Wound Care: an Emerging Career Path Drawing Physicians from Various Specialities with John Sory, President of Vohra Wound Physicians: Audio automatically transcribed by Sonix

Wound Care: an Emerging Career Path Drawing Physicians from Various Specialities with John Sory, President of Vohra Wound Physicians: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Saul Marquez:
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Saul Marquez:
Welcome back to the Outcomes Rocket everyone, Saul Marquez here. Today, I have the privilege of hosting the excellent John Sory. He joined a Vohra Wound Physicians in March 2018 after nearly twenty-five years of hands health care management. Today, he is responsible for the management of Vohra’s core operations and key strategic initiatives. Prior to joining Vohra, Mr. Story helped lead the University of Miami Health System as the Chief Executive UHealth Regional Alliance with responsibility for affiliations and expansion, health plan relationships, new reimbursement models, and population health operations. In his time with UHealth, he led the organization’s entry into population health and the transformational steps from fee for service to value-based health delivery. He expanded the health system through affiliations with physician groups, ACOs, employers, pharmacies, and foreign governments. Prior to joining the university, Mr. Sory was the Executive Vice President and Chief Development Officer for E Research Technology, a leader in clinical research services and electronic patient-reported outcomes. He was responsible for leading the company’s efforts to diversify internationally and expand with clinical research and health care services. He previously led Pfizer Health Solutions and really has just done an extraordinary job overall in population health programs in the US and in Europe today. He’s focused on this work at Vohra Wound Physicians, and I’m excited to learn more as well as to share with everybody listening today. So, John, thank you so much for joining us today.

John Sory:
Thank you, Saul. A pleasure to be with you.

Saul Marquez:
Absolutely. Absolutely. So before we dive into Vohra and the work that you guys do there, talk to us a little bit about what inspires your work in health care.

John Sory:
I would probably say it’s four things and it developed over time. I got into health care, some of the things you find an opportunity and then you stay with it. And I think over the twenty-five years, what I’ve discovered is, first of all, I’d say it’s professional. The well-educated, intellectually curious, committed people that you’re working with every day is is itself rewarding. I think. Secondly, it’s intensely personal. We all interact with the health care system. We all care deeply about it. We care about our own health and families, friends join any group. Health care is going to be a topic, the main topic of conversation. Third, I’d say it’s highly politicized, for better or worse, partly because it’s at the heart of who we are as a country. Our approach to it is a constant conversation. Every election is a form of it is being discussed how to refine and improve, adjust, partly because it consumes so much of the economy that it’s near and dear to so many hearts. That’s without COVID, that’s with any situation that’s happening. And then I think finally, its very nature is passionate people who are involved in health care, they come to work every day. And I’d say I do. And the people I work with every day come to work feeling passionate about what they do, especially because they’re making a difference and they can see it and feel it. I don’t know. There are a lot of great jobs out there, but I think in health care, we feel it in those four ways in particular, and it really resonates with me. And it’s kept me excited for over twenty-five years doing this. I’d say it’s it inspires.

John Sory:
That’s fantastic. And then you’ve done some amazing work in your career, made a big impact at the IDN system level, even for industry. So I’m intrigued by the work you’re doing at Vohra Wound Physicians and sort of the opportunity that is at the center of that. So tell us a little bit about the work you guys do and help us learn more about the value you guys are offering to the ecosystem.

Saul Marquez:
Great. So I had the pleasure of working in a variety of areas in health care and I honestly was not even that aware of one care specifically. So I’d say when talk about adding value, first is, is it an area worth focusing on or value to be had? And then the second is, do we add value by a better approach to it? So I wouldn’t share what is it? I mean, it’s we’re primarily talking about seniors. When I say wound care, we’re talking about seniors residing in nursing homes, suffering from pressure ulcers, diabetic wounds, venous in arterial wounds which are related to circulatory issues, all of which are growing in number. But two percent of the US population, nearly 15 percent of Medicare beneficiaries have chronic wounds. So this is a large area and it’s expensive, I might say. Well, why is it growing? What is it? It’s connected to the aging of the population, connected to megatrends like obesity, the rise of diabetes. I look at some of what’s happening out there, see diabetes, for example, diabetic foot ulcers. What does that? I think the estimate is about 13 percent of diabetics have foot ulcers. And these are related to all these same factors, which are connected to circulatory problems and hypertension as one and a half percent of the population pressure ulcers large. As I mentioned, there are these post-surgical rooms.

