Utah's Approach to Rural Hospital Financial Sustainability

Hello, everyone. I'm so excited for today. I'm Dr. Diane Hall, Director of CDC's Office of Rural Health, and we're so happy that you took time out of your busy schedules to join us today. It's wonderful to see so many dedicated rural partners and leaders, public health, health care professionals, CDC colleagues, other federal partners joining us today. Thank you so much. This is the launch of our new webinar series, Rural Public Health Success Stories from the Field, and the heart of this series is all about shining a light on the highly impactful, innovative work happening in rural communities across the country and helping rural programs succeed by facilitating peer sharing of real examples and partnerships. I'm very lucky. I get to know about these stories, and they're in my head, and they don't really do anybody a lot of good if they're just in my head, so we're so excited to be kicking this off. In rural public health, we know that the most effective and sustainable solutions aren't designed in a vacuum. They're grown locally, and so this peer sharing is essential. If somebody's figured something out, we want to make sure others know about it. Knowing what other rural communities are doing, how they dealt with barriers, how they're leveraging funding, what worked on the ground, all of that are things that we will be exploring in these webinars, and it's about practical lessons. So today, we're kicking things off with a fantastic example, Utah's approach to rural hospital sustainability. We have an outstanding panel of leaders who are directly involved in this initiative and are here to share their firsthand experiences, but just some quick housekeeping before we begin. So, for accessibility, live closed captioning is available. You can enable it in your Microsoft Teams toolbar by selecting more options and then turn on live captions. We are recording this webinar. After the session, the full recording and key takeaways from our discussion will be posted to the CDC Office of Rural Health website probably within a week. And lastly, we are not monitoring the chat for questions today, so if you have a question that doesn't get covered, please send us an email at ruralhealthatcdc.gov. We have a packed and exciting discussion ahead, so let's just jump in. Please welcome me and join me in welcoming Liz Kreiker, Health Systems Support Coordinator at the Utah Department of Health and Human Services, Dr. Jeremy Lyman, President of Blue Mountain Hospital, and Preston Marks, Chief Strategy and Innovation Officer at Uinta Basin Healthcare. I knew I was going to stumble on that. So, with that, I'd like to turn to each of our presenters to briefly introduce themselves, your organization, and your role in this work. Liz, why don't you get us started? Hi, I'm Liz Kreiker. I'm the Rural Project Manager for this program. I work in the Office of Primary Care and Rural Health with the Utah Department of Health and Human Services, and I'm the Health System Coordinator. Diane, thanks for having me. My name is Jeremy Lyman, President of Blue Mountain Hospital, an 11-bed critical access hospital in Blanding, Utah. I've been at Blue Mountain for just over 15 years and in this role for a little over 10 years, and I'm excited to participate today. Hi, everyone. My name is Preston Marks. I am the Vice President of Strategy and Innovation at Uinta Basin Healthcare. We are a rural, independent, 49-bed CPS hospital in northeastern Utah. We serve just over 60,000 patients across a massive geographic area, not as big as Jeremy's area, but still very large. I'm celebrating my 20th year working at Uinta Basin Healthcare and have seen such tremendous growth despite the challenges that we all face in healthcare. Thank you all so much. Before I jump in, I understand there's some people that are having sound issues. I just switched something. Is that better? Everyone seems to be working fine. Thank you. All right. So, to get started, I want to hear a little bit more about what was going on in Utah at the start of this project and what the project actually was. So, I'd like to start with that broader picture and how things got kicked off. So, Liz, let's start with you. What were you seeing in Utah at the time before this project started? So, we knew that hospitals had access to so much data, but actually putting it into action and gluing it together wasn't happening. So, we did an evaluation with the vendor of each hospital to see where their data silos were so that we could get a ground-level view of where they're starting and where they might need to go. So, that was used with carryover funds from our federal grants, and then we got the CDC funding. Okay, great. So, what was the project specifically? So, one of the things that we found is hospitals get inundated with vendors that give the magic, oh, we're going to find this, we're going to do this, and then they're gone. And we wanted to create a sustainable long-term relationship with a trusted vendor to help hospitals create disease registries, find real-time surgical data to match claims data with payment issues to recoup funding. Jeremy's Hospital was able to recoup a million dollars in one meeting of Medicaid when