Episode 3: Pat O’Dea-Evans

Ever wondered how care managers navigate the complex world of healthcare transitions?

Joining us today is Pat O'Day-Evans, Executive Director of the Post Acute Network at Advocate Aurora and founder of Silver Connections.

Pat shares her journey from psychiatric health to acute care management and leadership (00:00-07:00). Learn about the challenges and rewards of transitioning from direct patient care to leadership roles (07:01-14:00). Discover the evolving role of care managers in today's healthcare landscape and the impact of ACOs on patient outcomes (14:01-21:00). Pat also delves into the future of care management and the importance of addressing barriers to healthcare access (21:01-29:00).

Transcript

Ariadne: [00:00:00] Welcome to CareCraft, where a podcast explores the heart and science behind effective care management. And today we're honored to be joined by Pat O'Day Evans, who is the Executive Director of the Post Acute Network at Advocate Aurora Health, the largest ACO in the nation.

She's also the founder of Silver Connections, a nonprofit that helps seniors find housing and care that meets their needs. And they also provide continuing education for care managers in the Chicago metro market. So thanks so much for joining us today, Pat.

Pat: Thank you.

Ariadne: I would love to get started just understanding more about your background and how did you get into care management?

Pat: Well, it's interesting. I, you know, my early career, I worked primarily in psychiatric health and worked in inpatient psychiatric and I was having a fairly long commute to work. And one day I thought, gee, I would love to work at the acute care hospital that I could work in. ride my bike to, how do I, you know, get into starting to work [00:01:00] in acute care after spending my career and in psychiatric because they didn't really have much psychiatric.

And I thought of care management as a, as a entree because I had spent quite a bit of time helping people with placement and, you know, finding alternative care levels and thought that that might work as a way to transition. Into acute care. So I pitched the idea to the director of care management at the time, and she was pretty interested.

And it was it was a little bit of of luck that soon after I. I finished nursing school she had asked me if I was interested in talking to her about a position when, when one became open. So I was, I was really pretty lucky there, but, you know, the networking helped. She had known me because I had started working in the community doing some placement.

for elder, elderly, and she knew of my [00:02:00] work in that, in that realm. Surprisingly, when I went on the interview, it went really well. And, and then I went to meet with the human resources department and they said, why are you being hired? You have no experience in care management. And I started to question right away, like what, yeah, what maybe I'm in the wrong, wrong room.

So I went back to the director and I told her what HR's response was and she said it's very hard to train nurses on community resources and you know, I can train you on, on the nursing, but I can't train you on, on finding the resources for patients. So she gave me a chance and I'm really grateful she did because I love care management as a career focus.

Ariadne: That's incredible. How did you actually find the transition when you started the job? Was it difficult?

Pat: Well, there's kind of a culture of nurses eat their young. It's kind of the same. And when I walk into the [00:03:00] care management department and I had no No acute nursing care experience.

I was a brand new grad and they were not used to having brand new grads in the care management department. Often it's nurses who have been in acute care who decide they kind of need to leave the bedside because being at the bedside is challenging, hard, hard physical labor. And they have all the intellectual knowledge of being a nurse, but they kind of want to separate from that.

The physical demands of nursing. So it, it traditionally was a more mature crowd that was in those roles, but there were some wonderful nurses that took me under their wing and helped me and shepherded me through. And I, I had, had great mentors in that department and, and made some really lifelong friends.

So it ended up working out fine.

Ariadne: That's awesome. And have you seen the role of care managers change over the course of your career?

Pat: Yes, there's so [00:04:00] much the layers of regulation and, and demands and the focus on shorter lengths of stay and having patients leave the hospital quicker and the explosion of more post acute and external resources to choose from, you know, really, really, there has been quite, quite a quite a difference from when I first started.

You know, we, we used to send patients that had a knee replacement directly into a nursing home and they'd get rehab there and, you know, now those patients are expected to go home. And so there's so many different elements that make it more complex. .

 Right now you work as executive director at advocate Aurora health and, and they're a large ACO.

Ariadne: So how does that impact also the, the type of work that you're doing as a care manager?

Pat: I think that ACOs early on realized and recognized that care managers were essential to them being [00:05:00] successful because so much of what makes an ACO successful is how do we get the person into the right level of care and make sure that They're getting the care they need and care managers are just really well positioned to do that, that type of work and to help develop those, those workflows that really identify what the patient's needs are for, for their discharge needs and their post acute needs.

