The Role of Technology in Hospital at Home (ft. Constantinos (Taki) Michaelidis)

Thanks for tuning to Digital Voices Podcast, where we chat digital transformation challenges and opportunities across healthcare and life sciences. And now, your host, Ed Marx.

Ed Marx here, another edition of Digital Voices. Thanks for listening. We know you have a lot of choices and you've chosen us and Dr. Konstantinos Mike Elitis will make sure that it's going to be another fabulous episode. So I know for short we go by Taki. Taki, thank you for being on Digital Voices.

My pleasure, Ed. It's a delight to be here and happy Friday.

Happy Friday. And you are the medical director of Hospital at Home at UMass Memorial Health and also on faculty for your program for digital medicine. And if, if we have time, that'd be interesting to learn a little bit more about that. As well. So we first met really online. So I see what you're doing. I know you were at Medically Home previously and now at UMass and you're doing amazing things. And so it really caught my attention. I love the stories that are out there. I just saw another one very recently about, um, what it was, a patient and she was getting postpartum care at home and talking about what a fabulous experience that's been. So you guys are doing amazing things, really leading in the country. So that's why I asked you to be on here. And Taki, aside from all that, the most important question I have for the entire podcast is the following. What's on your playlist? What kind of music do you like to listen to?

So I tend to go very, very broad and probably my number one artist, and this is because growing up, driving to school with my father in the car, he was a huge early fan of Tracy Chapman in the very early days. This is the mid-'80s. Um, and so to this day, I would say Tracy Chapman is very high on my playlist. Uh, but I love all types of music for sure.

That's cool. What about a life message or mantra? Are there words that you live by?

Oh gosh. Be kind above and beyond. Be kind, be humble, be caring. Probably those 3. I try to, those are aspirational words. I'm not always kind. I'm not always humble. Uh, but I do my best.

Yeah, no, that, that's cool. Those, if, if, uh, if all of us could embrace those 3, the world would be magnificently Uh, different and better.

Yeah.

So tell us a little bit about your story. I mean, already with your name, it makes me wonder a little bit about your story. So where are you from originally or your family and, and how did you get to where you are today? For, for sure.

So I, I grew up in the Boston area in Hyde Park. Uh, mom was a visiting nurse, grew up in Southern New Hampshire. Father grew up in Athens in Greece. They met when he was a phlebotomist at Boston Children's and one of my mom's very first nursing jobs. Uh, so grew up in Boston, was a bio undergrad major at a small liberal arts college, uh, did healthcare consulting for a number of years. And, uh, all along the way, you know, my mom is a home care nurse and really has done 30 years of home care nursing, just retired in the last few years or so. And always just, you know, heard her stories about how well she knew her patients, how much she loved going into the home, um, how much many of her patients thought of her as a part of her family. And so I think always going through my career, I had that voice in the back of my mind. Um, so went off to, ultimately went off to medical school at University of Pittsburgh. Uh, got really excited about the intersection between clinical care delivery and economics and how we think about creating value, um, for patients, for families, for the healthcare system. So did a master's in clinical research, mostly in cost-effectiveness analysis, then came up to the Brigham for internal medicine training. Uh, went to business school as part of medicine training. I would say, as you can tell, I'm a generalist. Uh, I love generalism and we could talk about that ad nauseam for sure. Uh, but finished training, finished business school, and joined the folks at Atrius Health, uh, working very closely with, at the time, a small startup called Medically Home, very passionate about bringing acute and post-acute care to complex frail elders, predominantly in Eastern Massachusetts. So I was there for 3 years and it was a ton of fun, super rewarding building emergency department at home, SNF at home, hospital home care services. And then left and joined UMass in 2021 to help build and scale our hospital at home program. And I would say that, you know, my why and what gets me excited about what I do is we have so many patients who are older, complex, frail, vulnerable, where we know they do better in the home and we know they tend to have higher rates of complications in the brick and mortar hospitals. So I'm always asking myself, how do we focus on this population, bring the care to them, avoid those bad things, delight patients and families? Um, and so that's my why, and it's been a total pleasure. Our journey has been about 3 years in, so I would say we are We're maybe out of the infancy stage. We're in the kind of toddler phase of our home hospital program. Uh, patients are doing great. Uh, mortality is lower, safety is better, 30-day readmissions are lower, and patient satisfaction is higher. Our top box recommend, which in the brick and mortar is often, you know, 65, 75%, we tend to be in the 90 to 95% top box recommend from our patients and families. So it's super rewarding care for sure.

