

And you've shared a little bit or share a lot of that with the process map. Is there anything else you want to add? No. I mean, I think one important piece that will make it maybe work better is when you approach it in a team based approach where you kind of bring different providers, different professionals to work together because then they will have more buy in and understanding of what happened before, what happened after.

And then, like, you know, one thing that is also important and that is true for in the world of public health, as well as in health care and medicine, is that to help the patient through this journey, we have to alleviate the pressure and the burden from our providers, meaning that, you know, like how to really make things maybe much easier for our staff or for the providers. So then they do the right thing that, you know, like if there is an issue that it is addressed right away. So this by itself will allow kind of like relief of some of the burdens or some of the challenges that might face our providers. Right.

So whether it's giving them, I love how you said earlier, giving them flexibility of time, it's maybe tools, resources, technology, you know, just giving them the ability to do the things that they do instead of just saying that here's what we have to do and giving them more work and not giving them that support. Yeah, that's exactly right. And sometimes giving the context helps us to understand why we are doing what we are doing. So then it doesn't become just kind of like, oh, we have to do it without really understanding or our engagement in this activity.

Yeah, that's a big one. Give the context. It's the why, right? Yeah, exactly.

Policy has the power to drive real change and how patients experience health care, which I'm a big fan of the patient experience, you know, just really understanding what they see, what their families see on the front lines. Where do you see the biggest opportunity right now for both state and federal policies to improve? Really, it's a patient experience, especially as they go home. Yeah, exactly.

So it's a great question because a lot of times, you know, patient experience is a reflection when the patient doesn't have a good experience within the health care system. Many times it is a reflection of the fragmentation of what we are doing or how the system is designed. So many times, you know, like if the patient has to go to different facilities and reproduce their medical record or medical history like five or six times to six different facilities, in essence, that's a bad patient experience. But it is also a reflection of the fact that our systems, data systems do not talk to each other and there isn't really enough or kind of proper and accurate transferability of this data from one facility to the other.

So having some kind of like maybe data and interoperability foundation is very important. Then also the smooth transition from one facility to the other, because, you know, like to give the patient the proper experience and to help them heal, we have to make it less burdensome on them. So when they are fighting the disease they are trying to recover, we do not want to make it even harder for them by asking them for their medical history 10 times and then about the medications they are taking like 20 times and then asking them about or kind of like having them to deal with insurance and whether insurance will cover this stay or this operation or this procedure. Then the other thing that is also important for this patient journey and kind of like a patient experience within that journey is the before and after.

You know, like when, let's say if the patient is discharged and then they have to wait two hours in the, you know, a pickup area for their ride to come, you know, that negates maybe a whole week that they stayed in the hospital because they had that one, you know, pleasant experience. So we want to make sure that every single step, every single activity that and interaction with the patient is really a pleasant experience to ensure that they have really a good overall experience throughout this journey. Yeah, I agree. I have just three quick follow-ups, but so it's funny because for a period of time, my mom was unfortunately in the hospital for a lot of visits, but I got to the point where if he went to the ER or went to a floor, got moved, I had the same questions about medication.

So I just printed up an Excel document, put everything on and I would bring like 10 or 12 of them with me. And so they'd ask, I just hand them paper because I just couldn't do it anymore. And they're like, wow, this is great. But I can't tell you how many times I've had to print out that Excel document because it's the redundancy of like, you know, the same things over and over.

And I don't even know how anyone can really remember that, you know, for me as a caregiver. So I would just hand it to them here. In reality, I mean, this should be just a screen that should pop up no matter where you go, whether within the same facility or even when you go to a different facility. But yet this is just an indication that there is some improvement that we can have to our data systems.

Definitely friction. You know, you mentioned fragmentation in the beginning and now again, and Medicare actually says fragmentation in a lot of their episodes. They actually specifically speak about it. If that's such a, you know, important, you've brought it up and it's important, you know, as Medicare talks about fragmentation, you just wonder, you know, there should be so much more effort and thought into that area.