And that's, that's something that successful ACOs recognize that they need good. Care transitions and good care management to make sure the patients are getting what they need. Yeah.

Ariadne: Can you walk me through a day and the life at Advocate Aurora?

Pat: Well, it usually starts pretty early. My first meeting today, for example, was at 730 and, we were discussing with our CMOs at several of our, our chief medical officers from several of our hospitals, you know, how to reduce our readmissions, for [00:06:00] example, and what, what strategies we were doing, how we can collaborate more with the medical, Providers and our providers.

So we're making sure the patients. Are safe at home and they get the care they need and how to make those transitions better. So that's like a pretty typical type of start to the day. And then we have a safety huddle every morning. We talk about any readmissions that actually happened or any problems that happened for any patients and even our own problems that our staff members are experiencing.

So we can yeah. As an organization, you know, be always striving to be a safe place to receive care. And what can we do to reduce any risks of harm? And how do we make sure talking about harm is on everybody's mind so we can be proactive in preventing harm. Then after that, in my role, you know, we're dealing with sometimes staff shortages at different nursing homes that we work with and, [00:07:00] you know, what do we, do we need to change our, our flow of patients that go to certain places because of challenges, our Our sites are having, or do we need to rearrange our staffing to help their staffing and then I had an email from one of my team members that basically said two different hospital presidents wanted to talk. May have us do two different presentations on kind of what's happening in our post acute side of the business. So, you know, there's always a demand for more information and more data and more activities to support the mission of, of the ACO, which is to, you know, improve the quality of care patients are getting and to reduce the cost of their care and to increase the positive outcomes for, for the patient.

So there's, there's, it's a lot to unpack every day. And we try to just be in front of it.

Ariadne: Yeah, it seems like a [00:08:00] lot both from, like, a strategic perspective of where can care management plug in to help the overall mission. And then also, you know, from a very direct with patients, right? And which nursing home are you going to be referring them to?

How big is your team? And how has that changed in the years that you've been there?

Pat: Well, when I started we had two of our hospitals had a pretty tight network already, and I was lucky to come into a program that was already established and well recognized and, and had, had good outcomes and, and my leader wanted us to expand to all of the hospitals in our, in our network.

So we have 25 hospitals. About that work with this type of patient. We do have a few children in hospitals that we don't really work with, but for, for our hospitals. They wanted to make sure each hospital had good partners for their subacute [00:09:00] population to go to. So we have a real mix of programs.

I have a provider team, so that means advanced practice nurses that work with our physicians in the. In the skilled centers themselves. So they're physically rounding in those nursing homes and that, you know, they are the day to day face of, of advocate health with those patients and really have been them.

essential to us being successful because they are pretty consistently there. We've had the program for 13 years and some of those APNs have been in those jobs for 13 years, but those nursing homes have had different owners, different directors of nursing, different staff, and, but they're the ones that are consistently there.

So I, I'm most proud of. Our team's longevity and they're, they've had they have high team member engagement [00:10:00] scores there. They love that work and they are very good at it. So we're, we're really lucky to have them find Advocate Health as a great place to work. ,

Ariadne: that's awesome. It sounds like there's real continuity in your team.

How is it that you're normally called in to start engaging with a patient and where are they in the process when you do start engaging with them?

Pat: Sure. So it really starts like for the majority of them, it starts with they have an inpatient hospitalization. We do. I have some patients that come directly from home, but usually they have an inpatient hospitalization and then they need a post acute care and I primarily work with the skilled program, even though our division works with patients where we provide care in the home where advanced practice nurses actually go into the patient's homes as well.

And I work with that team very closely, but my team's primarily responsible for the skilled nursing network and we have a patient that had a medical procedure in the hospital, [00:11:00] or they ended up having a change in condition where they need to have some acute, like some subacute rehab or some additional nursing services that can't be delivered in the home setting, and then they, we know about them from the moment they come into the skilled nursing facility, we work tightly with our SNFs, and we have some tools that They give us the data that tells us that patient arrived at the nursing facility.

They don't always come from our hospital. They could come from any hospital, but they're considered in our ACO by CMS the Center for Medicare Services gives us basically a list and tells us these are the patients you're responsible for. So those are the patients that we really try to make sure we are following when they get to a different level of care.

