Good morning, everybody, and welcome to another Patient Safety Movement Foundation webinar. I'm Donna Crosser. I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. And today we're going to be talking about care coordination, most specifically focusing on those coordination activities that need to happen during transitions of care. So we have a lot to talk about today, as you can see by our objectives. We're going to talk about those typical gaps that are experienced during transitions, talk about potential solutions to improve that, identify strategies where we can engage patients and families so they can participate in coordination activities, and evaluate the impact that social disparities have on this, as well as looking at outcomes that we can evaluate to see how you guys are doing. So we, as always, are going to be providing continuing education credit for this webinar, for nurses, pharmacists, and physicians. This continuing education credit will be coming from MedStar Health. So if you have registered as one of these professions and indicated that you are looking for CE, then you should receive a webinar, I'm sorry, an email from MedStar within the next five to seven days with instructions on how you can complete an evaluation and get that information. If you are a respiratory therapist, depending on your state, you may be able to claim nursing credit that you can apply as well. This is an example of what the email will look like from MedStar so that you know what to anticipate. We will also be providing CE for healthcare executives through ACHE, so you can just lock that into your ACHE account, for CPPS and for board certified patient advocates, you'll receive a certificate from the Patient Safety Movement Foundation if you indicated that you are seeking that credit, and if you are a certified professional in healthcare quality looking for credit, then again, your attendance will be documented by NEHQ for that. So as you can see here, none of our speakers or any members of the planning committee have any financial disclosures to report. And so with that, I am so excited to get going and introduce our panelists today. So very quickly, I'm going to just run through who our panelists are and then we are, I'm going to let each of the panelists introduce themselves, but today we have Donna Gadson. She is a mother and a caregiver to her son with chronic illness in the U.K. Mark Williams is a professor and director for the Center for Health Services Research at the University of Kentucky and the Chief Quality Officer at U.K. Health Care. Misha Nair is a consultant and patient safety expert and the Senior Manager of Medical Affairs and Quality at Aster DM Health Care in the UAE. And Marty Moore, a patient safety consultant that's simpler, and he was previously the corporate Chief Nursing Officer at Medline Industries. So welcome to all of our panelists. I'm so excited to have you all here today. And so I'd like to just get started with Donna. Donna, I wonder if you could tell us just a little bit about your background and tell us about the gaps that you've seen in your experience and your coordination with your son. Yes. My name is Donna, obviously. I have a 32-year-old son who I've been a carer for about 12 years. And it's been a challenge. But we're getting there, it's things. So I'm sorry, would you like me to go through my first? Oh, no, no, just just tell us very briefly, you know, what are some of the things that you've experienced with your son and care coordination in the past? Mainly because of his long-term chronic care. That's when we find that sometimes it's difficult with different people coming on board, different teams that don't know. And that's where a lot of, you know, you have to start from the beginning. And that's when we do notice the gaps. Absolutely. Absolutely. Well, welcome to the panel. Thank you so much for joining us. And Mark, I wonder if you could tell us a little bit about your background and some of the gaps you've seen in care coordination in the past. Happy to do that. I think I obviously work as a physician, but I've also had the experience as a patient and also had family members as patients. And something I've witnessed quite frequently is with delivery of instructions to patients, there really often isn't the consideration that's needed of the condition of the patient. Both the personal family member had just had surgery, was literally falling asleep, dropping her head after the surgery as the residual of the anesthesia. And this earnest, friendly, wonderful nurse was providing post-op instructions. And then at the end of it, I asked, oh, did you have any questions? And I was listening intently, and so I knew sort of what was happening with my partner. And I said, no, we're good. I got everything. And then as I was wheeling her out, her comment as we got out, she said, what was that person talking to me about in there? And she totally was oblivious. And then my own personal experience, I had surgery. And I read in the post-op notes and so forth, I'd actually had a physical therapist who'd walked me upstairs and downstairs and said he's ready to go. And I remember seeing this person in the room showing me some kind of stretching exercise. I had no memory whatsoever of walking up and down the stairs. And so I think there's a lot that happens to patients and when they're sick, they're not ready to receive this information and the healthcare providers have to consider that and figure out, do we need to repeat this later when the person's awake? Or in the drugs have gotten out of their system? Or have ensured that there's a family caregiver who understands exactly what needs to happen? Well, Mark, thank you so much for bringing both your personal and your professional perspectives to this panel. We really appreciate you being here today. Misha, I wonder if you could tell us a bit about your background and the gaps you've seen and you're in the UAE, so you bring an international perspective to this. Hope you're on mute, Misha. Yeah. Thank you. So I've been into clinical practice for many years and also on the administrative side. So I would like to bring forward one of the major challenges that is exchange of patient information piece among all stakeholders. And this could include the patients themselves. And at times, you've been seen that patients seek out medical help when they reach to a vulnerable state. And this scenario we've commonly seen in case of migrant workers or maybe for global travelers. And here patients may provide only limited information about their health status or they may not have access to the details. So this has a potential to cause delays in treatment. And this may also call for repeat assessments, diagnostic tests, again, leading to more stress and more financial burden. Then from the provider side, I would like to mention that we've been seeing that there have been a lot of concerns related to handoff communications, more often on medicine reconciliation, lack of resources to coordinate, and also about the follow up care during transition. Wow, it sounds like no matter what country we're in, we're all seem to be having the same challenges. Well, welcome to the panel. Thank you so much for being here today. And then finally, Marty Moore, thank you so much for joining us and tell us your background. And I know that you are very passionate about this topic. You know, Donna, I've been a chief nursing officer for almost 25 years. And so I've been over health systems, magnet hospitals, and then as you shared, I was on the corporate side. And so it's always been a passion of mine. But now it is even more so because it's personal. So way back in early 1990, I was doing barcode medication administration long before people were realizing that it could be done working with the Institute for Safe Medication Practice. And so it's been part of my leadership. But now, now it's personal. And, you know, my father fell in the summer of 2020. And it articulated that he had incredible pain. He was scanned once, said he was fine, said that it was just a demotest ligaments. And there were seven points, seven touch times where he saw a provider. He was in the emergency department. He was hospitalized for severe neck pain. And no one rescanned, even though it was asked. And at the end, because the neck was unstable, he ended up having to have a pretty extensive surgery. And it was the causation of his death. And so, you know, when you're in side health care and you can't get people to listen, we've got problems. We've got problems. Absolutely. Well, you know, again, thank you all so much for being here today. And let's go ahead and get started with our content then. And again, here are all of the members of our panel today. So, but let's go ahead and get started talking about the different support systems in the community. And Donna, I believe that these are your slides. Oh, no, I'm sorry, Nisha, my apologies. My apologies, Nisha. Yeah. Yeah, so let's start talking about the support systems that are available in the community. Thank you, Donna. Yes, I would love to talk on this. So community care coordination systems, you know, they are gaining momentum for promoting prevention and improving health outcomes across. They've been instrumental in connecting individuals to a comprehensive area of health promotion services. And we see that they are coordination methods. They may vary on the objective they wish to support. Some may begin with a population in mind, such as chronic disease management, or supporting developmentally challenged people. Others may begin with some priority in mind, such as homelessness or food insecurity. And yet others we find they may start with some geography in mind. So we have health care organizations. They should come forward and actually collectively agree on the roles of care coordination for each of these sectors. And the partnership should be promoted with examples of how each provider can benefit from the association. So they can envision themselves utilizing the resources available across the community to the advantage of their patient care. We see that many community resources have been supporting logistical coordination. They've been supporting advocacy, identification of personal goals and motivators, as well as education. As health care workers, we can encourage as well as coordinate the participation of patients in these activities and also make them aware of the available resources. Then it's also fascinating to see how technology is beginning to transform care coordination. And it's helping individuals through common caregiving challenges. We see nowadays a lot of systems and apps providing information on health and community resources. They can help address different barriers of engagement, ensure the establishment of sustainable ongoing care plan for the patients. They can also support patient self-management. And one can also coordinate transportation, make appointments and reminders when needed using these resources. So we can move to the next slide, please. So as we see the new technology which is available, it's providing us with a lot of information which is there and people should be taking advantage of it. It's available across now and we can explore all these apps and systems