Yeah, no, it's, I, I think it is, uh, Everything you said and the future, which we'll get into in a little bit. I drove some of this at Cleveland Clinic and, um, you know, that was super aspirational for us. And I'm glad that you're out there doing it. But before we jump into more of that, uh, did your dad ever take you to Greece? Did you, have you spent much time there?

Yes. Yes. You know, I, I am so, so privileged to have had the opportunity to spend a lot of time in Greece over the years. Um, and so, you know, obviously still have, you know, he has a brother there, um, uh, extended family in Greece. Uh, and so would go back almost every year, every 2 years to see family. And I would say that, um, one of the reasons I think I love generalism is probably the same reason I love going to Greece is it's just rewarding and fun to expand your, your set of experiences and perspectives and ask yourself, why do we do it this way? Could it be different? Why could it be different? How could it be different? And so I would say that I'm very grateful for, for my mom and dad for stretching, uh, um, my, my experience and exposure, uh, from a very young age.

Yeah, no, that's super cool. When did you know that you wanted to be a physician? Obviously your dad, uh, and your mom both clinical oriented. Uh, what was there a particular age or particular thing that happened that said, aha, that's what I want to do?

You know, I think like, like many of us, our parents play such a big role in how we think about careers and excitement. And, um, I always loved science growing up. My father loved biology. I think in another world, he might've been a marine biologist. He was a serial entrepreneur for many years. But in another world, he would've been a marine biologist. And of course, having my mom have such important relationships with her patients, I think those 2 things, it just, it was, um, I just got exposed to those conversations from an early age and loving science from an early age. And so I think I myself might've been a marine biologist if I also was not a physician. But I love the combination of interfacing with human beings, understanding their goals, who are they, and then bringing storytelling at an individual level.

Yeah.

and a data level. And I think science and, um, and medicine do that in a, a really interesting way. And so to this day, I, I practice obviously as a physician in our hospital home care model. Um, but I also support our scientific research endeavors across our hospital home program and in our medical school too. So I think, um, in many ways the generalism as a human being carries through to the generalism as a professional.

Yeah, no, it makes a lot of sense. And as we pivot into talking more about Your role as a medical director and more about hospital at home. How important is it that there's a strong tech base already existing? So at UMass, right, you're blessed to have a good tech base. How do you work with your tech partners to make sure that everything you're doing, you know, is well supported and all the capabilities are there?

Yes, Ed, it's such an important question. And there is zero doubt that technology is critically important. We use technology in terms of our electronic medical record. In terms of our remote patient monitoring, we partner with a company called Recurrent Health. Um, in terms of our devices in the home, looking at biometrics in particular, uh, our video visit platform, our ability to bring internet to every patient family when they're admitted to our program. So technology allows us to reach patients where they are, to design for and ensure equity and access to care. Um, that said, technology is supposed to serve humanity. Humanity does not serve the technology. So we are always asking ourselves whenever we evaluate some new bauble, some new gadget, some new software, is this really helping us be more human in how we care for patients? And if the answer is yes, boom, that's great. We should think about, uh, you know, buying, purchasing, servicing, partnering, and implementing. But a lot of times the answer is no. Um, and so we just have to be very cognizant about how we think about technology. But the short answer is yes, it is critically important for sure. Yeah.

No, that's, that's super. And tell us a little bit about your role. What does a medical director for Hospital at Home do?

Yes. Uh, a little bit of everything for sure. So of course I care for patients in our care model about a third of my time, which is super rewarding. Um, and then I spend a lot of time working on quality improvement, on safety, on growth, on hiring and staffing, on training, a lot of supply chain partnership work. So we are fortunate to have, you know, 7 or 8 incredibly important, or excuse me, incredibly important partners.

Yeah.

In the central part of Massachusetts helping us care for patients.

So.

Um, we've partnered with organizations that help us with in-home physical therapy and occupational therapy, mobile imaging to do x-rays and ultrasounds and echocardiograms in the home, uh, et cetera, et cetera, et cetera. So it's, uh, partnership is incredibly important.

Yeah, we already talked about sort of the internal partnership, you know, with the technology and the team. What about the overall org strategy? How does, how did Hospital at Home emerge? Because I imagine it came out of a strategic thinking.

