Taking Healthcare by Storm: Industry Insights with Nancy D. Zionts

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Nancy D. Zionts, MBA, Chief Operating Officer and Chief Program Officer of the Jewish Healthcare Foundation.

Learn more about the Teaching Nursing Home Collaborative (TNHC).
Contact the Jewish Healthcare Foundation.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website: https://www.qualityinsights.org/qin/taking-healthcare-by-storm

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-ARPA-112224-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

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 Hello everyone, and welcome to Taking Healthcare by Storm. I am Dr. Jean Storm, Medical Director of Quality Insights, and today I am so excited to have Nancy Zients with us. Nancy is the Chief Operating Officer and Chief Program Officer for Quality Insights. for the Jewish Healthcare Foundation, where she leads important initiatives focused on quality and safety and healthcare, particularly in aging, long term care and women's health.

With extensive experience in improving healthcare systems, she spearheads the Pennsylvania Teaching Nursing Home Collaborative, which we are Basically going to be focusing on today, along with other topics, and this collaborative strengthens partnerships between nursing schools and long term care facilities to enhance.

education and care quality. It is so innovative and important and needed in the long term care space. Nancy has also played a pivotal role in various statewide initiatives, including those addressing the challenges posed by the COVID 19 pandemic. And we are still, I will argue, really facing those challenges.

especially in long term care. We are looking forward to hearing her insights on transforming nursing education and improving care for older adults. Welcome, Nancy. Thank you so much for being with us today. It's a pleasure. Thank you for asking me to be here today. Great. So let's just jump right in. Tell us how you came to do what you do.

So I have been in the field. Uh, healthcare and in the field of aging for the 40 years of my career, I literally just on September 17 hit the 40 year mark of working in the aging field. And I got into this work because I'm passionate about older adults, seniors, elders, I'm not as passionate about what the word is, but I'm very passionate about the people.

And, um, the first job I got when I moved to this country from Canada. was with a health system that had a long term care facility, and I got started in that work, and uh, it hasn't stopped. I've been at the Jewish Health Care Foundation for 30 years in charge of their aging agenda, as well as their women's health agenda, and on most days I don't tell those two things apart.

That's good. We don't want silos. I think breaking down silos is important. So, workforce challenges are significant, a significant concern in healthcare. How does the Jewish Healthcare Foundation attempt to address these challenges, particularly in the long term care setting where they're just so pervasive and difficult?

Well, thank you. The Jewish Healthcare Foundation is, um, We do our work. On behalf of with, and for the populations we are trying to serve, but we have recognized long ago that we're not in the direct service business that if we are going to make an impact and if we're going to help. The. And user the end recipient of health care.

I hate to say it in a very crass way but it's the workforce stupid and we've been very focused on workforce issues for at least the last 25 of the 34 years of the foundation. In fact, we have a sub organization of the Jewish Healthcare Foundation. Called health careers futures and it is focused on the supply and demand and training and upscaling and support and advocacy for workforce across the board.

So we've done a lot of work with midwives and doulas in the last five or eight years, a lot of work with community health workers, we run a behavioral health fellowship to try to ensure that we can help produce the right workforce for the behavioral health industry, and we have been in long term care workforce.

For at least the past 25 years, in addition to a focus on nurses and doctors and pharmacists, etc. It doesn't matter to us what category of worker it is it doesn't matter to us what setting. It matters that we figure out a way to support and educate train. And advocate for a strong workforce as well support.

Yeah, and I would argue all those different types of individuals working in health care, just essential in in reducing, um, health inequity, you know, addressing the social determinants of health. So I think, yeah. So workers to pharmacists to therapists to ethicists, they're all important. Yes, absolutely. So, leading the COVID 19 learning networks, I'm sure, presented unique challenges.

What key lessons did you take away from this experience, and how do you see these lessons shaping future responses to public health crises? So we came out of the COVID 19 pandemic and I so believe what you said at the beginning in the introduction, we're not out of it in long term care. There are other sectors that have decided that COVID is gone, but I mean, I speak to nursing homes every day, including today, where they have outbreaks and where they are concerned for their workforce, they're concerned for their residents, they're concerned for their families.

So the COVID 19, uh, outbreaks are not completed and they probably never will be. They'll just be a new outbreak. Uh, chronic disease or chronic condition that we're looking at year after year. But we went into the COVID 19 pandemic, uh, with a lesson learned. And that was, and we did a documentary on this, what COVID 19 exposed in long term care.