which are available. Next slide, please. So the WHO framework proposes five interdependent strip strategies that need to be adopted for better responding to people's needs throughout their life course. Now each of this technique is meant to have an impact on a variety of levels. Now from how services are offered to individual families and communities to how organizations, care systems and policy making operates. But then the key of success of this framework will depend on various factors. For example, it much largely depends on leadership support, the governance structure we have, the staffing levels we would have, the network and community resources and the partners which are around and the screening tools that we are using, patient communication and do we have a closed loop referral mechanism, the interoperability of the systems that we have. Also a lot depends on quality improvement initiators being taken up and also important as a funding to support. So those establishing the sustainable system based on this framework, it requires a lot of effort from both the healthcare providers and the community at large. But overall if we see the benefits are enormous. For example, it's next slide please. For example, it can offer better coordination of care that fills gaps in the services. It can promote effective communication among providers, social service agencies and it can increase effective utilization of resources. It also promotes quality of care, builds community awareness and perception. It can also support growing your patient loyalty as well as the volumes. And community care coordination can also support reducing duplication of services which is also a major challenge. It can help improve reimbursement and position the hospital for population health for the future. Thank you. Thank you so much, Nisha. Again, it's so interesting how the, we all have the same challenges no matter where we seem to be in the globe. And Marty, I know that you understand what Nisha was talking about from a healthcare systems perspective. But what are some of the patient needs that you're seeing in healthcare systems and how can we restructure them so that we can help patients better? Yeah, you know, it's fascinating because as I was preparing for today's webinar I went out and I Googled coordination of care and I looked at all the images that came up and every single one, every single one had the hospital as the largest image. Some of them had the hospital in the middle. And if you think about it in the lifespan of an individual the time that I've been hospitalized is just a blip.  And so we have to kind of reframe. And so many times we're doing things that are trying to kind of create these bridges. And I call them stereostrips and people have said, well, they're band-aids. You know, they're really and truthfully kind of band-aids except if you think about what is the role of a band-aid it is to heal. And in truth, what we're trying to do by putting in coordinators and navigators is we're trying to bring disparate areas together. And that's why I call them stereostrips. But the issue with stereostrips is they rattle up. And that's what we're also finding. So many hospitals have put in systems and or roles and or programs to try to think about how they bridge in and how they bridge out. But in true fashion of a stereostrip as it starts to roll up that's when the system starts to fall apart. Let me give you an example. Many times we will discharge coming out of the hospital. And by the way, discharge means that I am done with you. If you look at the definition, it says, I'm done. I'm discharging. I have nothing more to do. And that's actually one of the fallacies that we have. But if you look at discharge and you look at then that fact that somebody is being referred into home care what the system doesn't do is to say and what's happening there. We just do this kind of here you go kind of a moment. What we don't know is, is there a coordinated plan of care? Are they even gonna be able to get there within 24 hours most cannot? And then if you think about it and you go upstream and you start to look at, what are these points of intersection that we have designed into our systems such as primary care? Primary care hands over to a hospitalist and there's this discount. Now, the stereostrip that we're putting into that is the EMR, the electronic medical record. We're counting on people looking and understanding. Guess what? They don't. So if you think about and look at from a system standpoint health really is, is not about the hospital and yet our biases bring it in that it is about the hospital. It is about really and truthfully everything that Nisha did a beautiful job of bringing forward. And that's the challenge that we have because as system leaders, as a healthcare leader I will tell you that I lived in the big box and I thought about care coordination from the big box outward. And I think that's a challenge for us and I put in stereostrips. Wow, that is so well said. I love that thought because when I was a hospital administrator, I had the same thing. I thought, you know, the box was at the center.  Yeah, I think, I think we need a revolution, you know and, and I think a little later in the webinar I'm going to talk about maybe doing some design thinking and kind of bringing it out. But the first thing I would encourage people to do is to ask themselves fundamentally what do they believe about health and wellbeing because as a leader, it wasn't until I had to reframe kind of my thinking and then I needed to influence and engage others around wait a minute here, we are a moment. What is our role? What is our scope as a hospital, as a health system? Do we hold people's health and that we are the bearers of it or is it truly their individual health and we're partners? And when you start to uncover that you really do pull back a lot of layers that I think is very beneficial to have conversations about and to make sure that you've got that alignment in your strategic plans and additionally within your executive leadership and all the way through. Good point, good point. So, Donna, I know the UK has been trying this. They've been really working hard to improve care coordination across that entire continuum. So, you know, what has happened, what's been happening over there at the NHS? Oh, right, okay. As with every country in the world, the UK is wanting to improve the quality of service within patient care. If care coordination is not conducted with precision and unity, mistakes can be made that have devastating consequences for the patients. The latest framework to emerge only last month in the UK was in connection with patient safety and it's called the Framework for Involving Patients in Patient Safety. This came about from a review from an advisory group chaired by Don Berwick in 2013 after a spate of serious incidents in one hospital. The result was this, as we can see, a promise to learn, a commitment to act. It's called improving the safety of patients in England. In this review, this is what I'll be talking about. So, what's the connection between this and our topic? It's refreshing for me to sit, read this and that it's been recognised. What you have in the NHS is a unified system of care that is completely capable of identifying its problems, admitting them and acting to correct them. And yet even with a robust, unified system, there are still gaps within that system. The two most important times when care coordination are at their most critical, where problems could occur are during the admission and discharge processes. Both involve movement and information sharing. Both stages have the influence of claiming success or producing difficulties. One thing that's abundantly clear, healthcare professionals do not set out wanting to fail. In fact, completely the opposite. When things do not go according to plan, it is normally down to a chain of events and not just one factor alone. So, let's have a look at some of the reviews recommended for identifying the problems. Next slide, please. The first one, incorrect priorities do damage. Other goals are important, but the central focus must always be on patients. And this is very true. We have all experienced when other factors have made circumstances difficult for staff as well as patients. When responsibilities are diffused, it's not clearly owned. With too many in charge, no one is. How often is work delegated? Sharing the workload is good, but if it's shared without the responsibility, we generally say once you've handed something over, then it's their responsibility, but is it? And fear is toxic to both safety and improvement. How many times are we confronted with frontline staff that are blamed if things do not go according to plan and then again, when they are reluctant to act? For as a family member, it can be difficult to witness when you know that they are a very small cog in a very big wheel. Next slide, please. So, if we look at a brief overview of some of the changes necessary that we've addressed in the UK for these problems. Recognize with clarity and courage the need for wide systemic change. Systemic change also needs conviction, determination and the backing of people using the system, which is all of us. Healthcare professionals are not alone on wanting change. For the benefit of everyone, everyone needs to be involved. Reassert the primacy of working with patients and carers to achieve healthcare goals. So this is regarding the state, the importance of working together. Collaboration is achievable for reducing and removing the gaps within the healthcare goals when both parties are working towards the same goals and recognize that transparency is essential and expect and insist upon it. To demonstrate transparency, it requires two other factors that have a strong association and that is openness and honesty. If all healthcare professionals demonstrate this, it should not only assist in improving, improving the standards of care, but strengthen the working relationship with patients. And lastly, engage, empower and hear patients and carers throughout the entire system and at all times. For me, this is a powerful statement. How difficult would this be to incorporate empowerment with hearing patients and caregivers within your working day? Or even using the same strategy with your peers? Next slide, please. One recommendation that should happen from this, a promise to learn, a commitment to act says, patients should, when they wish, advise leaders and managers by offering their expert advice on how things are going, ways to improve on and how the system works best to meet the needs of the patients. The standard of healthcare has never been better than it is today. However, there is still room for improvement. The complete inclusion of patients in their care decisions is still in its infancy with many people embracing the joint decisions to be made whilst others appear skeptical and resistant to change. This would not be undermining the medical profession, but providing a long-awaited balance that is especially vital in all aspects of care coordination. Thank you. Thank you, Donner. Thank you so much. And it sounds like you guys are doing some great work over there in the UK, but again, everybody in the world is