Medicaid was able to see, oh, we'll just flip the switch and here we are. And out of that has grown a relationship with our team and the Medicaid team, and we have the rural hospitals come in probably, I think it's about once or twice a year to meet with Medicaid with this data, those that have this data to resolve claims issues. So, any money you can recoup more easily is going to keep the hospital open. So, you said one million? One million dollars. That seems very significant to me for a rural hospital. Thank you so much. That gives us a helpful sort of high-level picture of what was happening and the need you were seeing. So, let's shift to Jeremy and Preston. So, could you each describe what your hospital implemented as a part of this project and what you were hoping to improve? So, Preston, we can start with you. Yeah. As Liz said, if her department was skeptical of another vendor, we were very skeptical of another vendor that was going to fix problems that we had. But we, in good faith, decided to partner with this vendor partner, ReadyHealth, and the initiative started, as Liz said, with an analytic assessment, partially to assess what access we had to analytics, but also how our leaders in our organization used data to make decisions. The assessment was super eye-opening. For some of our leaders, their data literacy was very rudimentary. I remember specifically one of our leaders making a comment that the parking lot is full, so the clinic must be busy. And I thought, well, that is analytics at its, you know, highest level. But the assessment also unveiled that we had quite a few leaders who were making, wanting to make data-driven decisions, but spending a tremendous amount of time to collect the data that they needed using spreadsheets that were stored and housed throughout the facility and manually updating those. So, on the bright side, we did discover that our organization really wanted to use data to assist in making decisions, but we needed to see how that might look. So, to prove this theory, we decided to take a look initially at denials management and hone in on just a few of the denial reasons that were contributing to this huge amount of denials that we had. And this took some skillful extraction and coalescing of some of our EMR data, followed by the creation of several workgroups to use the data to promote change. And I'll talk more about that a little later, probably. Great. Jeremy, same question. Yes, I will echo a little bit of what Preston mentioned. You know, we were very skeptical. We've participated in other federally funded programs like this and worked with vendors and experienced, you know, minimal success or minimal benefit. And, you know, going into this, we didn't know, you know, we didn't know what we didn't know. And so, when we started working again with the same vendor, ReadyHealth, for those of you who are not aware, there are vendors out there who are very focused on rural health. And as we got started, we basically went through an exploratory process with ReadyHealth to look into what data we had access to, what data we were struggling to access. And again, as a small rural facility, probably not unlike most, you know, we don't have a team of data analytic people. And we were more or less beholden to the canned reports that our systems offered. But as they started to dive in, and we started to realize the importance of, you know, pulling that data out in real time, we ended up working on quite a few projects, a number of them in the revenue cycle area, you know, from reimbursement analysis. You know, Liz mentioned that we worked with Medicaid a little bit because they had, Utah Medicaid had switched over, made a conversion of the system they used for billing and payments. And, you know, we recognized after that transition that it didn't look like we were being reimbursed correctly, but we didn't have a way of knowing for sure what was happening until we worked with this vendor, pulled the data out, we were able to meet with Medicaid and show them the data, and they realized immediately that something had gone wrong. We quickly recouped over a million dollars from that project. But we, you know, did a number of other projects, medical necessity denials, ER registration denials, a number of, you know, charge master reviews, those types of things, and eventually moved also into, you know, quality improvement projects, and we'll talk more about that later. But our managers who were involved in that process went from being skeptical and really defensive about their time to now being excited about this type of work and really excited about finding out how to pull that data out and make it actionable. Wow. That sounds like that's huge. So, Jeremy, sticking with you, how did having better access to data, but even more importantly, understanding the data and thinking about it more from the organizational level or the systems level versus thinking about it, you know, sort of this is this patient's data, this is this patient's data, how has that changed how your hospital operates? What are you seeing that's different? Yeah. So, you know, one of the projects that we worked on was a surgical site infection project, and before the initiative, you know, Blue Mountain Hospital