Long term care did not do poorly with COVID 19 because of anything long term care had done wrong. In fact, it was 20, 30 years of neglect of the long term care sector that set it up for such a significant fall during the COVID 19 pandemic. So it exposed The lack of attention that had been paid up until now to investing in things like infection control, investing in things like making sure there were the appropriate supplies or there was an appropriate workforce that was appropriately trained, supported and valued.

So COVID 19 just exposed those issues and we, our commitment now is the same as it was before and that's doubling down. It's doubling down on what do we need in order to keep our residents safe in long term care but very importantly, what do we need in order to support our workforce, so that they can deliver the best care possible and receive the best care.

the best, not just recognition and respect, but also compensation and support for the work that they're doing. How do we, how do we strike a better balance between what resources go into the acute sector and what go into long term care sector? Because they are symbiotic and we have to make sure that we are paying attention to all sides of that equation.

I agree with you 100%. And I think the lessons most definitely are we need to really focus on our infection control, infection prevention practices and support our workforce. I mean, 100%. So you received the 2020 Kelly Pruitt Age Friendly Leadership Award from the Southwestern PA Partnership Program. for aging.

Can you share what this recognition means to you personally and how it reflects your commitment to improving care for older adults? So, um, I don't do this for the awards and, uh, they're nice. The recognition is lovely, but every now and again you get recognition in the name of, of people. And this is Mary Ann Kelly and Charlie Pruitt, um, that I knew personally, respected tremendously.

Considered both to be mentors of mine for the 40 years of my career for Charlie and about 30 years for Marianne Kelly, and they really provided me with a network with support. We learned a lot together. We advocated together. We struggled together with some of the problems in long term care and aging in general, not just in long term care.

And so to receive an award with their name on it meant a tremendous amount to me. It helps you to. realize that there, this work is only done in partnership on my first day of work on September 17th, 1984. I was told by my then boss, you're going to be working in aging. We're going to take you to go meet Charlie Pruitt.

And I went to meet Charlie Pruitt. And Charlie said to me something that stuck with me and that was going to be working in the field of aging. There's never going to be enough money to do everything we need to do. Work with others, partners, partner, collaborate and network. That's the best way we're going to get things done on behalf of older adults.

That has been a calling for all of us who work Charlie trained and mentored so many of us, and Marianne was a policy and advocacy genius and it was a pleasure and privilege to work with them so I have that award over my shoulder in my office, because it provides me with ongoing inspiration. That's fantastic in getting inspiration.

I mean, it, it just amazing. So I, uh, was recently lucky enough to hear a session, um, during the voice, which is the voice of inspired change for elders, the voice PA, um, their annual accord conference. I was able to hear a session before my session that I did on the Pennsylvania teaching nursing home collaborative.

And I was just. I've blown away, and I've heard of this collaborative, but just hearing it again, I really wanted, that was why I wanted to bring you on to talk about this collaborative. So can you elaborate on the primary goals of the Pennsylvania Teaching Nursing Home Collaborative and how it aims to strengthen academic practice partnerships between nursing homes and schools of nursing?

for listening. Or so this was something that came out of the COVID 19 pandemic as we were sitting on the sidelines, trying to be useful trying to figure out what was the most important thing we could do to show our support for those who were working in long term care and the residents that they were taking care of.

We got together with a colleague of ours, the Johnny Hartford Foundation, which is a national foundation out of New York. They had funded the original teaching nursing home project in 19 in the 1980s, which matched up primarily nursing schools and medical schools with long term care facilities, and they wanted to revive that they wanted to revive that initiative This idea that if we could bring Additional resources from academia to long term care, and we could help create a sense of ongoing searching for better options and ongoing research within nursing homes.

We could make a difference for the workforce and then ultimately for the residents. So we decided to come together and do a pilot project in Pennsylvania. And, uh, we contracted with three schools of nursing in Pennsylvania. It was Penn State and, um, University of Penn, uh, together with, uh, four nursing homes in Pennsylvania.

We partnered them up together. So we did the west, the central, and the eastern part of the state. And the idea was, could we develop tools and opportunities that would improve academic practice partnerships and introduce a framework for quality improvement, that framework being age friendly health systems.

And could we do that while trying to track and this was one of my key jobs during the first part of the initiative, trying to track some of the key policy or advocacy levers that also needed to be looked at if we were going to make sustainable change. We weren't far into the pilot project, which was 2021 to 2023 when the Johnny Hartford Foundation said, you know, this is really important.