Yeah, that is very true. And and, you know, like I believe that the topic of fragmentation has been in existence since I think the health care system came into existence because it was kind of like designed with not with fragmentation in mind, but it was designed in in pieces. And when you kind of like have this piecemeal design, then there is all there are all these hiccups that happen in the system and that creates the fragmentation. And I am in full support of kind of like maybe having maybe more incentives, whether it's financial incentives or repayment or reward incentives to reduce that fragmentation and eventually to eliminate the fragmentation.

It is still kind of like, you know, an uphill battle, but I think, you know, like step by step, maybe we are approaching that. But there are still kind of like certain big challenges, one of which is we do not have our incentives aligned. And once you align your incentives, then everyone will work in tandem towards that one goal. We have still one goal, but we have like different parties trying to achieve that goal in so many different ways.

And this create all this kind of traffic, I'll call it, and then crisscrossing and that's fragmentation. And then certain systems working against each other or kind of they cancel each other's efforts. Do we need kind of like a more concerted strategy? Totally agree.

A better system for incentives? A hundred percent behind that. So you brought this up a couple of times and I don't know if you're able to share or if you've got some specifics, but I'm interested because you speak about rewarding, you know, rewarding that through incentives. Can you give maybe an example or two?

Because I think you're a hundred percent right. I agree that they have to be aligned and I think you will get different results. And I mean, incentives a lot of times do drive, you know, behavior or, you know, drive, you know, those outcomes. So can you give us an example?

Yeah. So, you know, like probably the easiest or the example that we are all maybe more familiar with is 30 day readmission, for example. So for the hospital, as we talked earlier, you know, they are they did the procedure or the operation and then they discharged the patient. Now, whatever comes after that discharge has also to be aligned in preventing a 30 day readmission.

So when that person is, let's say, discharged to a rehab facility or to a skilled nursing facility or to, let's say, maybe back home, are all these providers or facilities aligned in kind of like making sure that this patient is kind of recovering properly? So then they prevent an episode of a 30 day readmission. That's what we mean by that. Like if you go, for example, to a skilled nursing facility, I don't think it is on their radar, the 30 day readmission that the hospital will be reimbursed upon because it's a totally separate facility.

And their way of thinking, their incentives and their goals are not aligned with the 30 day readmission prevention. Right. That's right. Which that's going to take some a lot more thinking.

Exactly. Exactly. But then like, you know, so that's where kind of like, can we have some of the metrics for the skilled nursing facility to ensure that there isn't any complication of those who are discharged from a hospital, for example? Right.

How are they alerting maybe a riskier patient or how are they, how is that handoff? Is that handoff done differently? Correct. Yeah.

Correct. And there is kind of like that's, you know, a paradigm of risk assessment because, you know, like maybe I always think of that 20, 80 rule, you know, like 80% of the patients might just recover as they should without any complications and maybe roughly 20% might have certain red flags or signs. How do we really pick up these red flags and intervene so then we address these kind of like, you know, alerts and make sure that patients are recovering properly? Right.

I think that's one of the things that, you know, we're kind of looking at and it was part of our mission at NovaNav is are those alerts, right? Can those alerts be very helpful for the caregivers and how that has, you know, that be, you know, kind of like the eyes and ears and really just setting up that system so that it only comes to the providers, right? If there's a problem, you know, there's some significant pain or there's something that's off and I do think the alerts are very powerful. Oh, absolutely.

And then there would be kind of like different levels of alerts, you know, like the, I mean, not all alerts are equal. So, you know, there are things that kind of like red, a big red flag and there are others that it is just maybe a yellow flag and then you address it right away. But that's kind of like an escalation tree here. That's a good point, right?

I always, you know, it's not just red, right? There could be yellow just to keep an eye on, right? That's a good point. So it would be interesting, these last two questions probably from a, you know, from your experience and probably, you know, whether it was in North Dakota or as you were doing work, I wonder how much the workforce shortage impacted, you know, the things that you've done in your career.

And, you know, I just want your just general perspective, it will impact the patient experience, right? So technology needs to be implemented. So what are your thoughts about the workforce shortage? How do we use technology and maybe some of those periods of time where we use tech, but really need the human touch?