trying to improve on this. So, Mark, I wonder if you could help people to understand how are organizations, how are they able to meaningfully measure how they're doing and why is it that more organizations don't measure this as well as some? Yeah, well, I think a key factor driving a lot of the work around care transitions was the Affordable Care Act and its inclusion of something called the Hospital Readmission Reduction Program, HRRP. And there was an article published with some colleagues, Eric Coleman, who I think everyone knows is a leader in care transitions nationally and was a MacArthur Genius awardee. He focused on this aspect of the hospital is a tiny, tiny part of people's medical care and health throughout their lives. It's what happens in their homes and in the community. But this is what was promoted as a way to try and improve care transitions. And we found in our study that was about almost 20% of Medicare beneficiaries were re-hospitalized. When these threats of penalties started coming out, you can see there's a pretty significant decline in hospital readmission rates for Medicare beneficiaries in the US, but they've been staying pretty stable. And currently about 50% of hospitals are receiving penalties related to the Hospital Readmission Reduction Program. And there's clear recognition now that one of the reasons or a major reason for hospital readmissions is not just the patient's medical condition, it's their home setting, their social determinants of health. Do they have electricity to cool things off in the summer? Gas or electricity to warm things up in the summer? Do they have food? Do they have transportation? Do they feel safe in their homes? Do they have community support? These are the key factors that are driving a lot of it. If you go to the next slide, another key measurement being used in the US is the hospital consumer assessment of healthcare providers and systems. So every patient or a large sample of patients when they're discharged from the hospital or surveyed, CMS collects this data. And again, based on the results, they will penalize hospitals for low scores compared to the rest of the US. And I think it measures some important things. It asks the patients and or their family caregivers if they're filling out the survey, which actually happens quite a bit. Were the nurses and physicians treating you with courtesy and respect? Were they listening carefully to you? Did they explain things to you in a way you could understand? These are all individual questions. And then from the hospital perspective, these patients and their family caregivers are asked, did the hospital take my preferences and those of my family or caregiver into account? And did they, you have a good understanding of the things that you as a patient are responsible for and managing my health? So these are things that are happening right now. One of the things that a collaborative team that literally involve people from across the US from California to Louisiana to Kentucky to Boston to Philadelphia was something called Project Achieve. And the next slide, this was funded by the Patient-Centered Outcome, the Research Institute. Achieve is a little clunky, but we came up with the acronym Achieving Patient-Centered Care and Optimized Health and Care Transitions by evaluating the value of evidence. What we attempted to do was literally study patients and their family caregivers as they went through the hospital discharge process. And we ended up surveying almost 8,000 patients and approximately 3,000 family caregivers. Next slide, it shows you some of our results. And another key aspect of this is we started off by conducting focus groups. It was the largest set of focus groups ever done with patients and their family caregivers related to the hospital discharge process. And the patients and their family caregivers, this is what they told us. They look for certain services and provider behaviors that really achieve what matters most to the patients and the family caregivers. They want the providers to communicate using empathetic language and gestures. In other words, sit down when you talk with the patients. Don't stand up at the door with your hand on the door handle. They say, you know, this is a new experience for me being a hospitalizer. I've only been hospitalized maybe a few times and I don't know what's gonna happen when I leave. You've been taking care of thousands of patients with these issues. You should know what's gonna happen. Make sure you anticipate what are gonna be my needs and help me as I transition to home. They wanna be involved in the discharge planning. They don't wanna be told this is what you need to do. And then if you're gonna provide information, honestly, patients and their family caregivers, they don't really care about the pathophysiology of disease. They wanna know what is the actionable information they need to take care of themselves. And then as was mentioned very clearly by Donner is that they want continuity. They want minimal handoffs or that there's a handoff. They wanna feel that the handoff has actually occurred and they know there's gonna be accountability from both the person who handed off and the recipient of that handoff. Next slide. So these are the things that they said mattered most for a successful transition of care. They wanna feel cared for and cared about by providers. That needs to be, I think, measured a little bit more explicitly. They wanna see that there's unambiguous accountability from the healthcare system. Not that they got sick. They called their primary care provider. There was a voice message, call 911 if you're feeling bad. So they do, they get transferred in. They see somebody they don't know in the emergency department. They then get admitted to the hospital to somebody they don't know. And a lot of times the primary care provider doesn't know what's happened. Maybe there is a scary strip of the EHR, but we found in previous places I've worked that you needed to have that phone call, that accountability to make sure that the hospital providers, whether it's emergency medicine or hospitals, talk to the primary care provider. And I think they need to be involved actually in the discharge process without question. They, the family, caregivers and patients wanna feel prepared, confident and capable of implementing these care plans. And one of the things that has now come out of our research that we have submitted for publication is the importance of trust. If the patients and the family caregivers trust the health system, they actually are less likely to be re-hospitalized from what we could see. So I think this is how we need to figure out how we measure trust among patients. And if it's not there, something needs to be done to establish that trust. Next slide. I think that's it, yeah. Thanks. Well, that's great, Mark. Great, wonderful solutions. And we've got several questions about some of this in the Q&A. So please keep the questions coming. We'll have about 15 minutes at the end to answer some of those. But in the meantime, Marty, Mark's brought up some really great ideas about how we can make those, we can create those solutions and systems. But what's the mental shift that has to happen in order for that change to take place?  That's the bottom line. If your life's work has been in healthcare and you know how to run health systems in hospitals or home care, it's really hard to reframe. But I want to kind of give a model to you. And you know, Mark did a beautiful job. And one of the things they talked about is, is what's trust? And I define trust as an outcome based on actions. And so when you start to think about, okay, what is trust? Trust is an outcome. Well, if there's low trust, then what are the actions? When you start to ask those kinds of questions, it then really kind of uncovers. And you know, the model that I use to help me reframe and to think differently is I personally had the opportunity to be trained in human centered design thinking, we're gonna be sending out information around that. I would tell you, put it into your repertoire of how you approach problems because it opens your eyes to really very different kinds of solutions. But the questions that you've got to ask yourself is do you believe in the three S's? And as you're doing design thinking, if you design the system to fit into its current system, you're gonna get continuously what we're getting. And so you've got to back out and you say, do I fundamentally believe in the three S's? And S one is self-management of health and wellbeing. Do I believe that individuals, those that I serve, those that I walk alongside in my communities are the ones who should self-manage their health and wellbeing? Or do I see it as part of my job and accountability once they land in whatever place they land in? The second S is advocacy of self and others. So when we look at that second S, one of the things that we have to think about is are we willing for people to be advocates? That takes active listening. And as Mark said, empathetic capabilities and empathetic presence. And then the third is, are we willing to blow up our systems to where we can allow and have self-navigation? Now, what does that mean? And that's when it gets fun because that's when you involve individuals outside of healthcare who think wild. They are wicked, wicked wild thinkers. And you encourage them to ask the questions challenge and to say, why can't we do this? And that's when we can fundamentally start on what I call this revolution of how is it that we can create health systems that are safe, that people feel comfortable navigating through. I like it. I like it. I want to be wicked. I want us all to be wicked thinkers. Nisha, any thoughts from your perspective about how we can do that? How can we all be these wicked thinkers and improve that holistic patient care and improve that patient engagement across the continuum? Yeah. Thank you, Donna. So what I would talk would be repeating most of the things what Mark mentioned. I believe for holistic patient care and engagement, the most vital thing is the empathetic hospital culture that values patient care and engagement. And this can thrive only when employees feel empowered and valued. Physicians feel that their patients are getting great care and patients feel that their services and the quality they are receiving are extraordinary. Next slide, please. Now, coming to the specifics, I would like to mention one important component is to focus on patient provider communication during pre- and post-discharge interventions. These would include risk assessments for adverse events or readmissions, medication reconciliation, patient engagement, patient counseling, tagging of red flags, which is so essential, and making disease-specific management strategies. It is also very important that we look into resources for addressing post-discharge issues, you know, especially related to communication when it comes to outpatient services, including the rehabilitation. Enabling skilled staff to aid appropriate follow-up is also going to add a lot of value for care coordination. And this is something very, very important that organizations should look forward to, that we do have skilled staff, that post-discharge, we do take care of our patients for communication. We should take care of reaching out to patients either through telephone calls or through home visit so that, you know, we ensure a safe transition and facilitation of a proper clinical follow-up, wherever it is applicable. And at all levels, I would say that it is very important to ensure that information is transparent and the organization that is providing care is accessible. We need to be available for our patients. And we all would acknowledge that with this pandemic, the digital technology has taken a lot of prominence as a means of enabling patient-provider interactions across the continent. We see more and more healthcare organizations embracing the healthcare technology like telemedicine, teleconcentrations, and all these. Lastly, I would like to add that privatizing quality outcomes and ongoing monitoring is also very, very essential, as Mark mentioned.  