Yes. Yes. And this is still very much evolving, but to start at the very early days, and this is, again, this is in November 2020 when CMS passed the acute hospital care at home waiver in the setting of a massive surge in COVID cases, hospitals across the country struggling with capacity, and our own medical center having 100 to 120 patients boarding in the emergency department. That waiver was critically important to everything we do. It allowed for reimbursement for home hospital, allowed for regulatory relief so that we could care for patients in the care model. Um, and everything we do sits upon that foundation. So that was November 2020 where that waiver passed. And I should say, and we can talk more about it, but, uh, if Congress does not act in the next 2 months, that waiver will go away. So again, I'm sure we'll talk about that a little bit later, but, you know, call your congressman, call your senator. If you want your mom, your sister, your brother, your daughter, your husband to have access to home hospital, you know, call, call Call your congressperson. But the short answer is, is that with the November 2020 waiver coming along, uh, that really allowed our safety net health system that often financially is really on the margins of, of maintaining viability. We care for a very disadvantaged patient population in our part of the state. So that allowed us to begin to think about building and launching our program. So we started planning in about January 2021, about 5 to 6 months of a lot of hard work investment, several million dollars of investment from our medical center. Uh, to address the capacity crisis in our ED. And then we launched our program in August 2021. So we're still very closely docked in and aligned with our medical center. And our main mission every morning is to help our medical center serve our complex populations of central Massachusetts. That said, we are also working to expand and offer the service to our surrounding and very important community hospitals. Um, so we have a CMS acute hospital care at home waiver, not just for the medical center. But just recently received one for Health Alliance in Northern Worcester County and are exploring that opportunity. And so I hope over time that we continue to think of our, of the home as a strategically important site of care for complex patients.

Yeah. Well, as you already stated, the satisfaction is higher, the quality's the same, the cost's probably lower. So you're hitting like quintuple aim sort of things and I think it's just the way to go, but yeah, we'll come back to that in a second. Can you share some examples how this works? So the great one for our listeners is they can look it up. It was covered by your local television station, the one on postpartum care. What other sort of use cases do you have to share?

Yes. So I think for your listener who is learning about home hospital for the first time and has no idea what home hospital is, I think the easiest way to think about it is this is bringing the care that you would otherwise normally receive in the hospital To your home with the same incredible nursing and paramedic and physician care, all the same diagnostics and therapeutics, just in the comfort and safety of your own home. And so let me share an example. Um, and so actually stepping back before I share an example, I'll share that we are caring for many of the classic conditions that are admitted to hospitalist services, internal medicine services in the hospital. So for your listener who knows less about what those conditions are, Those are things like folks who come in with severe bacterial pneumonias, RSV, influenza, COVID, severe skin and soft tissue infections requiring inpatient-level care, severe urinary tract infections, sepsis, exacerbations of heart failure, and chronic obstructive pulmonary disease. And these are all really bread and butter conditions we care for every day in the hospital, and we care for those exact same conditions in the home in our home hospital program. And we're also starting to push the boundaries in thinking more broadly. Could we care for patients who come directly from the operating room in our home hospital program after they have their surgical procedure? The short answer is yes, and we have done that and we can talk more about that. But there's a lot more, I think, really important things we can do in the home. So to share an example, and this is a patient I cared for about a year and a half ago who still very, very closely, um, kind of resonates in terms of my heartstrings and my thinking about who we can most help. So this was a 65-year-old gentleman. He'd had a history of, uh, end-stage renal disease in the past. And had a renal transplant about 3 or 4 years ago. He was doing quite well in the home, living on his own with family members about an hour and a half drive away, and a couple of neighbors who he's very, very close with and were a real part of his community. He came into our emergency department with a severe urinary tract infection, um, and he was actually pretty frustrated about having to wait for so long, and he left without being seen. And that's one of the real challenges of capacity crises is we do have folks who are leaving without being seen that we need to. Uh, we need to eliminate that categorically. So he left without being seen. Um, and then the ED team did a great job and they called him back and said, Mr. So-and-so, you know, we have your blood work back and you, you have a severe infection. We need to bring you back right away. So he came back to the emergency department, had his evaluation completed, and was seen by the infectious disease doctors and the transplant doctors. And then our home hospital program came and talked to him. Mr. So-and-so, we think you'd be a great pro— uh, candidate for our program. We asked him some questions. Do you have a home, running water and electricity? Are you interested in the program? Yes, yes, yes. We transported him home by ambulance. He was met by our nurse. We brought our technology platform with a tablet and remote patient monitoring, and we bring internet. They don't have to have any of this. We bring food, we bring everything. There's no additional cost. Um, and then over the course of the next 4 or 5 days, we do all the good old-fashioned acute care he would have otherwise received in the hospital. He saw his doctor every day in the morning on the telehealth platform. Our nurses were in the home 2, 3, 4 times a day doing blood work, giving IV antibiotics and fluids. We were talking to our specialist colleagues. So that's all table stakes. You have to do that and do it well to be able to provide acute hospital care at home. But what's special about home hospital is all the other things we find when we're in the home. So we find out that he actually doesn't have food in the refrigerator. We find that he has signs of mild cognitive impairment that had not been detected by the brick-and-mortar hospital teams or the clinic teams. Because it was very subtle and it was hard to know. And we noticed this being in the home. We also find that he was not taking some of his transplant medications because he was having a hard time affording all of his medications. We also find that he was taking about 4 or 5 medications that he shouldn't have been taking anymore. And there were bottles of medications strewn all over the home. So suddenly we have food insecurity challenges, medication affording challenges, um, cognitive impairment challenges, and meds that he shouldn't be on anymore.