Ariadne: Yeah, how do you end up tracking them as they go through their care journey?

Pat: Well, we besides our [00:12:00] providers actually seeing the patients on sometimes they see them every day if their needs require that. But usually it's a few times, two to three times a week. Our APN is, you know, actually doing a valuation management visit with the patient in the nursing home.

We also have a nurse that functions overseeing all the patients as they're kind of being shepherded. Did through the skilled nursing home journey and we go to the interdisciplinary team meetings at the nursing home has about the patient's progress. So we discuss every patient every week with that team and make sure that we're planning for a safe discharge home for as many of them as possible.

We really want to get them home in a timely way and that's one of our, our focuses.

Ariadne: It seems really critical to understand kind of the network of resources that you have and all the community resources that can, you know, really help these [00:13:00] patients. How do you stay on top of that? I'm sure it's constantly changing.

You know, as far as the organizations are staffing.

Pat: Yes it is always changing and it's part of sometimes it's good and sometimes it's challenging because we, we have seen a shift in ownership at quite a few of our skilled nursing facilities, for example, but, you know, we try to really have open, transparent communication with all of our, Nursing home providers.

So we kind of know what's going on. I mean, I got a call yesterday from a nursing home owner letting us know that they were going to sell one of their buildings and, you know, they want us in the loop so we can help with, with what's happening going through a sale is. Is challenging for a nursing home.

It means the people working there start to question if they're going to have a job. So sometimes they think, okay, maybe I should leave. And you know there was a lot of transition when there's a change in ownership, so it can be very challenging. [00:14:00] We've seen quite a bit of that in our market area on the last.

You know, four years, I would say it's been pretty constantly changing. The other thing we, we try to do is we really try to have a good network and I try to have a good network personally of who I can approach when I have a question and who I can rely on for up to date information about. Changes in the marketplace.

So not just with skilled nursing facilities, but all the providers that provide services to patients when they are in a home setting too, because that's where we're discharging our patients too. So we want to know about. different home health providers. We do have, you know, we're lucky advocate has one of the largest home health agencies in Illinois and also in Wisconsin, which is our, which is my primary market area.

So they're great to rely on. But then there's also other providers such as people that do [00:15:00] in home, you know, psychiatric services, people that do in home caregiving services. And there's so many, you do want, and I got a text yesterday from a family looking for a dietician that can go to the home that speaks Korean.

It's like, okay, we, we have some resources for you. I had actually three resources I was able to give her. So I think that, you know, there's so many different challenges. You do have to keep up with your networking in order to, to really connect people together.

Ariadne: Transitioning into the other work that you've done building silver connections, which very specifically is about you know, helping seniors connect to the right care for them.

Can you tell me more about the history there and how you decided to start that organization?

Pat: Sure. So I was part of a group it was part of a small group of people that worked the first few years that a place for mom had started their company and had learned it. [00:16:00] About the whole idea of resource and referral and a place for mom.

He had a had an interesting idea. It was, gee, we can have a website. I mean, nobody else had a website 20 years ago. And you know, I. I enjoyed that work very much, but I was more interested in making sure there was a, you know, that it was also a a nursing resource or a social work kind of resource to the component, that it was a professional level person that was.

Helping them and that's where we kind of separated and I, I did start silver connections with the idea that we would be a little bit more personal and local and know more about the, basically the, you know, the Chicago market, which is where, you know, we're, we're primarily located. So we just kind of developed that way.

And then [00:17:00] really wanted to work on providing continuing education to care managers and social workers and nurses. We've expanded a little. We're now doing you know, we've always done like CCM, like, care management CEs, but now we're also doing licensed nursing home administrators as well.

But part of doing our CE program is not just bringing education to the care management community and the case management community, but also helping connect them up with the different Individuals that work in the post acute marketplace, people that are providing different levels of services. We have quite a few different.

There's so many resources that it's hard to really learn about all of them and know about them and and have a relationship with them unless you are exposed To them. Oftentimes when you're working in the [00:18:00] brick and mortar of the hospital as a care manager, you know, you first of all, you really don't have that much luxury of time to be out in the community.

So how can we, you know, do Do events that kind of bring everybody together and help people, you know, share some of their expertise, but also what some of the resources are in the community. And, and we have found a great reception to those activities.

Ariadne: And what type of continuing education are you providing?