Like, how do we incorporate it all? Sure. Yeah, that's kind of, I think it's a fundamental question, especially nowadays with all the kind of like discussion and, you know, open possibilities of AI and technology. But I think they are complementary strategies.

So we know that our healthcare workforce is kind of like in really bad situation because of the shortage. And that shortage has been in existence even before COVID. So in 2019, we were still talking about healthcare workforce shortage. And of course, COVID and the pandemic happened, and that shortage became even worse.

At the same time, we are having all these automation, AI, more technology being instilled within healthcare, which is and supposed to help in this shortage. So in essence, I mean, there are a lot of automation, a lot of aspects that could be used in technology, healthcare technology, that will relieve some of the burden on from workforce, as well as will allow kind of like, you know, to fill the gap of that shortage. You know, so for example, I mean, you mentioned NovaNav, for example. So having this system that will monitor various signs and symptoms after discharge or even in the pre-op stage, this will allow you to kind of like as if you are putting it on autopilot.

So then there are, you know, these signs and symptoms are being input or captured by the system. And if everything looks okay, then it's smooth sailing. But the system also is taught to recognize certain deviations from the normal. So that's where we can see those yellow flags or red flags.

Maybe yellow flags are things are very easy to address. Red flags are escalated a little bit higher. But what that allows us to do is that, you know, for 80%, and again, the 80-20 principle, 80% of the patients, you know, like you put them on autopilot, and hopefully they will have this smooth sailing. Then it relieves a lot of work from our workforce.

They do not have to worry about the 80% that are recovering properly. That's right. And the 80% could be like calling the office, you know, just all those things that take time versus, like you said, I love the autopilot. Yeah, exactly.

And then, you know, like and having the AI piece will allow also to have kind of more intelligence in the response. You know, like if the patient says, oh, I have redness around the wound, for example, or the incision, there might be a follow-up question. And then, okay, is there any bleeding? Is there any oozing?

And then if it's not, okay, let's watch it for 24 hours. And then it might be resolved in 24 hours. And that would be the end of it. Now, if there is something that say bleeding in 24 hours or whatever, that will escalate and that will give the notification to a nurse or to a healthcare provider, then they will do the follow-up.

So then again, it's kind of like, you know, then our workforce is relieved from a lot of the recovery that is going properly. Right. That's perfect. That's exactly what our vision is.

And it really will help, you know, workforce shortage. But I also just think generally speaking, I think that time that they get back goes back to your point about maybe giving other scenarios more flexibility of time. That's how reality, you know, just not always about workforce shortage. It could be about spending more time with patients in different ways.

So this is a big one. You know, Congress passed the $50 billion rural health transformation program. And I think the funding is a big step. But maybe you could share a little bit about, instead of me asking a question about it, you probably are very familiar.

North Dakota is a big rural, has many rural hospitals. So you've had to care for or oversee rural hospitals. So do you see this as a good thing for hospitals and investments for patient care? Yeah, that's a great question.

Thanks for asking. And that's, you know, the rural health transformation program now. So it is available in all 50 states. Each and every one of the states is getting really a good chunk of money.

The design or the strategy is to use it for rural health transformation. But that by itself touches every aspect of our health care system. So again, this is maybe an opportunity, a very rare opportunity that will allow rural health, whether it is hospitals, critical access hospitals, or FQHCs, federally qualified health centers, or even rural public health departments, to have some investment in infrastructure. And so one of the things that always comes to mind is having this kind of like infrastructure of technology, documentation, and data transferability.

You know, like a good example, you were giving that, you know, situation where you have your medication or your mom's medication printed out on a paper. Now, guess what? I mean, when you handed it to the provider, what did they do with it? They just read it and then put it in trash.

If not, I hope they shredded it instead of just tossing it in trash. But so are there ways here? And this is the golden opportunity to work on this kind of documentation and kind of make sure that this system will handle all the information that is needed by the provider in order to provide proper care, timely care, and patient-centered care to the patient that is before them. Now, of course, when we talk about this interoperability, now it has to be connected to the other bigger healthcare systems within the state.