John Sory:
It’s larger than I realized. It’s growing and it’s in need of work. In other words, what is the way to take care of it so we come back to many of these folks with chronic wounds are in nursing homes, how are they treated? And the way that it’s historically been treated has been a patient or a resident of a nursing home, is put into a vehicle and taken to a wound care clinic or a hospital for their wound to be treated. And this really gets to the genesis of the practice. And the practice started with Dr. Vohra going being part of Wound Care Clinic, which is affiliated with the hospital and seeing a patient on one day of one week. Then they go back to the nursing home. There’s no influence over what the care is in that nursing home. So when he sees the patient again a week later, there may be no improvement. Or nobody is educated on exactly how to take care of a complex wound. So it started as well then let me go out to the nursing home and see the patient where they are. So all of a sudden, we had to not just transporting somebody to a hospital-based clinic, which by its nature is very expensive, but also you have somebody who is an expert teaching the staff of the nursing home how to take care of the patient for the next six days because we typically once a week to make certain that that person has the care that they need.

John Sory:
So you avoid the infection risk, the risk of fall, the hospital-based costs that are so great, educate the wound care team, which has ongoing benefits. So as these numbers and the prevalence of wounds rise, you want to make sure that they’re treated where they are. And increasingly, we’re seeing the trend of people being treated at home. And if you’re a nursing home patient, your home is the nursing home. You’re a resident there. So many of our patients, about 70 percent of our encounters are with patients who are nurses or residents of those homes and will be for a long period of time. So I think that’s really the growing need for wound care. And then a model that says, how do I do it more efficiently with a model that is keeping you out of the hospital, with people who will be learning from you, the doctors, so they know what to do when you’re not there. It’s really helpful for continuity of care. It’s helpful for the ongoing benefit for the next time that one sees a patient. So that’s how we feel about what we think of the benefits sort of in summary form, I’d say.

Saul Marquez:
Yeah. Now, that’s really interesting, John. And I’ve heard some stats around these sports certified wound care nurses. Sounds like the bulk of them, a good 90 percent are actually working inside of the hospital. And at the side of care is about 10 percent. And so how do you get this care delivered more efficiently is, I think, what you guys are doing. Right?

John Sory:
Exactly. I mean, so part of it is if the experts are in the hospital, then personally the patients have to go to the hospitals are wonderful for the care they provide. In other words, it’s in this day and age we saw how critical it is to have a hospital. But you want to be in the right place of care for the services that you need. And I think driving a lot of what we talk about is accessibility. And how do you make certain that a patient needing the care has somebody who’s accessible to them? So our doctor is going to bedside as opposed to, again, so many have to go to the doctor. It’s a new model. It’s something entirely different. So we go to the patient in much the same way. We’ll also this is a bit of digitization of health care and the changes that we see, which is the telemedicine option. In other words, let’s say somebody shows up in the nursing home and they have a wound that it’s on a Thursday and we don’t really round there till Monday, they can reach out to us and say, what should we do with this patient? Do a video image.

John Sory:
We’ll see the patient take us to the next three days. This is what you should do. We’ll give that advice so we don’t lose time. And also, very importantly, the person gets the care that they need. So we will use the benefit of technology to make sure that there’s even more access. And I would add one more way, which is we can take that same patient who is discharged from a hospital, from a nursing home, from a long-term care facility of any type. And we can have telemedicine into the home working with the caregiver, the home health nurse, to make sure that they’re taken care of as well. So its accessibility is a real driver of value. And it’s one that says it’s not just one place of care that’s meaningful in the health care ecosystem. How do we support it all? And once you’re expert in a certain area, in this case, especially wound care, we have the ability to try to make certain that we’re available when people need the services that are specialists can provide.

Saul Marquez:
Yeah, that’s super interesting. And so it’s really it’s an access play. It’s using technology. Right. And also just bringing the skills necessary to the bedside instead of the other way around. So give us an example, John. Give us an example of what you guys are doing is improving outcomes or bettering business models within health care?

Saul Marquez:
Well, I guess this is an outcome show. Right. So I guess what I would say is what’s the tale of the tape for us? We did a study a couple of years ago, which is to prove out that our model was was effective. And so what are the key endpoints? That number one is the reduction in the overall cost of care, which is almost twenty thousand dollars per patient, driven in part by an eight percent reduction in hospitalizations, faster healing times by almost twenty-one days, reduce loss of limb. So think of it, not to mention the improved quality of life, not having to go somewhere to be taken care of. She’s put all those factors together and all of a sudden you have positive outcomes. And I think those outcomes, they do speak for themselves, but they come from just the fact that you have somebody who has gone through year’s worth of training in a specialty to make certain that the decisions they’re making not only are the right ones for the patient, but they’re so consistently that is course the therapy needs to be adjusted. They can provide just that adjustment. And this is a field of health care where it’s incredibly fragmented and there are no clear clinical protocols.