Yeah.

And we can address all of those together. So I think that's the magic of home hospital. It's good old-fashioned acute care at home, much higher patient satisfaction, and we're addressing all the social determinant challenges in the home.

Yeah. You're making me super excited, you know, 'cause I hearken back to, as I mentioned, where, where I recently left and being responsible for many of these things. So exciting to see it progress the way it is. What are some barriers to adoption? Like maybe one or two barriers that many organizations may face when trying this? Other than, and yeah, I do want to repeat that, uh, the waiver needs to be, um, uh, continued. And yeah, definitely be active, talk to your government affairs, uh, people in your health systems, hospitals, and make sure that that's addressed. But in addition to that barrier, uh, what are some other ones?

Yes. And stepping back, I think that even, uh, a corollary point to that, um, Ed, is that When new home hospital programs launch in their state, it's not uncommon for them to need to spend some time really closely working with their payers. Obviously, the Centers for Medicare and Medicaid Services represents most hospitals' number one payer by volume.

Yes.

And certainly it does for us as well. So I would say that the first barrier for all programs across the country is working closely with their payers to, to, uh, ensure coverage. We are very fortunate in our state of Massachusetts where about 90% of patients arriving in our ED have a benefit and are paying for home hospitals. We're able to provide the home hospital care. We're also very fortunate that our state Medicaid agency is very supportive of home hospital. We're actually doing a claims-based analysis with our colleagues at UMass and at MGB and MassHealth together, collaborating to describe the results in patients with Medicaid as primary or secondary payer. However, that's not the case across the country, and there's about probably 35 to 40 state Medicaid agencies. that are not yet covering home hospital. That's a huge equity challenge. And so we continue to work with other state agencies, other state health systems to say, to share our outcomes, hey, these outcomes are incredible. If anything, they're even better in our most disadvantaged population. We have to ensure state Medicaid agencies are covering this care model. So I'd say the payers are part of it. Um, and part of it too is just good old-fashioned change management. You know, we've got doctors and nurses and paramedics that are used to doing things in one way for, you know, 20, 30 years. And we're coming along and saying, hey, we can actually do the same exact thing, but just in the home. And it takes some time. And there's also some patient discomfort. Um, and so I would say that what we notice is that when a patient has been cared for by us before, they're probably 5 to 10 times more likely to say yes to us if they come back. And we actually have some patients who come back and they'll be in the waiting room saying, can I go to home hospital please? And, you know, we have to say, well, first gotta have the evaluation and, you know, we, we have to make sure we know what's going on, but, but. They are, they know the experience is so much better.

Yeah. No, that's super interesting. Where do you think we're headed? So, Tuckey, I had this, you know, when I was planning and leading this, I anticipated like pretty exponential growth for everything sort of virtual hospital home, virtual visits, those sorts of things. Pandemic happened and everything accelerated, right? Your program was really launched and born. And then post-pandemic, for many organizations, the numbers went way down. Um, where do you think, assuming the waivers are renewed, where do you think we're headed ultimately?

Yes. Um, it is such an important question, and I think all of us have maybe backslid a little bit more in terms of our adoption of telehealth than perhaps we may have desired. coming out of the pandemic. And I think there's a lot of complex reasons for that that we could get into in depth. That said, when I think about acute care at home and telehealth and how we think about, um, you know, serving complex patients in the home, the first thing I think is, holy cow, this is early days.

Yeah.

It was only 2020, just 4 years ago, where we couldn't do any of this.

Yeah.

Um, in, in a way that was aligned with all of our usual structures of care. The second part of it is that, you know, all of us, especially safety net health systems like our own, require certainty. And so there are probably about 360, 370 hospitals today that have CMS acute hospital care at home waivers, but not 360 home hospital programs that have launched.