relied on a largely manual process to identify and track surgical site infections. That process required a significant amount of staff time and depended heavily on manual chart review. It was difficult to ensure consistency, eliminate bias, you know, and know with confidence how we were truly performing. So, through this process, we implemented a more automated data-driven SSI surveillance process, and, you know, everyone from our quality people to our providers were really excited to see the data in real time. You know, so now we've developed a system to pull relevant data from our electronic records, validate the data for accuracy, create a process for identifying potential infections, and really help meet our goal, you know, to improve the reliability and timeliness of our surveillance efforts so we can better understand our performance, identify improvement opportunities, and enhance patient safety. You know, so that just really enhanced what would be our overall goal that we were struggling with prior to that. So, to me, it sounds like you hit the trifecta there. So, improve patient safety, more staff engagement and buy-in, but then also recouping some finances that you would not get. That's fantastic. Absolutely. Fantastic. Preston, same question. So, how did better access to the data, better understanding of the data, change how the hospital operates? Yeah. If a lot of you out there like us, you just invested a truckload of money into an EHR vendor, you know, some years ago and maybe expected that that one investment was going to be the end-all, be-all. And we learned quickly that if data was provided, analytics wasn't. And there's such a difference in being data-rich and analytic-poor, which I think is what we were. With some trusted data that was focused, we were able to make some changes with more precision rather than what we'd done previously, which is throw it against the wall and see what sticks. And there are a lot of unintended consequences as a result of doing some mass changes based off of high-level data. Which is what we've done in the past, speaking of denial specifically. Instead, we were able to dig in more deeply and attack specific denial reasons and hone in on specific areas. And it allowed change to actually happen rather than it being like we're trying to eat that whole elephant at once. And we knew that most issues, or any issue, is rooted in either people, process, or technology, or a combination of the three. And by using the data, we basically created a scoreboard for the group to explain where the issues resided. And in absence of that clear data, we were unfortunately resorting to finger-pointing and typically blaming other departments that were upstream or downstream of us. And one of the things that we did that was so helpful is we brought frontline staff and others involved in the work and allowed them to experience some self-discovery with the data. We surfaced the data and didn't draw conclusions to the data, but let them look and see. And it was pretty amazing with that self-discovery. We all came to the same conclusion about a change that we needed to make, but there was so much more buy-in from those end users and adoption, and it's created a ton of sustainability for us. That is fabulous. I was sitting here thinking that you probably have a lot of people touching these data. And if you've got this sort of fragmented tracking process where everyone's sort of doing their own thing, it would really be hard to have that organizational level view of it. That is really exciting. So Jeremy mentioned how they were also able to do a project around better serving patients. Do you have any examples where that's also the case? Yeah. For us specifically, we did look at some financial measures. And maybe on the surface, you would think that looking at denials doesn't affect the patient, but we've kind of found that rural health is very, very good at providing care, but not necessarily great at the business of healthcare. And as we were able to be more knowledgeable about our billing practices and why things are being denied, the patient outcomes were much improved. And we've identified that a lot of the opportunities still reside in the actual billing process of our organization, not necessarily the clinical care. Thanks. I think that distinction between providing the care and then the business angle of it makes a lot of sense. And thinking about the billing piece is really critical to patients. Hospital bills are not easy to understand all the time. So thank you both. I'd like to bring Liz back into the conversation. And so, Liz, can you speak a bit about how this project helped meet rural needs in Utah and how you've been able to sustain this work over time? You're on mute. There we go. One thing that I've been very pleased to see is that the hospitals, particularly these two who have caught onto the vision of the return on investment and have funded their own work because they're saving so much money. I remember somebody on Jeremy's team saying, I don't have time to do this. And then she said, I don't have time to not do this. For a small hospital to recoup any money is critical. And as you know, hospitals are the hub of their community. They're everything. And