John Sory:
Partly it’s because as a subspecialty, it’s not widely recognized. So therefore, when you have well-trained physicians and a team that work together, they can develop those protocols and make certain that you have positive outcomes. We train the nurses that we work with. We have room care nurses in the three thousand or so facilities that we go to every week. We offer them wound care education, we do in services. We make certain that they see why we choose what we did. In fact, just this past weekend, we had a nurse conference, three or four nurses who were you seeing patients with wounds. And we went through list of twenty-five different cases. What would be the decisions you would make in these cases when you see a patient presenting with this kind of a wound? The point is it’s not just relying upon the doctor, it’s reliant upon a whole team. That team-based approach is meaningful. So we see it as, yes, educating the team, being a leader, treating a wound care team around the patient. And it’s a team-based care. I think those are some examples.

Saul Marquez:
And the numbers are clear. I mean, you guys are certainly improving outcomes in a big way. So who are you guys working with mainly. You partnering with the provider organizations, the payer organizations as well? What’s the make-up there?

John Sory:
Well, we’re largely in nursing homes there, about fifteen thousand two hundred nursing homes, and we’re at about three thousand of those. We operate now in twenty-eight states. So there are plenty more nursing homes that we can work with. We also go into assisted living facilities increasingly about twenty-nine thousand assisted living facilities. Now they’ll have lower acuity. So you’re not likely to see the same kind of patients that live in an assisted living facility. But as you know, as people age, they might migrate toward a higher form of care, more intense support. We go into long-term acute care facilities, which might have rehab like work. We go in there. We increasingly are taking care of patients via telemedicine in the home. And that’s not just a COVID result in that patients are staying at home. It’s also a function of the fact that we have the technology to connect. And there are about seven million patients with wounds at home today. It’s going to grow to almost 10 million in the next five years. When will we see that as a need? And we also see that caregivers don’t necessarily know how to take care of a loved one with a large pressure wound on the sacrum, which is very common. And by the way, what do you watch out for? If you give a wound, you might also like that of a heal. Wounds heal because the pressure that you’re on and the pressure wounds are they’re dangerous? Yeah, it can be really difficult to live with. And one reason that I keep an eye on it is what is it that they need? What kind of support kind of dressings are appropriate and a bed supportive. So we work together to try to make sure that there’s somebody that we can work with to help extend that physician and the care even further beyond the time that we’re there.

Saul Marquez:
That’s fantastic. And so for the home care, as you well know, Right., I mean, that’s a big thing right now. And care in the home is something that many are exploring. How does that relationship work? Is that more social contract through an insurance plan, managing a population?

John Sory:
So any and all of the above? I guess so. We’ve worked very closely with some large health plans. And whether it’s Medicaid or Medicare, there have been some that if you think about this value model I mentioned, which is trying to keep patients out of the hospital, it speaks directly to a health care initiatives and health plans have created over the years have been to drive better care, but also to the care that is coordinated in such a way is that they don’t need to knock on the emergency room door. And it’s not hospitals are not good places. Emergency rooms are good places for complex chronic needs. But the rise of care coordination and chronic disease management programs which have been inspired by payers like commercial payers, that it’s really to make certain that wherever they’re aging and wherever they’re where trying to improve their health, they’re doing it in the right environment. So, yeah. So the big Medicare Advantage plans, in particular, are our customers. We have hundreds of Medicare Advantage contracts. We’re seeing the rise of different groups that even inside of nursing homes, you have these institutional special needs plans, the isness that developed that are really trying to make sure that they can take a group of patients inside a nursing home and manage all their care and keep the cost down. And just like Medicare Advantage, you can keep the cost down for the federal government, Medicare. So. An ISTEP keep the cost up to the federal government much the same way, a capitated rate per day, and they work that out. So we’re seeing a lot of growth in that area and have some wonderful relationships because, again, we’re on the same side of the value curve as these kinds of organizations are trying to keep, the right kind of specialty care in their network so they can see better care at lower cost.

Saul Marquez:
Yeah. Now, that’s fantastic. Thank you for sharing that, John. And really meaningful work. And I love how honed in you are on the total available market and just crystal clear about what the opportunity is, what your share is within it. It’s always for me and I know for the listeners as well, inspiring to talk to a leader that knows the business that they’re in. And it’s certain that you do. And obviously that’s what it takes to have success with the outcomes. And so talk to us about setbacks. You know, I feel like we learn more as leaders from setbacks than our successes. Maybe tell us about one and maybe a challenge or a setback and what you gained out of that’s made you guys even better.

John Sory:
Well, so the practice has been around for 20 years. So to get to this point, after over 20 years, there are a lot of experiences, many, many before I join the practice. I mean, it’s the reality that how do you work through a new model of care? Of course, I can say that the biggest first challenge that comes to my mind when we talk about this is inertia. I hate to say that, but you know that that it’s very hard to change a system that’s been routinized for a long period of time. So what does that mean? It’s when I see a wound like this, I put them in a vehicle and I transport them elsewhere. So let’s say you don’t need to go elsewhere. You can go right here. You can stay where you are and work together with us. And so that idea of changing the model of care was the first big challenge. I say to what do we learn from that? Is the outcome speak? You have to say, just let you meet the doctor. Let me show you what we’ve done, let me show you the outcomes, and let’s walk through the process. I’d say we learned from that that people fight this fragmented health care system and ask what are ways that we can simplify. And so having a doctor kind of simplifying. But the other is we have multiple people coming in here and saying we’ll provide the dressings.