Let's see whether or not we can do a deep dive and do a phase 2 to disseminate this across Pennsylvania and invite in other states to watch the deep dive dissemination so that they could be next in line to do this as well. So, the three components are improving the partnerships between a school of nursing.

And a nursing home and then also implementing age friendly health systems for nursing homes specifically. And when we started this in 2021, the age friendly health systems for nursing homes was brand new. In fact, the model was very focused on primary care and hospitals and didn't work for long term care.

But by the end of 2021, there was a new guide and there had been some tests done on what a curriculum specific to long term care could look like using the four M's, which are what matters medication mentation and mobility. And so that was able to be implemented in the pilot project, and now in phase two in the dissemination project.

What was really important to all of us was identifying the fact that we had leaders in the long term care sector and leaders in the school of nursing sector that often felt completely disconnected from each other and often felt that long term care was looked at as a stepchild of the health care system and wasn't given the same respect for schools of nursing so that you often didn't get a practicum in a nursing home at all.

And in fact, if you didn't have a champion or leader in your school of nursing that really was passionate about long term care, you often weren't even offered a long term care placement. And if you were, it was, well, we're sorry, all the ICU placements are taken. So you'll have to do long term care as if it was a punishment.

And we wanted to really change that paradigm. We wanted to reinvigorate a geriatrics in schools of nursing across Pennsylvania and across the country. And we have been so thrilled with, um, how the energy has grown within our schools of nursing. That was my biggest surprise out of phase. That's just, um, wonderful to hear makes me very happy.

So can you share insights learned from the initiative? What specific outcomes have emerged from the enhanced partnerships between academic nursing schools and, and nursing homes? So the insights and the outcomes are different. The insights are, um, it's not a radical insight, but it's really important champions and leaders matter.

So when you can identify a faculty person, or a dean, or even some professors that will champion geriatrics and champion long term care within their school of nursing. You are halfway there. And if you can't, it's a really heavy lift to get your school of nursing to want to participate. But if you do have that champion or that leader who is proud, not even not afraid, but proud to stand up and say they started their career as a CMA, or they have a real passion for geriatrics, and they have not had a placement but they'd like to work to develop one.

That became something that was, you know, really an aha moment for us. The second aha moment for me came when I went to the Padana conference, that's the Pennsylvania, uh, association of directors of nursing administration. And I went to their, a statewide conference a few years ago. They, and they are partnering with us on this project and they invited us to present.

And I know the old Perry Mason adage, you shouldn't ask a question you don't know the answer to. And there I was at the podium. Asking the question I thought I knew the answer to, and I got an answer I wasn't expecting. So the question I asked was, how many of you, it's a room full of nursing home administrators, how many of you have a relationship with your school of nursing?

And I had thought I would see a small smattering of hands. What I saw instead was every hand go up. So then I thought, well, that wasn't what I was expecting. Now I'm going to ask the follow up question. And what was the follow up question? How many of you are satisfied with that relationship with your school of nursing?

And that's where I had a smattering of hands staying up and most of them going. So that became our challenge. How do we create an environment where those relationships are better? What's missing from those relationships? And what we found out when we spoke to the nursing homes in particular was that they accepted anybody who came into their nursing home that wanted to be placed there, and any school of nursing that made an overture to them to place a student.

But other than that they felt they had no power. If that's too strong a word, they had no power in that relationship so they didn't feel they could ask anything of the School of Nursing. For example. Stop sending us students in their first semester that haven't had any exposure whatsoever to body mechanics or to a principles of nursing etc because they could do harm in the long term care setting.

Make sure that before students come into a long term care setting they've had some exposure to common conditions for persons living in a nursing home, dementia, being one of those that is at the top of the list. But so is multiple chronic conditions or polypharmacy, so it became a question of how could we help the schools of nursing and nursing homes in a, in a more collaborative way.

Understand what was important for a student to know before they came in, and what it was important for a student to know as they were there in their placement. So that was the first thing that I think. took down the, the curtain in between the two of them and got the nursing homes and the schools of nursing collaborating.

And that has been very exciting to see that there have been now protocols and not in a punitive way, but in a very collaborative way. What should a good placement look like? When should it happen in the nursing students curriculum? When should it happen in their trajectory of their career? And also there were nursing home, uh, staff and leadership that were prepared to serve as visiting faculty, adjunct faculty, guest lecturers at the School of Nursing.