Right.

And a big part of it is if you are a safety net health system and you know that if you invest $2 or $3 million in a 6-week period, You might not be able to do home hospital anymore. There's not the certainty to continue to invest at a high level.

Right.

And so I think the certainty from a regulatory perspective is really important. Um, I would say the other part of this is GME, graduate medical education. Um, we have to change hearts and minds and thinking about structures of care for patients. And that starts with our medical students and residents. Um, and so today in our home hospital program, we have internal medicine and family medicine, uh, uh, residents rotating through with us on a regular basis. Part of it is that I can tell you as a medical resident or as an attending what we do, you just can't believe it. It's not possible to believe it until you come and see it. And so they might say, oh yeah, home hospital, this is super cool, but I'm not gonna send you this patient. But we find when they come and rotate with us, they go back to the hospitals and they're like, I get it. And that team is incredible and the outcomes are incredible. So yes, I'm gonna send patients to them. And then of course, there's a broader payment discussion to be had outside of the CMS acute hospital care at home waivers, which is that today we live in these very siloed inpatient, outpatient, home infusion. There's all these very, very structural, you know, box around them type of payment models that don't allow a lot of clean transitions between care. And so even in our home health system, we're continuing to understand what is the best org structure to build. Hospital at home, emergency department at home, SNF at home, all of which we're offering and providing in our, in our health system. How do we bring those together? How do we make them seamless and invisible for the patient in a way that just feels right to clinicians, to patients and families? And it's still early.

Yeah. That's super insightful. I really had never thought about it from the GME point of view. And certainly the payment structure. Yeah, that's a major bugaboo. But all this is fixable, you know, is addressable, which is the good news. And I tend to be rather bullish on the future as well. Yeah, we took a step back, as you mentioned, a little further than I think any of us intended to or anticipated, but I think it's going to, you know, continue to rise and go surpass what happened during COVID So speaking of GME, tell me a little bit about this faculty role that you also have, this program for digital medicine. That sounds super fascinating. Can you, can you? share a little bit about that? Yes, for sure.

For sure. And I think I want to come back to a point you made around the GME before I answer that question, because you just jogged my memory. The other point I'll share is, you know, I finished training. I did my internal medicine training and extended a year for business school, but I was in internal medicine training 2014 to 2018 at an amazing program with amazing people. And I myself never did a telehealth or home visit in training. And that was only 10 years ago. And I think if you ask many attending physicians today who trained prior to the pandemic, Many of them will say the same thing. And frankly, many of them will say they've never done a home visit, full stop.

Yeah.

So I think that's an area where we as internal medicine docs need to do a lot better in general and how we think about training. Uh, for sure. Um, and so in terms of your, uh, your follow-up question around the program in digital medicine, yes, I am very fortunate to work at the intersection between our health system and our medical school and work with an amazing MD-PhD colleague, Apurv Soni, who is really the research chops in our home hospital program. And he and I, he and I meet regularly. We talk about a research agenda, we execute against the research research agenda. And there are so many areas where we need to better understand outcomes. We need to better understand risks, even basic things like what is C. diff risk in hospital at home versus brick and mortar? We think it's lower, it appears to be lower, but we have not risk stratified and done that cohort study.

Yeah.

How does antibiotic use vary between programs? Um, do we have differential acceptance across populations? Now we do have good data on that, and we're starting to get ahead of publishing that because it's very important from an equity perspective to ask, Who's got access? Are we seeing differential access, differential outcomes, differential readmissions, differential escalations? The good news is in our program, the answer is no. But we need to be confident in that going forward and, and follow that on a sort of monthly and quarterly basis. So the short answer is there's a, a heck of a ton of hard work going on, and I haven't even mentioned all the cool new technologies that we're a part of, uh, thinking about deploying.

Yeah.

Uh, and, and Dr. Soni, if you could hear me right now, I will not talk about your smart toilet seat, uh, but it is quite neat.

I know you're, this is not good for me because you're making me want to jump back in and, um, it's so exciting. Hey, I want to pivot now to leadership. Obviously you're a great leader because of things that you've done before, but leading, this is pioneering work really. Um, I want to ask you a couple of questions. What's the one best piece of advice that you've ever received?

Oh goodness. Um, I think it goes back into the early days of our early minutes of our conversation, I should say, which is, you know, be humble, be kind, listen. I would say that all of us just went through an election that on both sides was pretty tough. And I would say that, uh, probably the lesson that we can all learn from that process is that we're not listening enough to each other and we're not developing the empathy that we need to. And there's lots of complex reasons for that. But I would say listening, empathy, humility, and kindness. Those are 4 powerful words.