it's very interesting in a small community to see hospitals treating their family, treating their friends, treating the community, and they all know each other. And if you can have better data to treat someone, how much better is your treatment going to be and make a real difference in that patient's life, you know, to catch a surgical site infection in real time before the patient goes home, you know, to help with registration errors all the way to claims management because the registration or insurance errors can start right at the front desk, you know, to nobody's fault. It just happens. It's also been neat to see our vendor sit down with the hospital and literally bring out Legos to teach them data. And they sat down elbow to elbow. It was that granular. And that really helped make it successful. And aha moments came. And instead of poking at the data, we started shining the light on the data. Nice. So, I've gotten a sign that we're actually a little bit ahead of schedule. So, I have to ask you, Legos to learn data? Yeah. Can you say more about what that looked like? Or any of you can say more about what that looked like? Our vendor had a picture from the table down. And I could see all these hands and the Legos, you know, and just showing them if we move this, this means this. If then, then this, you know, I mean, it was very granular. Just, you know, a lot of staff in hospitals are from the community, maybe didn't have the opportunity for that learning to no fault of their own. And like Preston said, to see, oh, I see my part in this. Oh, I see where I can make a difference. Oh, I can see how this can change a patient's outcome. That's really incredible. Yeah. I would imagine that's also really helpful for staff to feel like they're part of that bigger picture. Oh, absolutely. Nice. All right. So, all three of you, if you could think about a decision, a partnership, a strategy that made the biggest difference for you, I would love to hear about it. So, Liz, let's, let's stick with you. I went on a road show to visit as many of the hospitals as I could. It was post-COVID. We'd had some staff turnover like everybody else. And we were able to have personal conversations with the staffs and with the vendor to create buy-in and understanding what we were trying to do. It took a minute, as things do, you know, but that vendor and I collaborated and I listened to the hospitals. That's the most important thing. So much funding comes out that sometimes doesn't have the needs of the hospitals exactly targeted. So, I worked really hard to meet the requirements of the grant, but also meet the needs of the hospitals. You don't just spend money and make a contract. You know, you've got to be involved. And that was the funnest part, to be honest with you. These hospitals are amazing. Yeah, they are. So, this sounds, that just sounds really collaborative to me. And it doesn't sound like you were coming in saying, I'm from the state, and I'm going to tell you what you need to do. Because, yeah, that doesn't work. Jeremy, same question. Is there a decision, partnership, or strategy that you feel made the biggest difference to your success with this? Yeah, I mentioned before, you know, that in the past, we've done similar projects. And with most of the vendors we've worked with, we've had some value, you know, I'm not here to disparage any of them. But it's been, you know, here's the engagement, here's what the funding is going to pay for, and then it's over, and they're going to go on. And we may or may not have gotten a whole lot out of it. And certainly, not enough that we would, you know, continue the engagement and just pay for it out of pocket after that. So, when we brought in the vendor this time, I'm grateful for the introduction from the state with this vendor. It was just a night and day difference between the way we were approached from other vendors. You know, these guys sat down with our managers and just spent time asking them questions, getting to know our processes, getting to know our needs, our strengths, our weaknesses, where we were missing out on things. And just continued to dig in more and more. And honestly, you know, it really, I kind of raised my eyebrows, like, what are these guys doing? Like, this is not the typical experience we have had in the past. And when the fruit, you know, when the fruits started being born from all of that, again, we had, you know, our, gratefully, our chief quality officer engaged early on in the process. And some of the other managers who, you know, kind of tried to dodge out on it and weren't that excited about it. You know, she was able to bring them in and say, no, look what we were able to do. Look at these dashboards. Look at the data we're pulling out. Look at the difference it's making. And, you know, she really recruited them to come and engage in the process as well. And so, I have no doubt there are other vendors out there who are focused on rural health. So, I would say, you know, when you have a funding opportunity like this, one of the key, for me, the key decision is, you know, who are you going to work with on this? Who do you, who could be referred to you that has a track record of really caring about your facility? Not just, hey, you