Thank you. Thank you so much.  What are some tips and some strategies that you can provide to others that, you know, can help patients and families be more involved in their care transitions? Yes, I have.  And what we found is, I use the same strategies for care transitions as with every aspect of my son's care. And we mainly simplify everything because everything else in his life is so complicated that it's most important that we find the most effective way of dealing with stuff. And these are just four points which, you know, it's going to be a very brief overview, but this is what we use to design for maximum benefit. Greatest advantage of using strategies such as these is that they are easily adapted and they meet individual's needs, you know, and you can change them or add, it depends. So the first one, be honest. And that means with the professionals too. Honestly, it can be a difficult one to achieve, especially if identifying gaps in care coordination needs to be brought to staff or sometimes even the patient's attention. But this should always be a two-way street for communication. To be honest with, you know, both sides need to do this. Alleviate anxiety and fear. These are possibly two of the most negative traits as human beings we possess. Overthinking can occur to the most level-headed of us when we find ourselves in vulnerable situations beyond our control that renders us unable to fully engage. Fear is generally created by the unknown. It's left to build, when it's left to build, it then turns into anxiety and then, you know, complications do set in. But the more you deal with the fears and the anxieties and the triggers that cause them, the less they appear and they do become reduced. So both of these can be crippling to a person and yet they're both able to be managed. And the next one, insight, use it. Oh, sorry, not the next slide, sorry. Insight, use it. The one common factor between many patients and their carers is the experience and knowledge that they have accumulated from the medical conditions, their experience, the treatment that they've received. By information sharing, everyone benefits. And then the last, expect the unexpected or the human factor. Just as it doesn't matter how much planning or goal setting is prepared prior to any form of patients transition, life as a habit of throwing a curveball, no one expects. And this is the human element. And as we are all human, it affects all of us. In times such as this, I find that I just have to pause, I take a step back and breathe. I process the situation and this is usually when I find myself to say expect the unexpected as a patient could deal with these type of situations every day or even several times today. Next slide, please. And finally, I would like to leave you with this statement from the World Health Organization. This demonstrates that the clinical and patient aspect of care are two halves of which we're all responsible for bringing together. The term transition of care is broader than clinical handover because it encompasses the clinical aspects of care transfer and other factors such as views, experiences, and needs of the patient. By embracing patient involvement at every point of the clinical process, this will be one less factor being the cause of breakdowns in care coordinations. And I'd like to thank you. And that's it. Thank you, Donner. I really appreciate you being with us today and all of our panelists. It's time for us now to get to some questions. Before we do that, I just wanna wrap up just a few more housekeeping items just to remind everybody, if you were here in the beginning, you saw this. If you are interested in receiving CME or ACPE credit for this, then it'll come through MedStar Health. And again, respiratory therapists may also qualify for nursing credit for this. You'll receive an email from MedStar if you registered as one of these professionals indicating that you would like to seek the CE. And if you are any of these folks, if you're seeking ACHE, CPPS, BCPA, or CPHQ credit, then if you indicated that, then you'll either receive a certificate from us or you can log it into your system for ACHE or NHQ will take care of it for CPHQ. Here at the Patient Safety Movement, we are so very, very excited to be able to offer these webinars on a monthly basis for free. But we could certainly use your support.  So if you would like to help us to continue to be able to provide this education for you of charge to everybody, then please visit our website at patientsafemovement.org slash donate. We would really appreciate any support that you can provide. So thank you everybody, but we're gonna move ahead onto our Q and A session. And there are lots and lots of questions going on here in the chat. I think one of the big questions that I'm seeing here is related to how do we, well, first of all, here's a great question and maybe Nisha, you can start is, is there anybody that's doing this right? Is there any healthcare system in the world that has successfully figured out how to manage care appropriately across the continuum? Nisha or anybody? If you know the answer, please tell me. Exactly. I don't think there's any organization across the world which is the perfect. There are learning from each one of them, you know? Yeah, yeah. Well, and I think what we've all learned is, there is no healthcare system that is gonna fix this without involving patients and families. But there's a lot of questions in the chat talking about how do we adequately prepare patients and families who don't know how to do this? Mark, I saw that you answered several questions in the chat. You wanna expand on some of those thoughts? You know, I think a key aspect of all of this is that Gabe's getting reputed over and over again is that one, we've got to involve the patients and their family caregivers.  And so look at what's happened now with cars that they don't go in the repair shop nearly as much. And as we are about to make this transition to electric cars, I don't know if anybody's seen this, there was a company in Southern California that bought a whole bunch of electric cars and they thought it would be a novelty. But one of the things that they found it out is that these cars were still running 500,000 miles later and really just needed their windshield wipers and tires replaced. So I envision a time where we begin to design our system so that people get good education and good food as they're growing up and they're taught how to take care of themselves. Instead of this, let's wait for them to get sick. And I remember when we published our original health literacy paper way back in 1995, there was this incredible editorial by a PhD educator. And what he basically said was that trying to deal with this when patients are 65, 70, 75 may be too late and we need to invest in making sure patients know how to read and I completely agreed with them. And I would agree more as I've gone through my career. Unfortunately, we just can't negate the idea that we still need to address these other individuals who are now, they are 75, they're sitting in front of us. But we've got to begin to undertake if you will, some preventive care. And there was the original slide that talked about the different steps and it was mentioned the hospitals in the middle of a lot of these graphs. Well, that diagnosis and treatment steps, those are gargantuan from a financial perspective and it would shrink if we invested more in the education and prevention components. And there's no doubt about that, but this has been, I think one of the difficulties we talked about, all this new technology that's coming out in medications that cost $100,000 a year and so forth. I was gonna also share that at least here in the US and our payer system is many times now jumping over hospitals. So many of our insurance companies have said, listen, we've got to figure out how to help our covered lives, our individuals that we care for to where they self-navigate and they can make the right choices and their advocates for themselves. So remember the three I talked about, we're sitting down in the payers. Now, what's fascinating is is many times health systems are not part of those conversations nor are they part of that plan. And so they're really kind of still over here. And I would encourage you, and I saw one person say, hey, I think health premiums many times are kind of influencers of that. I would sit down with your top payers and let's do a pilot and let's talk about, let's be wicked and ask those questions about how can we can design it? I can tell you one payer is sending food to identified covered lives. They have exercise programs that they're bringing in via the women from Chicago. And there's just so many things that they're doing to really create this health and well-being, this self-navigation. Partner up, I would encourage you for the partner up. I would agree. I would absolutely agree. Donner, there was a question in the chat about whether or not we could use virtual reality to train patients. I wonder if you could give us your perspective on that. And what are some of these technologies that we can use to better train patients to participate? Well, that is a very good question. I mean, with technology and the way it's going. We do have in the UK videos and films that use like a virtual tour around the hospital and what they're actually, you know, will come up against, you know, from entering into the hospital and they work through the process. So yes, that could be something that could be looked into. But yes, it's very interesting because it's not just the health care professionals that need information, it's the patients. And yes, and family members because a lot of people come in and they don't know what to expect.  