So you weren't asking the School of Nursing to learn all of the distinctions with long term care themselves, but you were inviting them in to share that with the faculty of the School of Nursing. That was incredibly popular and those relationships became Very positive. What's the role of the medical director having medical directors interact with schools of nursing medical directors interact with students from the School of Nursing when they were there for their placement.

So, all of those things help to enhance the academic practice partnership. But the second thing that happened that was really important was that integration with the age friendly health system methodology. So age friendly health system was created by the Institute for Healthcare Improvement, together with the American Hospital Association and the Catholic Healthcare Association that are helping to implement this model of age friendly health systems.

And what they were able to find out is it's a really good framework for organizing student learning and workforce learning, as well as implementation of a quality improvement strategy within nursing homes. And what became really valuable for the students to do when they came to a nursing home is maybe they weren't ready to change wounds on day one.

Maybe they weren't ready to pass meds with LPNs on day one. But where they could engage that was making a difference in the lives of residents, and in the lives of the students, and in their understanding of why choose long term care, and why commit to geriatrics. The students were engaged in a portion of Age Friendly Health System called What Matters, and so many of the students were engaged in interviews with the residents.

They got to sit down one on one or two on one, so it was usually two students and one resident together to have a conversation with a resident about what mattered to them. Because it's, it would help to break down some of those stereotypes and some of those images that people had of what it was really like to talk to a senior.

For so many of the students, this was a wonderful, wonderful experience. It connected them to the residents. It in many ways inspired them to want to go into this field and that to us was some of the greatest work that was done by implementing the four Ms as part of this work. I just am so very impressed with this initiative, I will say this for so many different reasons.

So you touched briefly on the Age Friendly Health Systems 4Ms framework and how crucial role it played. So how do you see the implementation of the 4Ms improving the quality of care in nursing homes? So the framework is so simple as to make people skeptical about the fact that it could really move the needle on quality.

And to be fair, we all know, and I know I'm certainly preaching to the choir here, the number of regulations and the number of incentives. Programs are quality, um, initiatives that nursing homes have been exposed to. It would be fair for people to cynically say this is like the flavor of the month. So is this one going to stick around and do I really change how I organize my quality work?

But when they got down to it, in addition to having the what matters as the first thing. So if you're talking to Mrs. Jones and you find out that what matters to her, is she always liked to stand up at the mirror and do her own, um, face washing or putting on makeup or whatever it is, but she liked to do that herself.

That mattered to her. That was, uh, for her, it was dignity. It was since it was retaining her independence. So then you start to think, okay, how does that now I have it for one of the Ms of what matters, but now how does that relate to something else that she's doing? So now I have to look at the other ones.

And in that case, It was around her mobility. How do we get her to the sink? How do we get her to be able to either stand up or if not possible to sit by the sink to have her, um, her supplies in a way that she could reach them so she could do that by herself. That became part of her mobility plan. So instead of the mobility plan being she's going to walk up and down the hall three times a day for those it was more about her stamina to be able to stand.

in her bathroom at her mirror for five minutes. So what is the mobility plan? What is the therapy plan to allow that to happen? So that became a specific tie into the Florians. Deprescribing is a huge issue under medication management. Uh, one of the things that we did learn in COVID is people have medication regimes that we stick to for years and years.

We don't question them when things get added, when things get changed. And during COVID, when we were trying to reduce the number of times that we passed meds to reduce the number of exposures and the number of times that staff had to wash their hands, we in those days got very creative about looking at the med plan and saying, you know what, we could change either the order or the grouping of these meds to have this one, not maybe every day, but maybe it's now every second day and we saw the same results.

Thanks. That got people thinking about new plans for deprescribing and medication management, a very core piece of, um, the medication, uh, M in the forends. Mentation was another one. How do we engage? Um, how do we look at the behavioral health issues that are facing so many of our residents? And then there were some key quality indicators around the prescribing of antipsychotic medications.

For engagement with persons with, um, some anger, uh, management issues that needed to be addressed. All of those things that, and obviously how do we work with persons living with dementia, making their lives fuller, safer, etc. So the forums really do capture a lot of the day to day core issues of the people that we are all looking to serve as residents in nursing homes.

Yeah, and what you described as person centered care. Absolutely. It's person centered care, right? What matters is nothing more than person centered care, and then you, you cascade it down to all of those other areas. So we can say person centered care until the cows come home, but how do you put that into a plan that makes sense to the frontline workers?

And it is everybody's job. It is not one person's job. Everybody is involved in age friendly care and person centered care. Absolutely. So you, you touched, you talked a lot about how you are exposing, uh, nursing students to long term care careers, how thoughtfully that is done. What feedback have you received from some of the participants?