know, we're going to get a paycheck out of this. We're going to provide a, you know, similar project that we've done with a bunch of other people and you're going to get some value out of it. But someone who's going to come in and say, no, what are your needs? What makes you different? Where, you know, where can we help you? That's fantastic. So often in rural health, we say one size does not fit all. And what I'm hearing you say about this particular vendor is that they were invested in the outcome and that I don't even know that vendor's the right noun to use. It sounds like they've partnered with you on this and really were invested in helping your facility do the best that you could with the data. That's amazing. Preston, same question. Decision, partnership, or strategy that you feel made the biggest difference to the success for you? Yeah. Maybe I'll share an example that can illustrate this, I think, better than just about any. So we, as we were going through our initial project, we discovered a pretty significant number of denials due to failure to collect a Medicare ABN form from the patient, which probably isn't unique to our facility, people collecting and signing an ABN. And probably in the past, without deeper understanding of data, we would have made a change management plan to really reinforce to our staff, hey, you need to collect ABNs on every patient that doesn't have a diagnosis that meets that need. Well, with the data, we were able to dive into, well, which orders are prompting an ABN all of the time and take that upstream to our providers. And our providers were oblivious to the fact that their patients were on the hook for these orders that they were placing. They thought it was the right care, the right thing to do for the patient, but they didn't know that it wasn't being covered by their insurance. And I will tell you, I mean, my hunch is if you are ordering vitamin D, it's prompting an ABN because there are very few diagnoses that actually cover that. So, and there were many others, but that was one that stuck out to me. And that was the cool thing about that is all of us in our facility, as well as this partner, had it in mind of what's best for the patient. And the best thing for the patient was for the ordering provider to get the right diagnosis attached to that order to avoid the ABN rather than us collecting it and making it on the patient side a burden there. So, I would say investing in people that have some expertise to help surface that data is really the key strategy there. And then having a change management plan for rolling that out because data opens your eyes. It doesn't make the change for you, but it opens your eyes and allows you to then go and make change. Great. Thank you. So, what I'm hearing from all of you is that this did not happen overnight. Liz did not show up with a magic wand and say, I've got the answer right here. This was work. This was an investment. Liz said return on investment. This involved the need for buy-in and staff commitment. And those aren't small things. So, I commend you all. I've been hearing about this work for years. Liz grabbed me at a conference years ago, and she's your biggest champion, biggest cheerleader on this. So, she's just so proud of it. And so am I by distance. So, we do have a little bit of time. So, I promised you I wasn't going to add questions, but I'm going to add a question. Sorry. For each of you, what was your favorite part of this? It could be anything. What did you like best about this? Okay. So, we talk about utilizing data to make decisions a lot. And we do our best to do that. But historically, we've been pretty limited in our access to that data. And really, not just the access to the data, but the way to view it in a meaningful way. And so, for me, I guess the most exciting part of this was being able to say, hey, this thing we've always said we should be doing, and we've done minimally, like we're doing it now in a much bigger way, in a much better way. And it's something that I'm sure larger systems and stuff take for granted because they've got those resources and those teams, and they can do that. But for a small rural facility, where you're pretty limited in those ways, it's really exciting to be able to move the needle on that for us. Liz? It was very awesome to have the opportunity. I was newer in my role. We hadn't been able to travel because of COVID to go and visit the hospitals. You cannot say I've seen one rural hospital, I've seen them all. And then to work with a vendor that was willing to see that, we talked to multiple vendors, and they said, we don't want to take that on, it's too small. It's not enough return on investment for us. And so, to have someone step up and say yes, and we were probably on the phone, the vendor and I, almost every day. Text, call, email, whatever it took. They were traveling, I was traveling. Whatever it took, we were communicating. And that was an extraordinary experience, because I built relationships with this vendor and with the hospitals that I'm really proud of. Great, thank you. Preston? Yeah, what comes to mind is trust. This was a funding opportunity that had a great deal of trust in it. A lot of other opportunities for funding or projects we've