And, you know, it's very confusing. It's very daunting. So yes, I think we do have a lot of scope there, but it's just actually finding something that is going to be suitable for the wider audience, you know, the higher, bigger patient thing. Yeah, so that's going to be interesting to see where we go from there. Yeah. Well, I think it's, you know, it's really interesting, Donna, because you bring up that different perspective of the patient and I think there's also some thoughts in here in the chat about how healthcare professionals, healthcare clinicians are dealing with patients that may be quite, you know, or patients' family members who may be a little bit aggressive, probably because they are very afraid and they're very overwhelmed. But, you know, Mark, I wonder, Mark, do you have any thoughts about, you know, how do healthcare clinicians who are very overwhelmed in this very complex care setting, trying to do everything they can, how can they better deal with these families that are overwhelmed and may be perceived to be overly aggressive? Yeah, no, no, I saw this pop up a lot of times. This has been a frankly troubling issue that's coming up more and more. In a way, it can be almost even equated to what we're seeing happen on airplane flights where passengers basically lose their sanity. And I think there's a lot more just stress in the world with everything that's going on, certainly with COVID-19. And, you know, when I see family acting out, it just tells me that there's a huge amount of stress that they're experiencing and there hasn't been the resources to begin to address those issues.  And I think if we're able to maybe get this care delivery out of the hospitals and into people's homes, even especially before they're sick, that would be a truly transformative change. I mean, the information on hospital at home, it's staggering. And the thing is, you know, people, Bruce Leff at Johns Hopkins, I mean, he showed this 15 plus 20 years ago. I mean, there was a systematic review 10 years ago that was published showing its effectiveness, shorter length of stays, even though the patients at home, they literally need hospital care for a shorter length of stay, reduced readmissions, huge increases in satisfaction. And so the key factor in a lot of this is that I've been realizing quite well actually, the funds flow has got to go towards better care for the patient that is more, you know, encompassing of the community and not rewarding more surgeries, more procedures, really super expensive pharmaceuticals and so forth. But it's gonna have to be balanced. I mean, there are some expensive procedures that have astonishing life-saving outcomes and we now know that. The issue is we're gonna have to have, and I think Don or had this, we've got to begin to be honest. There's a cost when we decide to pay $100,000 for a medication that has marginal, if any benefit to patients or maybe it benefits one patient and to a thousand that you give it to. And we're then depriving thousands of people of something that we know works. Yeah, that's very, very true. You know, and I think we also have to recognize somebody had asked a question about lean and when a hospital implements lean and everybody is now pulled in so many different directions and so much to do. And I think that's a fairly interesting question because yes, our clinicians are overwhelmed, our patients are overwhelmed, our administrators are overwhelmed, everybody is overwhelmed. That's not the definition of lean, right? Lean isn't supposed to lead to, everybody is too overwhelmed and too busy to do what they need to do. So, you know, any thoughts there about how we can improve that? Or Marty?  And so you've got to step back and say, wait a second here, you know, as we're looking at the principles of lean and we're utilizing that in whatever system we're looking at, this conversation we're talking about care transitions, we have a fundamental system that is strong that we then can move efficiencies out and then we can bring it in. If it's not strong, then you're gonna do stare districts. I mean, that's what you end up doing and that's what I've watched with, and you know, I've done Kaizen Advanced, Malini, I've done tons of them. And we just take a little bit and we bring this and we bring this and we put a stare strip on. But we didn't step back to ask the question of fundamentally is the system strong or what is it that we need to fix here? And then go forward from there. Well said. Well, we are right at the hour now at 8.30 here on the Pacific coast. So, you know, we didn't get to all of the questions in the chat and in the Q&A, but as always, we will download that content. We will confer with our wonderful panelists here today and we will make sure that we post those along with this video, the PowerPoint. And I believe there was a question, Mark, you brought up an idea by Eric Coleman and you can make sure that we post any references that anybody made to here on our YouTube page. So thank you to all of our panelists. Honor, Nisha, Marty, and Mark, it was a pleasure to have you here today. Thank you. Thank you. I'm here for everybody have a wonderful day and we'll see you next time.


I want to share something with you that will help you to continue strong in your walk with God as you face difficult seasons. Many believers aren't aware that the Holy Spirit has a hiding nature. Now when I say that He has a hiding nature, I do not mean that He abandons you. But Jesus said, I will give you another and He will never leave you. The Holy Spirit doesn't abandon you. The Holy Spirit doesn't reject you. Many believers imagine that if they make a mistake that the Holy Spirit flees at the first sign of that mistake. Well you have to ask yourself if you believe that, why would God take from you your only power to be holy as a punishment for you not being holy? That is a performance based legalistic perspective on the Holy Spirit. That is to think of Him in terms of religion and law. And we imagine that our performance determines His presence when it doesn't. Your performance does not determine His presence on your life. But these truths that I want to give you concerning the Holy Spirit and His hiding nature can help you to be established even against the most severe trials in your life. The Holy Spirit does not abandon you. He does not reject you. He does not leave you when you make a mistake. The Holy Spirit abides faithfully with you. He is the indwelling presence of God. The deposit on your life marking you forever indicating that you belong to God. The Holy Spirit abides. And if we understand the hiding nature of the Holy Spirit, again not that He abandons us. But if we can understand the hiding nature of the Holy Spirit then we can have a better grasp on what God is doing in certain seasons of our lives. Because like it or not there are seasons when you feel like God is a million miles away. There are seasons when you feel like nothing is working in your favor. There are seasons when you feel like even the hand of God is against you. As if God has just left you to the attacks of the enemy. Luke chapter 3 verses 20 and 21 say one day when the crowds were being baptized Jesus himself was baptized. As he was praying the heavens opened and the Holy Spirit in bodily form descended on him like a dove. And a voice from heaven said you are my dearly loved son and you bring me great joy. The presence of the Holy Spirit in Scripture is often symbolized in the form of a dove. Symbolized. It doesn't mean the Holy Spirit is a dove. It just means that's one of the symbols of His presence. And as we look at Scripture we see that according to the Bible that doves have various different traits. For example the dove is considered innocent. See Matthew 10.16. The dove is considered pure. See Leviticus 14.22. In Nahum chapter 2 verse 7 we see that it's in the nature of doves to mourn. Grieve not the Holy Spirit. The gentle dove. Yes the Holy Spirit is a gentleman. Of course he'll surprise you. Of course it's his nature to come upon the scene suddenly as we saw in the book of Acts. Of course there is great force behind his power. Of course he is strong. Of course he speaks sternly, firmly and sometimes with righteous indignation. But the Holy Spirit is also gentle. How do you know? Well what's one of the fruits of the Spirit? Gentleness. How can he give gentleness if he doesn't have any? The Holy Spirit is gentle. That doesn't mean he's dull or boring. It just means he's gentle. There's a certain class about him. There's a certain air of royalty about his presence. True moves of the Holy Spirit have a certain elegance and beauty to them. There's a beauty and an elegance to the power of the Holy Spirit. Now let's look at the Holy Spirit's presence briefly in the song of Solomon. I'll show you several things here. The Holy Spirit appears a few times in the song of Solomon symbolically that is. He's the unquenchable fire of God's love for us. You can see that in song of Solomon chapter 8 verses 6 and 7. Of course that is a reference to the symbol of fire. He's the sweet and alluring wind that draws the two lovers together. That's song of Solomon 416. That wind is what fans into flame, that love that we have, that union with Christ. In song of Solomon 2.14 the young man tells the young woman, my dove is hiding behind the rocks, behind an outcrop on the cliff. Now this is not directly talking about the Holy Spirit. Of course because the young man is calling the young woman the dove. But what the Scripture reveals about doves in that verse is that doves have a hiding nature. In Jeremiah chapter 48 verse 28 let me show you something else. Jeremiah 48 28, you people of Moab flee from your towns and live in caves. Hide like doves that nest in the clefts of the rock. So the doves would nest and they would hide. That's in the nature of the dove to do. We see that of course in the Scripture revealed. In the book of Psalms the Israelites were said to have found treasures in plunder. Psalm 68 13, even those who lived among the sheepfolds found treasures. Doves with wings of silver and feathers of gold. So in the symbolism of who the Holy Spirit is we find that one of his traits is that hiding nature. Now what do I mean by that hiding nature? Again I emphasize I am not saying that he leaves you. And if anybody tells you that's what I said they didn't hear the full message. The Holy Spirit abides in you. But that hiding nature is to draw you closer. Now my daughter loves to play hide and seek. When I play that game I have to hide in a certain way that she can find me. Because if I hide too good she will not find me.  