Pat: Well, we had an event yesterday and we, we, it was just a three hour event, but we had a seminar done by a psychologist on how to help patients accept help. And we had another presenter was a pharmacist who does in home med reviews for patients. She did a session. We had a session on pain management done by a physiatry APN and a session on by a physician [00:19:00] on how to bring technology into the home.

So. It's just exposing different resources, but also providing it's truly educational content. They're not really set up as sales pitches, but then we also invite different exhibitors to be at the event and they help support the event. And then they're there to share. Some of the services that they're providing in the community.

So we had MD at home and we had several different home health agencies and care management agencies and some assisted living providers and tell telephone providers for people that are hard of hearing. And, you know, it's just amazing, you know, to have our care management participants just.

Being able to see some of the resources that that are out there that can help support patients in the community. Yeah, It

Ariadne: seems like the type of profession that you really need to know both the clinical aspect and also the social and help people navigate [00:20:00] that. What's your advice for people in a relatively early stage of their career that are looking to get into more leadership roles within care management and how would you advise that they try to progress their skills?

Pat: Well, leader leadership is probably a whole nother topic, right? So, I mean, I was, I was lucky in my career that I was. I, I started my career as a recreational therapist and you know, that was many years ago and I, I loved healthcare and I loved helping people, but I also liked having fun. And so it was a good combination for that.

And I really loved being a rec therapist. It is, it is a fabulous profession, but unfortunately the pay scale was never that great. So I did figure out at a young age that if I wanted to improve my skills, I should look into. being a leader because I was probably guaranteed a little higher salary.

And I, I was, it, it, it taught [00:21:00] me some great skills being able to start in the small scale. So I think my first leadership role, I, I supervised two individuals, but I learned quite a bit and mostly by listening to them and they helped me learn how to be a leader. And I think that it's, it's always great if you can take some leadership skills you had in another industry, you know, maybe before you became a nurse, you worked as a young person in a retail store and helped manage the store or whatever, but take those same skills and.

You know, hone in on that because health care needs good leaders. It's, sometimes there's people that love being, being a nurse or being in care management, but they don't want to be in a leadership role. I mean, there's, there's people that really want to do that. So if you want to do that, I encourage you to develop your skills in that arena because [00:22:00] there is a need for good leaders in health care.

And an example is our, I have a wonderful APN manager who really didn't, she, she liked being an APN. She didn't really want to be a leader, but I thought she could be developed into a leader and I hired her and she was a new leader and she had. A challenging first couple of years, because there's a lot to learn about leading people to be a good advanced practice nurse versus being a good advanced practice nurse.

I mean, those are two completely different skill sets. So I, I think, if you, you need to be a little intentional, if you want to become a leader and really plan that in your career and work towards that, take on projects, take on extra responsibilities volunteer to, you know, maybe your, your organization is doing a you know, a drive [00:23:00] for the American Heart Association, you know, and you can get involved as a volunteer leader, do those types of activities because it's You'll gain experience, but also gain exposure to the skills needed to be successful, and that will be attractive if you want to move up in your current role.

Ariadne: What did you find the most challenging about going from being a care manager to a leader of care managers yourself?

Pat: I really like being a leader. I enjoy mentoring staff. I enjoy really having the big picture view of things and putting it all together and. I enjoy everything about being in a leadership role.

So for me, it was again, when I started as a care manager, I wasn't in a leadership role because I was a novice care manager and I couldn't just walk in and say, Oh, well, I directed this department at the psych hospital. So I should be the leader of the care management department that was [00:24:00] never going to fly.

Right. So I think. I just looked for opportunities where I could, I think I, I started by leading the educational committee at our hospital. You know, in our department, we had a pretty big care management department. It was about You know, 30, 30 people. And I, I volunteered to, you know, take on the task of helping to coordinate our educational programs because I have an interest in that already.

And some experience in that already. So they were glad to give me a volunteer job because, you know, sometimes those jobs, nobody is asking for extra work for some of that stuff. So I think that was a really good opportunity and helped me You know, establish my, myself as, as someone that, you know, could be relied on to, to lead the team.

And that's the type of things that are out there for people to, to get involved in.

Ariadne: What do you advise people as they think about the different places [00:25:00] that they could be working in care management? I, I know there's big teams that health plans, of course, in different health systems, a variety of settings.

Really. How do you kind of think about that for yourself and for others?