had had a very narrow focus and really limited our ability to follow the data to where the problems really resided. And with this initiative, there was trust that we as the local healthcare providers have the best sense of what our communities need. And by giving us some funding, we were empowered to go and make those changes that we needed to make. And yeah, I mean, it sounds very altruistic, but I just regained confidence that you believe in us and that empowered us to go and make change at the grassroots level. So, that was awesome. That is so exciting. I think it's awesome too. So, the word sustainability was in the title. So, I'm going to ask, where's this work today? This is no longer funded by the same federal agency. What does the work look like right now for you? Let's go to Jeremy first. Yeah, thanks for the question. We are continuing to work. I mentioned before that in most cases in the past where we had a similar funding opportunity, the vendor partner would come in and at the conclusion of the terms of the project and the funding, then they would move on and we would move on. And we might look back and remember a little bit from those or gain some value. But in this case, we were able to determine really without question that these projects are paying for themselves, for us. And so, even though the funding ended, we continued the engagement with that partner and continued to start new projects. We're hardwiring the old projects. We're continuing with all of those and finding new ways to hold data, find new ways to create dashboards for our managers to make real-time decisions, utilize data in that way. So, really, this is the first time I would say that is the case, that we've proven that the ROI is there, not just from a financial standpoint, but certainly from an operational efficiency, quality, patient safety standpoint. No question for us, we're continuing to work with the partner and continue this work. That's exciting. Preston? Yeah, I think this really was just a proof point for us that we proved that we could use data to go and make change. And it's really energized us to go and do that. Our biggest challenge is not finding what to do, it's really just honing in on, okay, what do we want to focus on? Because as soon as you see data, you see so many opportunities to improve and to change. And we had to always be honing it in to say, hey, yeah, we see that, we'll tackle that in the next project. But just when your eyes are open through data, you just see opportunities that are there. And it's really wonderful. And then you see a cultural change where staff and leadership begin to see it more holistically, rather than an episodic thing to say, oh, we're seeing a trend here, which is something that we just hadn't done very much before. Great. Liz, did you want to jump in on this one too? So we continue to work with that vendor through FLEX, the Medicare Flexibility Rural Hospital Program. And that's a program that we receive funding from HRSA every year. And what we do it is promote financial and operational sustainability projects, quality improvement projects. So we worked with the vendor through our Utah Hospital Association to do charge masters. So a charge master is aligning prices, basically. And it gave recommendations to the hospitals about what to do with aligning their pricing. It's the first line of defense for a hospital that is struggling. And it can help bring in more money, but you can also analyze it to see what your community can sustain regarding an increase. But we're doing that for several years in a row and getting data on return on investment for that projected return, which is incredible. So I want to make sure I get this right. So you started off with the HRSA FLEX funding, leveraged that for CDC funding, and now you're continuing to use the HRSA FLEX funding, sort of piecing all that together for this. Right. And then I'm watching hospitals like these two finding the value in the return on investment, and it pays for itself. So it was almost like it was an accelerant or a matchstick starting a fire, a good fire. I like that. All right. So fire doesn't actually segue into my second to last question, but so I don't want to seem Pollyanna. I'm sure that a lot of the folks that are listening to this are thinking, okay, yeah, this was once in a lifetime stuff. This was a perfect storm, see not fire, that Utah did this. This isn't doable anywhere else. What advice do you have for somebody who's looking at this and saying, oh my goodness, we should do something like this? So let's start with Liz. You can start small. You can start small. You don't have to conquer the whole world at once. If your claims returns are an issue, work on a portion of that. Start to see the return on investment. You don't need funding from the CDC or the FLEX program to initiate the work. Now I know hospitals do need funding to get things started, but if you had $5,000, you could start something. So don't let that be your blockade to thinking further. Thanks, Liz. Preston. Yeah, I think to really focus in on projects that will derive value for you as an organization because sometimes there are so many things to work on, but if you look at items that will really drive value for you, like