She's like I couldn't find you. But I'll have to hide in such a way that I'm still playing the game but she can still see me around the corner or maybe through the door. Now I do not have to abandon my daughter to play hide and seek with her. Now I'm not suggesting that this is a game that we're playing. But I'm simply illustrating the point that God does not have to abandon you to take you to the place of testing. To take you to that place where you do not sense him. Now I'm about to say something that many might misunderstand so I want to make sure that I'm doing a good job communicating it. And I want to make sure I'm saying this correctly. The more you mature in faith the closer you come to Jesus. The less you rely on experience. The less you rely on feelings. The less you rely on miracles. And the more you rely on your trust in his word. See I think much of the church has it backwards. We imagine that if I'm constantly having these encounters and there's nothing wrong with having these encounters. But far too many believers are reliant upon the emotion of those encounters and they panic when they can't feel God in their emotions. They lose their whole sense of identity. Maybe God is trying to teach you what it is to truly have faith. Yes it's good to have encounters with God. We sense his presence here in these meetings. And it's a wonderful thing. I look forward to it. I love when I sense the presence of God in my life. I love when I sense the physical power on my physical being. I love when I see miracles. I love when I can feel him in my emotions. When my being is responding to him and there's nothing wrong with feeling him in your emotions. People often criticize moves of God saying well you're just being emotional. Well did not God create the emotions? Is there any part of our being that wasn't created to respond to God? We don't pursue emotional experience but emotional experience sometimes is the result of having a true encounter with God. People often ask do you want a true encounter with God or do you just want emotion? But that assumes that encounters with God have no emotion. How can you stand in the presence of God and be aware that he's near sense his goodness and his love and not be moved? But still to rely upon that as the test as the measure against which you hold your life and encounters with God the test, the measure against which you hold your spiritual development if I'm not feeling, feeling, feeling I must be doing something wrong. My friend, you don't understand the hiding nature of the Holy Spirit. I'll show you why he hides. Number one, when the Holy Spirit hides and when I say he hides I mean that he's withdrawing the experience in terms of our emotions, our physical being and that human experience. In the spirit we have to learn to encounter him 24-7 but we'll never be able to do that if we're relying upon the outer shells of who we are to indicate to us what's happening in our spirit. Isaiah 45-15 says verily thou art a God that hideeth thyself O God of Israel, the Savior So number one, when the Holy Spirit seems to be hiding from you number one, he's testing you Granted, there are times when you're not going to be able to sense his presence because of sin and because of compromise but that isn't always the case So you have to do self-evaluation You have to examine your heart before God You have to say, like the Psalmist wrote, search me O God Be vulnerable before him Ask him to reveal to you any sin or compromise and if you find none then stop fretting about it because then you fall into the trap of legalism torment yourself saying there must be something I've done wrong somewhere along the lines Well thank God our repentance doesn't necessarily rely upon our memory because if we had to remember every sin and repent of every sin verbally then we would be in trouble because we've probably done so many things wrong we can't remember everything we've done but instead of panicking we realize, okay, if there's no sin, there's no compromise something is happening here I must know what that is Second Chronicles 32-31 Listen to what it says here Watch this now Second Chronicles 32-31 However, when ambassadors arrived from Babylon to ask about the remarkable events that had taken place in the land watch this now God withdrew from Hezekiah in order to test him and to see what was really in his heart There's a great testing that comes in those seasons Great crushing is what produces great anointing There will be seasons in your life where you will feel as though everyone around you has abandoned you I'm not encouraging isolation we as believers are to live in fellowship but there are some seasons when no matter how close others even try to be to you there's just this sense of disconnect where you feel no one really knows you no one really understands you where others criticize your love for God calling you a fanatic saying you've lost your mind saying you're taking it too far and they criticize it because they don't understand it and the enemy lies, tempts, and tries to torment he speaks things and we with the word of God and the shield of faith defeat those lies but still there's this sense of the question God, where are you? if you fail a test you have to take it again I remember there was a season in our ministry where I was so stressed about one of the projects that we were doing and I said to the Lord and this I am not proud of I'm very ashamed to say this but I'm being vulnerable so you can learn from my mistakes and things just weren't happening the way I wanted to see them happening very ambitious I have a lot of drive I'm a perfectionist in some ways and I want to try to do my absolute best and I set these goals and expectations on myself put those on myself and that can be torture and many of you who are like that know what that's like the Holy Spirit has had to help me say why are you putting standards on yourself that I didn't that's what Pharisees do they raise standards God did not and so I remember I came to this place and I said to the Lord again foolishly speaking I said Lord if you don't come through for this I'm just going to have to quit the ministry and you know what the Holy Spirit spoke to me he said then quit and I'll raise somebody else I said no, no, no, no, no, no, no no, no, no, we're good, we're good well this project took me like three years to do I kid you not this one project we were trying to do this was probably I was maybe I want to say 17, 18 years old we're just starting this thing out and by comparison to what we're doing now this was nothing but at that time it was just very difficult and I'm pushing and pushing and pushing and I remember a whole year goes by and I find myself frustrated again and in my foolishness I repeated what I had said and I don't know if this was verbatim with the Holy Spirit spoke word for word but this is the message the idea he dropped in my spirit when I said that out loud the Holy Spirit spoke you just bought yourself another year and I realized I had been failing the test I repented another year goes by still trying to push this through I came to that frustration again and this time I said Lord I know you can do it I surrender, I give it to you and he came through God wants to trust you and when I say trust you he wants to entrust you he wants to entrust you with things to steward think about what he's given you think about how he's raised you so far think about the favor he's put on your life and sometimes we're so focused on then and there that we're not thankful for here and now and if we're not careful when we sense and we feel like God isn't doing anything he's not showing up, he's watching to see how you respond because here's why it's in the testing it's in these moments these seasons that he begins to purify your motives because only someone who is pure in heart will continue to serve God even if they don't get what they wanted out of it lift your hands and say test me Lord test me Lord you write it in the comments section test me Lord you gotta watch out for those tests you ask for God to use you he'll test you before he uses you you ask for God to bless you he will test you before he blesses you and he'll test you and to God it's not a matter of time, what's time to him a decade to us is nothing to God, he'll test you again and again and again and again and some of us are stuck because we just haven't passed the test because every time we hit those seasons where we feel like God is distant we fall apart we start complaining we go back to our old sinful habits we go back to the old nature and the old way of thinking but we start identifying with our struggles and saying things like well I guess God just doesn't love me or I guess just nothing good could ever happen for me and we start to see ourselves as just the one who always struggles and we fall back into these old patterns and because of that we don't strengthen ourselves in the spirit God will bless you but only after he tests you and then when he blesses you he'll test you again because he wants to see what you do when you finally get what you wanted from him think about what Joseph went through he obeyed God and was eventually put in prison for it what do you do when doing the right things seems to put you in the wrong place when having integrity costs you when standing up for what's right costs you do you fall apart and say God what did you do I thought I did what was right now you're supposed to why did you do what was right you see Joseph eventually came to Potiphar's house if I were him I may have looked around well I'm in charge I control wealth this is the dream come true I would have thought it was the fulfillment be careful what happens when God finally does bless you don't lose your awareness of him it's in the testing that motives are purified number two he purifies you the Holy Spirit will go through these seasons where he seems to withdraw his presence remember he abides in you but in terms of your emotions in terms of those physical sensations that we sometimes get in these meetings he'll withdraw in that sense for a season why Hosea 1012 so to yourselves in righteousness reap and mercy break up your follow ground for it is time to seek the Lord till he come and reign righteousness upon you when you sense that distance between you and God what happens you begin to seek him and so when the Holy Spirit begins to pool like this what happens it alerts us and it causes us to realize that something in us needs to be purified something in us needs to be worked on now that's a constant reality which is why the Holy Spirit is constantly leading us to deeper places but when he does this in certain seasons where you feel that distance he's purifying something in you these are difficult places indeed no one wants to talk about this we'd rather hear about the moment of breakthrough or the day of the miracle we're talking about that too but if I don't prepare you with these truths then when you face difficult times some of you may think God abandoned you or I don't feel or sense in fact I found that the closer I've come to him the less I even need those experiences and encounters that we would call feeling God why because I go from experiencing God in just body and emotion to actually just walking with him in spirit and there's this consistency this stability to where you're not going up and down one Sunday you're standing worshiping God praising him and by the next Sunday all I'm defeated again the enemy got me I want to walk with him in such a way that even in the midst of difficult circumstances I have a firm foundation that I'll clean to him even when life throws at me unexpected tragedy and trials not saying God where are you where have you been not allowing myself to get bitter and angry at God for not doing everything exactly like I thought he should be doing to you in those seasons where you feel like he's not there there will be seasons where you're going to feel him close praise God for those there will be seasons where you don't feel him but he's still there praise God for those seasons too so number one he's testing you number two he's purifying you number three he's drawing you closer he is not leaving you he is leading you to deeper places as he walks on ahead he fully expects for you to follow it's like he says follow me come this way he starts walking why are you leaving me the Holy Spirit says come here I want to show you something he walks away and we start panicking wait where are you going my friend when he walks ahead he's