So, uh, I am a woman of a certain age who will never see me doing a TikTok, but I love receiving from some of our nursing home partners, the TikToks from their students who've talked to other students. About just how, um, Satisfying their time has been in nursing care. They have become the people who are promoting long term care to their colleagues and fellow nursing students.

They talk about the experiences that they had for the day. They talk about how that relates and has changed their view of working with seniors. They also talk about something that we don't talk about a lot when we look at because we don't often look at the difference between long term care. and acute care.

But if you are a new nurse in acute care, you are at the bottom rung of a ladder that is very tall and very wide. And the opportunities for you to get involved in a leadership role takes a long time in an acute care setting. In a nursing home, there, it's a much flatter organization. It's much more team based.

And so the opportunities for some of the younger newer students to come into a long term care facility and get involved in a small team in a project where they can bring their, maybe it's up to date tech skills, maybe it's ways for them to discuss and relate with others, their ability to do that sooner.

In a long term care setting has been very inspiring to them. So it's a great way. We we have a partnership with the University of Pittsburgh Graduate School of Public Health that is doing the evaluation and they have developed QR codes where the students can After every interaction within a nursing home, the day placements, the week time placements, etc.

They're able to grade and give feedback on their experiences and nursing homes, which we can then use. Not just to prove that the intervention is making an impact, but also for us to identify opportunities where it could make a greater impact in others, in other nursing homes as well, or other schools of nursing.

And I love to hear about social media working as a force of good. That's great. Yes. Exactly. So the collaborative officer offers a variety of resources and learning sessions. Can you share a success story around their implementation? Well we are, we've developed, firstly the, the, what I want all of your listeners to know is these resources were developed with a lot of generosity by the Johnny Hartford Foundation, the Jewish Healthcare Foundation.

In phase one, we also had the, Uh, Henry Hillman Foundation, and we've had the Independence Foundation, and we've had partnerships that have enabled us to produce resources that are free to all the long term care facilities. I could say that again and again. So we're developing guides, implementation guides, how to get started.

We have monthly meetings where people who are already involved and who are ahead of anyone who hasn't started yet are coming together to tell their stories and to say, here's how we got started. Thank you. We are we're in a rural area, so we do it a little bit differently because our nursing home only comes in for argument's sake once a quarter, or we're in a city area we have four or five nursing homes here so we're accommodating them all at the same time.

You can hear directly from the people who are doing this work. And once a month we also have office hours, where we have people who are coming together to ask each other questions, and we had our largest office hours this past month we're seeing a growth. And people who want to get involved in this teaching nursing homework, and we want them to get involved.

So they're coming together. The best, uh, the best resources we have are the people who are doing this, and have already done this, and are happy to share what they're doing. But we've developed, uh, tapes, We have all sorts of videotapes and, uh, written stories of how this is being implemented, and we are connecting people on an ongoing basis to the pioneers, the ones who did this first, who are not afraid to say, you know what, we were too ambitious at the beginning, and then we decided if we pared it down and, and listened to our staff and went in this direction, we could be more successful.

Everybody wants to know. It's great to see the success story, right? But that doesn't necessarily make something approachable for people to figure out how to get started themselves. So we've created a number of mechanisms for people to hear from the others who have gone before them and who are just maybe one or two steps ahead of them and are prepared to share with what worked and what didn't work.

And those things are all incredibly valuable. The last resource that was developed, and this is the only thing that costs money because it was done by a publisher. There is a brand new first ever textbook. For frontline workers in long term care called practice and leadership in nursing health. And it is called building academic practice partnerships and the textbook is available, and that it was co authored by 40 of us who've been involved in this work over the past few years we get nothing for any of us, but we this textbook has been we can really very valuable for some of the schools of nursing and some of the nursing homes to be able to.

Understand the stories and what goes into this work. Absolutely. You know, you touched a little bit on the dissemination phase and its impact on local and national levels. So other states, how do you envision the future of academic practice, practice partnerships in long term care evolving? So I would like to say that, um, our, our ambition in phase two, it's one of our goals, is that every single nursing home in Pennsylvania is involved in the Teaching Nursing Home Collaborative.