Pat: Well, I do think care management has tons of opportunities and they just seem to be growing all the time because I think it's become very recognized that we need, we need help with care transitions. It's, it's complex. There's many steps to care transitions and they're happening at, in between all the levels of care and they're high risk and they're high volume.

So. Most organizations recognize they need professionals, nurses, or social workers to help families and patients navigate the health care system. Our health care system has Lots of opportunity to be better . I don't know how to say it any other way. There's plenty of ways that the healthcare [00:26:00] system can fail an individual if they don't have some guidance in, in working with it.

So there is so many different avenues if you're interested in care management to, to work in either in, in acute settings and outpatient settings and even remotely now that there's, there's there's. Plenty of opportunities. So really getting some entry level experience. So you, you may decide, you know, this is the ultimate job that you would love to have.

Maybe you would love to work directly with patients or you would love to work remotely, but you have to kind of figure out how do I get my foot in the door first and, and then work towards what it is that you, you really want. And let people know what it is you're looking for. And it's amazing how much care managers like to help people.

So, if you start talking to other care managers about what you really want, you're probably going to find the job you want.

Ariadne: It's a very giving profession. He talks a little bit about, you know, you [00:27:00] think care managers are really being appreciated because of the role they play in health care and, and also how a lot of the regulation has changed that, you know, you have to keep up with, I guess, what trends are you seeing that excite you for, you know, where care management might be in five or 10 years from now?

Pat: Well, I think that care managers, if I, if I could predict, I think they're really going to end up being positioned as key to healthy transitions for people that really transitional care management is going to become more important and not as. Transactional as it is now more. How do we really get the right setting for this person?

How what is the right level of care for this individual? How do we get them the resources they need? I just think it will evolve to be less transactional and more person centered. We're going to be depending on [00:28:00] data to help us get there. And you know, how do we identify you know, the risk, the high risk points so we can really target our, our work demands of our time are, are increasing and, you know, we need to utilize data to help us get to the right goal.

You know, the crux to the matter and get get the patient to the right setting.

Ariadne: And where do you see yourself personally in, in five to 10 years? What do you hope to be doing?

Pat: Well, I hope I'm still doing more of what I'm doing now. And maybe just for a broader area where our, our health system that I work in now has merged with the health system I work in now is merged with a health system.

We're now one health system that used to be you know, three health systems or more. And so our organization is growing. So I hope to grow along with that [00:29:00] and just do more in, in other areas and maybe take some of my things that I've, I've done for our Illinois and Wisconsin division and help them develop in, in other parts of the country.

So I'm excited that that might be the potential for me down the road. But Hard to say if that those decisions are out of my you know, out of my pay grade. So I'll just be waiting and hoping to give the right information at the right time.

Ariadne: Well, I hope everything comes your way. The last question, which I always like to end on is you know, if you had a magic wand and you could, you know, change one aspect of your work, what would it be?

Pat: Well, I can get pretty philosophical with that, but I think the biggest challenge for is, is our patients having access to the care they need. And, you know, that's something that. You know, we can't always solve with [00:30:00] legislation or money. There's so many barriers to people getting the care they need that, you know, whatever we can do to whittle away at those problems and help people get what they need is, is, is where my heart is and care management is helping people find the solutions and, and kind of helping them get.

The care that they, that they really need to have that, that would be my magic wand thing. I think.

Ariadne: By access, you mean more like the transportation and

Pat: It could be anything that is a barrier. I mean, there's so many things that can be barriers to people. Sometimes it's not knowing where to get the help.

Sometimes it's getting. To the place, like you said, transportation, sometimes it's feeling they can't afford it, or they can't afford it, or maybe it doesn't even exist in their community, what they really need. So there's, there's so many what's interesting about telehealth is it kind of opened up healthcare for some [00:31:00] populations that really didn't have access to healthcare provider and in more rural markets, for example.

So there's access to getting care is, is a big. Issue and sometimes it's that they don't even know that because of health literacy, they don't even know, like, what it is that could help them have a better health outcome. Yeah, it's very complex.

Ariadne: From a personal level and also a community level, right? And, you know, there's not an equal distribution of the types of resources that you would need for every situation.

So that's very challenging. Well, thank you so much for joining us today. It was great. I know we only scratched the surface. I feel like you're a well of knowledge about working in care management, but really appreciate the time. And yeah, thank you again for being with us.

Pat: Thank you.