not abandoning you he's summoning you to the mountain he's calling you to deeper places Acts 1727 says his purpose was for the nations to seek after God and perhaps feel their way toward him and find him though he is not far from any one of us Jeremiah 2913 says if you look for me wholeheartedly you will find me how many times have you heard someone say well I tried to seek God and I couldn't find him you're a liar you are a liar let God be true and every man a liar you say David that's harsh that's the truth if you say I've tried to seek God with all my heart nothing you're lying either you're lying to me or you're lying to yourself but you're lying because the Bible says that if I look for him wholeheartedly I will find him that's a fact so if I haven't found him yet it just means I haven't looked not truly God's not hiding in the sense that he doesn't want to be discovered he's pulling us in deeper places you know he likes to shake things up he will disrupt things that distract you well just ask Jonah God gives him a command he says go Jonah says no and he goes the opposite direction and what does God do he doesn't just let him get away with it the Bible says that a wind came from the presence of the Lord I believe that was the Holy Spirit and it destroyed and it was destroying the ship God will destroy your means of disobedience God will destroy what you're using to disobey if you're in a relationship you shouldn't be in God will destroy it if you're going somewhere you shouldn't go God will make it to where you can't get there if you're participating in something you shouldn't be participating in God will make you miserable in it God will disrupt now you say God isn't disruptive yes he is I didn't say he's destructive which means he changes your plans without your permission people talk about Jonah and the whale what about Jonah and the wind that is what destroyed any chance he had of stepping outside of the call of God the Lord loves you too much to leave you in your disobedience he loves you too much to leave you to yourself the Lord loves you too much to let you destroy your life you think he's just going to stand by and watch you be distracted and wander aimlessly know my friend when God marks you and calls you there's nothing you can do to get away from that nothing you can do and so sometimes part of that sense of withdrawing because when things go wrong we feel like God's not there so part of that sense of his withdrawing is really just him trying to get our attention and he will do what it takes to get your attention he will do what it takes to cause you to turn back to him there's a reason why you're unsatisfied outside of the call of God there's a reason why you're miserable if you try to go back to the things of this world you're ruined for anything less than his presence he will shake things up he will remove what you're depending on he will remove he will remove what is familiar he will remove what you're relying upon think about some of the things that have happened in the past three years alone how much our world has changed in the past three years there's no going back to normal everyone can feel it something's different now something's different in our world that's not a doomsday prophecy it just is but you know I can't tell you how many believers came to me saying I'm so worried now I don't know what I'm going to do the financial system may collapse I said well what was your faith in and to many of us when we started hearing about financial collapse to many of us it actually revealed that our trust for provision wasn't in God it was in the system and then when that got shaken up we found oh it was God taking care of me all along when we heard about disease when we heard about war when we heard about unrest all of these things caused the heart to become unsettled but when you're unsettled when you're filled with fear let that reveal to you that you're misplaced trust let your fear reveal to you your misplaced trust and so sometimes the Holy Spirit will disrupt things make you uncomfortable it's actually drawing you to deeper places I don't know what I would do if it wasn't for the constant correction of the Holy Spirit now guys as you continue to pursue the call of God on your life as you continue to step into what God has destined for you to do you will face seasons where God seems distant you will face seasons where you wonder if he's near to you and it's tempting to get angry with him it's tempting to become fearful it's tempting to ask a frantic list of questions what did I do is he mad where should I go what is wrong and we fret and we worry and we work ourselves up have peace have peace if you sense the pooling that was drawing he's not saying go away he's saying come up here he's not saying leave me alone he's saying come closer and we begin to see that nothing around us, nothing in this world mattered as much as we thought it did it doesn't matter as much as we thought it did and we step into that perfect walk of faith one day as Jesus was preaching on the shore of the sea of Galilee great crowds pressed in on him to listen to the word of God he noticed two empty boats at the water's edge where the fishermen had left them and were washing their nets stepping into one of the boats Jesus asked Simon its owner to push it out into the water so he sat in the boat and talked the crowds from there now I'm at verse 4 of Luke chapter 5 when he had finished speaking he said to Simon now go out where it is deeper and let down your nets and catch some fish verse 5 master Simon replied we worked hard all last night and didn't catch a thing but if you say so I'll let the nets down again and this time their nets were so full of fish they began to tear a shout for help brought their partners in the other boat and soon both boats were filled with fish and on the verge of sinking what the disciples had attempted to do in their own strength what the disciples had attempted to do by their own power with their own knowledge they were actually able to succeed in with the help of God's power these were fishermen they knew what they were doing they caught nothing it was only after they found the Lord to make use of their boat that their boat was blessed turn to somebody next to you and say blessings on my boat you have to understand the law of stewardship you have to understand the law of stewardship the law of stewardship states that if I do well with what God has already entrusted to me then He will increase my responsibilities now whenever God increases someone God doesn't increase you just for the sake of you or as James says to consume it upon their own lusts I want you to take a moment to think about this you watching online do the same maybe you can even write it in the comments section who would you bless what ministries would you bless who would you help what difference would you make if God suddenly were to triple your resources would you help your struggling parents help an orphanage feed more of the hungry would you go to your pastor and say pastor we can get the building would you help that friend in need who can't buy their groceries would you bless that single mother who can't pay her rent I think you would you online as well I think you would the only step that keeps us from getting there is fear we say things like God if you bless me I'll start giving no my friend God will meet all your needs whether you give or not because you're his child period he's not going to abandon you and no he's not going to curse you if you don't give that's just not true it's not even in the Bible not in the New Testament sense anyway you not giving to this ministry is not going to curse you you can you can leave here without giving a sense I'll still love you Jesus will still love you and you'll still be blessed you'll still be provided for God will still take care of you you know why because he loves you because you are his child


Okay, so let's take apart the standard algorithm for multiplication and see where that comes from and so the standard algorithm is based on three key ideas. First of all, the most fundamental concept is that multiplication is a repeated addition. Second, the properties of whole number multiplication, particularly the associative and commutative properties, and then also the base trade rate, which allows us to write our answer in a standardized form. So as I preliminary to the introduction of the standard algorithm, let's consider the problem 60 times 4. And so, literally read by the definition of multiplication, 60 times 4 is the sum of 64s. However, we also note that because multiplication is commutative, 60 times 4 is the same as 4 times 60, so 64s is going to be the same as 460s. And the reason that that interchange is useful is that I don't really know at this point how to add 64s together short of just adding them together, and that's a lot of things add together, but I can add 460s a lot more easily as follows. I'll use the place value chart and I'll set down the factor that I'll be adding repeatedly. So I'm adding 460s, so I want to start my place value chart by showing a 60. So here I have, here's my ones, here's my tens, 60 is 6 tens, 0 ones. Now I want four of each of these, so I'm going to take four 6s in the tens. And because the trade rate is 10 for 1, I really shouldn't write down this number, but rather I should write down what it's going to be once I simplify everything. So I will bundle sets of 10, that's a 20 and a 4, and then I'll trade that 20 at my trade rate of 10 for 1 for 2 in the next place over. So there's four 6s, it's going to be two in this column, hundreds, four tens. And I also want four of the zeros, because again I'm going to take four of everything, and four zeros is after a bunch of thought, zero, and all together arithmetic is bookkeeping. So what we want to do is we want to keep track of how many of each unit that we have. So here I have two hundreds, four tens, zero ones. So I'll just go ahead and write those down, and so that tells me that 60 times 4 is the same as 4 times 60, is two hundreds, four tens, and zero, 240 in standard x terms. Well, the reason that that example is important is let's consider the product 67 times 4. So again by definition 67 times 4 is the sum of 67 4s. And I could do the same thing I did the last time, convert it into the commutative product 4 times 67, and find the sum of 4, 67s, but I'm going to need to do the multiplication as it is, because there's a limited number of times I can do that commutativity usefully. So I want to view this as the sum of, well, let's see, that's 67 4s. Well, 67 4s is the same as 64s together with 7 4s. So let's go ahead and write that down. So again what I have is I'll set down 4 in my place value chart, and I want 64s, and I just figured out what 64s is. That's 240, so that's 240, and again I'll bundle. There's my set of 10, and trade at 10 for 1, I'll bundle, set of 10, and trade at 10 for 1, and there's my 64s. I also need 7 4s, and that's going to be 28. And again I should bundle and trade, and so there's my 64s, my 7 4s, and so again arithmetic is bookkeeping, so I want to determine how many of each unit I have. So here I have 200s, I have 6 10s, and I have 8 1s. And my product then is going to be 67 x 4, 200s, 6 10s, 8 1s, 268.