So rural is somehow connected to non-rural, to the urban, and the bigger medical centers. There might also be kind of like now new models that we start kind of like thinking about where critical access hospitals become kind of like more like the spoke for a hub, where kind of like they receive situations or patients when there is urgent or emergent need, but then they refer them to bigger healthcare systems for more specialty care. Because again, I mean, it's been well studied that, you know, like you cannot have specialty care in a lot of rural America because it's not sustainable. And sometimes there isn't even enough patients to keep a specialist busy.

So are there ways where we can kind of like, okay, we can provide the essential care in rural setting and then refer that patient, whether it could be virtual care or it could be really in-person care, to a bigger, more specialized hubs. And these hubs, they do not really have to be like, you know, the biggest city in the state. They could be regional hubs that are designed so then they provide specialty care and to an extent they are, you know, in close proximity to where the patient is. So we all kind of like recognized and realized that the patient recovers best when they are in their community.

And that has been kind of like the whole focus in the last, I would say, 10, 15 years, where kind of like we want to keep the patient closer to home to get their medication, to get their diagnosis, to get their treatment, and to have the recovery. So that's where kind of like, you know, okay, how to really provide all these services as close to home as possible. Are there opportunities to expand and maybe have more in-depth virtual care? Especially there are some specialties that, you know, virtual care seems a no-brainer.

Of course, the other aspect of this, and it is happening over, it happened over the last, I would say, 20 to 30 years, there has been shift to outpatient procedures from inpatient care. And with this kind of increase and more expansion of outpatient care, that might also be helpful to ensure that the patient recovers in their community. Because you go for that, you know, outpatient procedure, it could be in a regional center, but then you have the possibility, the ability to go back home to your community and do the rest of your recovery. So all these, I think, ways that hopefully the money that is being infused in the economy for rural health transformation will be best spent in these kind of like bigger ticket items, the infrastructure pieces, because then you wouldn't really need as much money to sustain it and update it.

You know, you need this kind of like upfront investment, which we are glad to have this kind of like big amount of money being infused, but this is not gonna last forever. So we'd better kind of like have it as a future investment in our system. Yeah, you gave so many great points. I think one of the things I hadn't thought of was the connection between rural and urban.

And I just want to follow up a question on that. It's true, right? You know, we think of making the rural hospitals, critical access hospitals self-sufficient, but what you're saying, well, no, maybe that's not the way to think about it. The way to think about it is the other way, like how do we connect them to like a hub or what is the connection to the urban hospitals?

Yeah, that's exactly the point. I mean, because if we are trying to think that rural health can be isolated from the rest of the healthcare system, then I don't think we are really understanding the extent of our healthcare system. Whether it is that data infrastructure, it has to be all connected. As well as when we talk about specialists and the availability of specialty care, a critical access hospital will not be able to provide deep specialty care.

So it has to be really very well connected with a smooth transfer process, like systematic transfer that will allow the patient to transfer and move through that journey that we're talking about, to go from that rural setting to maybe a more specialized setting that could be regional or it could be urban. Or, I mean, it could be through virtual care within the rural setting. So there are multiple ways to achieve that based on the specialty, based on what care the patient is needing. But we cannot really isolate rural health from all of health.

Yeah, that's a great point. Because I even love the idea of having a patient in an outpatient setting, maybe not in their community, but coming back to their community so that there is coordination there. So the specialty is, whether it's a hub or an urban hospital, but the recovery, the follow-ups are back in the community. I love that.

It's really very well, it's very, very smart. And so you've probably seen those scenarios work then as well. Yeah. And there has been multiple pilots that are done, but I think it is about time to kind of start really systemizing and formalizing some of the solutions that make sense and that will help the patient through their wellness and illness.

Right. It's a really thoughtful process map as well. So we'll go back to your process map earlier, but now just taking it in a bigger, different way. Yes, full circle.

Yeah, full circle. Dr. Wehbi, thank you so much for your time today and your very thoughtful, extensive answers to the questions. I really enjoyed the discussion.

Thank you. Well, thank you, Lisa. And thank you for the opportunity to share some of that information and best of luck. Okay.

Thanks for listening to The Surgical Journey. Join us next time as we continue examining smarter, more connected approaches to perioperative care.