Jeremy said, we've transitioned from having funds to sustain this to us funding it because we've found the value in the data and data becomes an investment and an asset for us rather than some novelty that's a bit of a flash in the pan, one-time sort of thing, and we all get excited and then it goes away. Well, now it feels like we have some sustainability because we are funding it now and we're seeing some ROI. That's great. Jeremy. So I guess two pieces of advice. Number one is, you know, find the right partner. I mean, they can bring technology and expertise that you don't have, but you've got to find the right one. You've got to find somebody who is committed to making a difference. And number two is you're going to have to put in the work too, right? So this isn't just, hey, this is paid for, they're just going to come in, they're just going to do it. No, you're going to have to dedicate a significant amount of staff time, you know, leadership time to work with that partner to really help them understand your needs. And again, you may not know what your needs are. Like I said before, we didn't know what we didn't know. So it's not like they showed up and we told them, you know, here's what we need you for. It was more like they showed up and we said, I don't know, what do we need you for? You know, and they didn't know either. So it was exploratory and it took a lot of work. It took a lot of time and continued effort. Now, you know, as we continue with this, you know, we could just take the pieces we've built and right off into the sunset with those, but we recognize the value. So we're continuing to put in that time and effort and, you know, encourage our leaders to do that as well. So what I'm hearing as a theme here is it's an investment and play the long game. This is not going to happen overnight. And just start with something that's going to make the most sense for you. What's going to have the biggest impact of the most value for you. All right. So before we wrap up, I want each of you to share one key takeaway piece that you hope people get from this. And we will put a slide up that includes things that you shared before. Liz? I don't want to quote this exactly, but everybody on this webinar keeps talking about sustainability. So it's value that lasts. So when you get a grant and you can sustain a hospital and the hospital can sustain the work and you can use funding and then other funding and then funding, that's what makes this work. Thank you. Jeremy? So I'm sure there's a broad range of, you know, different types of hospitals that could be taking advantage of this funding from very small. I mean, we're an 11 bed critical access hospital to obviously larger systems and stuff. But I would assume that regardless of your size, you probably have some data blind spots. You probably have some data that you haven't been accessing, haven't been analyzing. And so leverage these funding opportunities. Take it as a challenge to say, hey, we've got this funding right now. We could just sort of squander it and let it go. Or we could decline to even participate. But I would say key takeaway is you can leverage this funding and really help expose those data blind spots and take advantage of those. Thank you. Preston? My words of wisdom sound a bit cliche, I get that. But when we have trusted data made available, an ambitious leader might begin to swing it more like a weapon rather than a tool by enforcing compliance through this newfound accountability that's there. And my lesson learned is that a higher, more sustainable approach is to use the data to build trust and to foster cultural buy-in. And I have to share the experience of Crystal. Crystal was a receptionist that we'd invited to one of our workgroups. And as she had her path of self-discovery of some registration issues that were causing denials, she began to weep. And she said to her tears that I wish I had known that what I was doing was causing problems downstream. And I thought at that moment how tragic it would have been if we had used the data as a weapon against her rather than a tool to help her change and improve. And we've gained so much more cultural buy-in by using it as that tool. It was a really sweet experience. That was lovely. You're getting some hearts. That's a lovely story. So Liz, Jeremy, and Preston, thank you so much for sharing your experiences and the lessons you've learned through this work. This conversation has reinforced how strong partnerships, data-informed decision-making, responding to local needs, and an early focus on sustainability can help strengthen rural health systems. Thanks so much to our partners, Blue Mountain Hospital, Uinta Basin Healthcare, Utah Department of Health and Human Services, and Ready Health. Thank you to everyone who joined us today. We appreciate your time and commitment to improving health in rural communities. We will be reaching out with a link to the webinar recording. We've also dropped a link in the chat with a brief survey to give us some additional feedback. As I mentioned, this is a series. This was our first one. You can visit our website by scanning the QR code or just email us at ruralhealth at cdc.gov if you have any questions. Thank you so much and have a great day.