That is a large, hairy, audacious goal. Um, but I have been so pleasantly surprised with the number of nursing homes that have come on board already. We're far greater than halfway to that goal within Pennsylvania. Thank you. And once the nursing homes are ready and have academic the mindset and have the tools and are ready to go, each one of the schools of nursing could partner with upwards of 10 nursing homes, because there are 600 nursing homes in Pennsylvania, over 600 nursing homes in Pennsylvania.

That is a huge hill to climb. I will say that this is a personal belief, not every single nursing home we want every single nursing home exposed to age friendly health systems. I'm not 100 percent sure. How your listeners feel but I don't know that 100 percent of the nursing homes would make good teaching sites, but 100 percent of those that would make good teaching sites should be good teaching sites, and they should have access to the resources and they should be bringing in students.

Some of them are doing full classes. Some of them are doing, um, uh, just one or two who are doing graduate level projects, but that to me is part of our goal. And we have invited in other states where we can't work as closely with them on the matching, like we can do in Pennsylvania, we have a matching map in Pennsylvania, but we can share all these resources with other states and I know that quality insights is more than one state.

We're looking for leadership in other states that wants to say we'll be the lead. Give us the resources will will take the lead on reaching out to the nursing homes and schools of nursing in our state, and we can have those states side by side with us in our quarterly state and national advisory meetings, getting the information and taking the lead in their states and they would be most welcome.

I will say my wheels are turning now. We also are, you know, our ultimate dissemination goal is across the country. So sitting at the table with us since day one have been wonderful representatives from CMS. We've had people from CMS from HRSA, uh, at the state level, we've had people from Department of Health, Department of Human Services, um, Leading Age, other of the associations that have been sitting at the table with us, ready, willing, and able to grab this and take it and run with it.

And that's our ultimate goal, getting us out of this business, pushing it out into the field, and then having some CMS and HRSA changes that enable these partnerships to take place and incentivize them to take place across the country. Yes. So last question, looking ahead, what are the biggest opportunities and challenges you foresee in healthcare quality improvement, particularly in aging, long term care, and how is the Jewish Healthcare Foundation positioned to address them?

So I think the best opportunity we have is to build our workforce. I'm really proud that just two weeks ago we were awarded an Appalachian Regional Commission grant, To work with nursing home partners within Pennsylvania. They're already named. They're already selected as well as S. C. I. U. P. A. To help train and hire and upskill CNAs for long term care.

We have to fix the supply and demand issue. We have to fix this training issue. It's the mission of, as I said, health careers futures at the beginning, but I think that the biggest challenge is going to be the adequacy of our workforce in terms of numbers. so much. And the support that that workforce gets in terms of their compensation in terms of perhaps a better understanding of how the regulations do and don't facilitate good quality care.

And so I think that's one of those areas that we are very focused on in terms of opportunities in terms of challenges. You said it early on and I just want to reiterate the day to day work in skilled nursing facilities is hard work, it is hard work person by person. But it is really hard work right now in an industry that is under siege financially, under siege for regulation, and it is facing some existential crises relative to workforce.

So, and frankly, as we said twice during this podcast already, COVID is still there, and if it isn't COVID, it could be pneumonia, and if it isn't pneumonia, it could be the flu, and so on and so forth. So we really have to meet our nursing home partners where they are. Uh, if we are fortunate enough not to be in that very hassled and harried environment every day, we have to at least recognize that our partners are and make sure that what we do contributes to reducing their stress and improving their productivity.

And their ability to have positive outcomes and doesn't just become one more A straw to break the camel's back. That's certainly not our nancy. Thank you so much for joining us today. I am just continually I was blown away over the last 40 minutes from the good work that the jewish health care foundation is doing you can hear the passion in your voice and I am so excited to hear about everything that the foundation has accomplished in the future, and I would love to get you on again to talk.

I would love to come. You know, we've had a wonderful relationship with quality insights also for over a decade and anything that we can do to help our providers in the field is something that's going to help our residents. The older adults that and, and others, um, living in nursing homes that we're trying to take care of.

So these partnerships are so important and we're so grateful for the people who do the work every day. So thank you. Yeah. Yes. So we will link, uh, any information. If anyone is interested in learning about more about the Jewish Healthcare Foundation or the Pennsylvania Teaching Nursing Home Collaborative, we will link those.

Please link to PAT nhc.org. And the best way to get ahold of us is to fill out a Join us form. And once you have filled out a join us form, you will be in our family and we will be happy to share anything that you want or need from us. Thank you. Yes. I encourage all our, all our listeners in the long term care space.

Join the family, Nancy science. Thank you so much for joining us today. My pleasure. Thank you. Have a good day.

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