And what about a time that you failed and how did it shape who you are or how you lead today?

Yes. You know, I, I have a vivid memory of a patient I cared for, uh, in my very early days of training. I was a brand new intern and I walked into the room of a 70-year-old African American gentleman who had not been seen in the healthcare system for years, and I had done some research and read about his prior health prior to the several years earlier when we'd last seen him, but he'd lost and lost a follow-up for a couple years. And I was, you know, being a good doobie, I've gotta, you know, make sure I understand every preventative care and what happened to that kidney lesion that was on his kidney 3 years ago. And did he have his colonoscopy and his prostate cancer screening? And, and I walked in and instead of just asking myself and him, you know, what matters most to you? How can I help you? Why are you here today? Let me serve you. I kind of brought my agenda to the, to the discussion. And I was like, we gotta do these 15 things and if we don't do them all, and, and he had lack of trust in the healthcare system. And I think he saw me as probably a young white male physician who probably was a little bit, you know, too aggressive about doing these things. And I wasn't able to build the trust with him.

Yeah.

And so we weren't able to get some of the things done. And so I think for me, what I learned out of, from that experience was a couple things. One is that nothing matters more than trust. And the second is, is that for people who are impatient, and I put myself in the impatient category. You have to recognize your own impatience and, and tame it. Um, and, and recognize that you're, you, you're almost always accomplishing more than you think you are in any given moment, but on a day-to-day basis, you may not recognize that.

Yeah. Yeah, that's, that's a, that's a great, great lesson. Thank you for sharing. Uh, last question, cuz you know, a lot of the audience is sort of digital and tech and you're a clinician and you've crossed the chasm of both and bring both together. What do you wish more sort of tech leaders knew? You know, I'm talking about nonclinical tech leaders. What do you wish they knew more about working with clinicians? Like, what's the best way to work and partner with someone like you? Yes.

Uh, I, I, oh man, I love that question, Ed. Thank you for asking that question. I would say this comes back to empathy and, and being in the weeds of what's happening. So I would say we have incredible technology partners, uh, in our hospital home program. And a big part of why they do such a good job is they just come and they sit with us and they watch.

Yeah.

Um, and they're there and they listen and they learn. And so I think all technologists need to speak a little bit of clinician. All clinicians need to speak a little bit of technologist. And, and in doing so, we can cross this chasm. The number one failure I would say, uh, and this is such a classic failure that it's, it's almost interesting that it continues to happen, is a technology built for the sake of the shiny object technology that doesn't actually solve a problem for the patient. the family or the provider or nurse or paramedic. I would say that happens probably 10 times more often than you might guess.

Yeah. Those are some good lessons. Taki, we covered a lot of ground in less than 30 minutes. Really, a common theme has been be kind, humble, caring. You use the word empathy a lot, which I love and a big believer in. It was great to learn about you personally and how you grew up and your parents, uh, and then your career and how you got to UMass and then You know, thanks to a lot of different things, uh, that got set in motion, you know, the pandemic is horrible, but we did as a result of the pandemic move forward in some areas that are really helpful to patients in our communities that we serve. And so we talked a lot about that and really in depth in Hospital at Home and the whole program and the different use cases and the different obstacles and the different ways that you got over those obstacles. And the third time we're going to say it, call your representatives and make sure the wing—

Yes. Thank you, Ed.

We all have to be active. Uh, in that is super important. It's super, super important. And then we talked a lot about leadership and you were very humble and forthcoming in terms of failures, as well as great advice and how to work best with clinicians. All that said, what did we miss or anything you want to double down on? I'll give you the last word. Yes.

Uh, Ed, first of all, it has been such a pleasure. This is sort of a top moment, uh, in my week, if not month and year. It's been a total, uh, it's just been a super fun conversation. I would say my last thing I would share is just remember your why, because all of us who are pushing the front edge for patients and families, we all have great days and we should be humble when we have those great days. And we all have terrible days. And when you have those terrible days, just remembering why we are doing what we're doing and recognize that tomorrow will be better. Um, and, and leveling out those swings from the best of days to the worst of days.

Love it. Taki, you're an amazing, uh, person. Uh, clearly a clinician and leader. Thank you for being my guest on Digital Voices.

It was a total pleasure. Thank you, Ed.

Hey, that wraps up another edition. Thanks for listening.

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