Hi everyone, Joe for jaskiescasebrakes.com doing a quick random number block randomizer for Diamond Icon's Baseball 23 for the following teams. Works just like this, you get a block of numbers basically, it's a serial number break inside the Pick Your Team break. Thank you to this group here for making this happen. There are the numbers here, let's roll it, let's randomize it. Five into three, eight times for names and numbers, one, two, three, four, five, six, seven, and eighth and final time, five into three. Got Sean down to Brittany, five into three, eight times for the numbers, one, two, three, four, five, six, seven, and eighth and final time, after eight, six, down to eight. All right, Sean with six, PJ with four and one, Sean O has zero, so remember zero gets any and all redemption for those teams in that tab right down there, including one of one redemptions, PJ you'll still get live one of ones, Brittany with five, Darry with seven, PJ with three and two, Darry with nine, and Britt with eight. Let's sort this by column B and coming up in a separate video will be that diamond icon to ask these case breaks.com.


What's up everybody, Jason here for Jagsby's Case Breaks.com. We just sold out 2022 Flawless Collegiate Football One Box Break Picketing number two with this R&B that features the Patriots, Falcons, Packers, Jags, Bucks, Bills, Cardinals. And again, you get a piece of all of these teams. If they do hit, we deliver the hits out to the customers by random number block. You get a number of signs, zero through nine. There's your examples there. Any one-ones go to spot one, any and all redemptions, if there is any, go to spot zero. Now, of course, if there's any non-numbered cards, which is unlikely, it'll be randomized to the group, but I don't think I have to worry about that too much here. So, here's the dice roller. Let's click dice roll. Let's roll. It's a one out of five, six times. Good luck. Here we go. One, two, three, four, five and six. No? Six? Come on. Is it on? Come on. It's still loading, guys. Wow. There it is. Six. Now, we have a number man down to Chad. Now, we have six times, one, two, three, four, five, six. Six times, zero down to eight. All right, so Adam with zero, Kenny with one, Donald with three, Chad with five, Stephen Kendrick with four. Steve Lockwood. How'd you get nine again? Man, round of the orchards. Chad with six, Donald with two, Adam with seven, and Chad with eight. So there you go, folks. You never know what numbers pop out of here. Break coming up next. Good luck, everybody.


Another 10 reasons to move to Moodle 2. This presentation is the third in a sequence of three presentations, so be sure to check out the first two. The Moodle 2.0 contained a significant number of compelling new features, and Moodle 2.1 also pushed a feature list to improve the platform. Between the Moodle 2.0 now has a large range of feature improvements over Moodle 1.9. So which are the top 10? Join me in this road of exploration through some of the Moodle 2.0 features. So what can you say about the Moodle navigation block? Well, it raw. The navigation is personalized, so it relates to you and your permission. The new navigation block of Moodle provides easy access in one place to all other users' courses and topics within those courses. So if you're doing a program where you have six different modules, you can drum from the content in one module to another using a new navigation with just one page load directly where you want to go. This is going to be a huge time saver for students and lecturers alike. The settings block is a great centralization of all the setting-related data. Now what do I mean? Well, if you're in a course, it will provide access to the course settings that you have permission for. If you're in a forum, it provides access to the forum settings that you have permission for. This standardization of where settings appear for an activity or a course or a user saves a lot of time for existing Moodle users once you have got used to it. And for new users, it just makes sense and works. The new HTML editor is the Bees Needs. It's now this industry standard tiny MCE, and it seems to be in every web application nowadays. It's more standard-proof and more usable than other whizzy-wig editors. The deep integration in the new repository features makes life easier. The one thing I like the most is a resizable editing area, which is Ace. Overall, this is just much easier to use. The new theme options and support are just great, providing excellent browser detection. It also provides the ability to better support mobile devices. So you can have a specific normal theme for the web and a different one for mobile devices. The 20-year-old themes, which ship with Moodle 2, provide a diverse choice of styles, and most of them also come with some extra settings, so you can customize them through the backend interface. The new activity completion recording is really useful. Course creators are now able to specify if a resource or an activity should be tracked for completion or not. And if so, how is this to be completed? Should it be done automatic through a grade, or through being accessed or viewed, or by enabling the student to tick the activity as complete when they're done with it? There's also a great course report to provide an overview of the status of completion for all students.  You can register your site to the hub and then choose to share the course either as a download or just marketing its availability so that if someone wants to enroll on it, they know where to go. There is a global Moodle community hub called Mooch on hub.moodle.org, and you can also set up your own local or private hubs should you wish, such as in the school districts or on a campus between faculties. Hubs are also very useful for storing course templates, or even just isolated configured activities in Moodle that you might want to reuse sometime. After a student has completed some work in Moodle, it will be nice to be able to extract that effort and Moodle to provide this feature with a new portfolio API. A user can elect to publish or save items from Moodle to other places, either their desktop through downloading or by exporting to Google Docs, Mahara, box.net, Flickr or Picasso. The export supports multiple formats and certainly brings the usefulness of having Moodle and Mahara to a new exciting level. Enrollment controls and courses are now very powerful. You can simply select which of the enrollment plugins are enabled easily and configure them to work as you want them to. If you want to have self-enrollment now captured in number of users, that's fine. Just set a value. If you want guest access treated in another way, well, then you can do that too. For managing groups of users, you can also now set a cohort enrollment. The feedback activity in Moodle 2 now provides you an easy way to create custom surveys. When creating the feedback survey, you can select from a good range of question types and layout options. It is very easy to configure and you can simply reuse the form in multiple courses. Managing roles and capabilities in Moodle 2 is much simpler than in Moodle 1.9. There's a new improved interface which provides a better overview of roles and abilities. The administrator role is now isolated so that it's a much more of a decision in assigning admin powers to a user. There's also a new manager role which sits between the teacher and admin sort of. You will just need to try that. So that was it. Another 10 reasons to move to Moodle 2. This presentation was the third in the sequence of three presentations. Be sure to check the other two out. Also, be sure to check out on my blog somerandomthoughts.com for information on the poll to decide which are the 10 top reasons to move to Moodle 2. Thank you.