John Sory:
For example, the doctor says this is what the patient needs. How does it get to the patient? How does that dressing what do you put on that wound after you’ve treated it? What do they need for the next two weeks or thirty days? And what we found was and this sounds so horrible that we would recommend something and somebody would come in afterward and seemingly change the order. In other words, say, well, maybe they need this and they double sort of doublethink what the physician was recommending that they put in behind us. That is not the care model that we’re looking for. In other words, I don’t think anybody wants that. So we said, OK, well, we’ll just set up a process where we can just order directly on behalf of the patient for the dressings that they need to take care of their patients. So it was trying to, again, eliminate fragmentation because that was hurting communications. It was sort of the delivery of care. It was we thought it was affecting our outcomes. So we then just took it upon ourselves to create a side service, if you will, that many of our facilities have taken up, taking advantage of. So I think I guess the third one that comes to mind that on the fragmentation side is how to communicate what happens. So we have a little over a million encounters per year. So that’s a patient with a physician.

John Sory:
It’s substantial. The question is, how does what the doctor, how does it get in the hands of the nurse? As much as we talk about electronic medical records and integration of systems, unfortunately, it doesn’t always work so easily. In other words, our mess, our physician goes up to a portal where a nurse pulls it down and it sends it to the medical record in their system. But that is somewhat of a time-consuming process. And as nice as it is, it almost feels almost like fax. So we’ve done is we’ve now integrated with the largest EMR provider in the long-term care space to make certain that our note can seamlessly move right into the medical record and save everybody a whole lot of time. It also helps us in the front end to register that patient and get all the information, demographics, and increasingly medical history. So now we can move more quickly. But it took us a while to get there. So we felt the bumps and bruises of not having as unified a system as we all aspire to. I said those are some learnings and then all of which have sort of have a good, good endpoint now. Certainly, the ones that where we stepped their toes over the years, just as we try to learn how to do it. But those are the ones I think now that feel the most powerful in terms of the alleged is something good.

Saul Marquez:
That’s a great message. Right. And there are so many examples of communication breakdown that leads to gaps in care and then the EMR integration. I mean, I love the focus that you guys say, hey, you know, we’re not on the major EMR platform or not synced. Let’s make it happen. You did. And I’m sure that that has shown major improvement in overall outcomes. You know, the other thing that comes to mind, John, is so I appreciate you saying that is this concept of, OK, you know, you take care of something at the point of care. But then what happens between that and the next visit is a lot of times what connects the dots and ensures for the best outcomes. How do you guys deal with that continuity?

John Sory:
So it’s a great question. And I’m just a departure of an engineer, a primary care doctor seeing a diabetic, and you give them the advice on what to do. And you see them a month later and you wonder why their hemoglobin’s is worse than ever. They didn’t take the advice, right? I didn’t write about healthcare’s behavior as well. In our case, these are pretty typically elderly, somewhat disabled in bed. So the question is not so much what behaviors they can do because they’re sort of a controlled environment. The question really, I think it comes down to who is who’s involved in the process of care during the next six days, which is why I talked so much about a wound care team. We educate the wound care nurse. If it’s home. We try to make sure that we have programs that the home health nurse can learn. Again, we believe that home health aides, home health nurses, will be a big part of the future. So we have an education platform just for that. Those are the primary ways that we work every quarter with our corporate accounts. We have the quarterly service reviews. How are we doing? Are we communicating how we would consider reaching out, making sure that the communication between the physician and team is working? So this is like a 360 review that we increasingly do.

John Sory:
And then what I also would say is if anybody is listening from a long-term care facility, they will tell you that a large number of folks working in long-term care experienced great turnover. It’s a very, very tough environment. I mean, it’s people working in nursing homes are working on the side of angels. I mean, if you really think about how tough that that is to people who think that it’s challenging and you’ve got to get to really love the care about passion in health care. But there is a lot of turnovers. So often we find ourselves as the point of continuity we see in services and consistently educating to make sure that whoever the next group is is knowledgeable. So we might have a history with the patient the newest nurse doesn’t have. We can train and educate them. It’s also bringing somebody up to speed who is new to us and even new to the facility. That’s what we see.

Saul Marquez:
Some great takeaways, John. And again, just distinguishing how the practices that you guys have made you special and unique. And obviously, the reasons why you guys have been able to be around for 20 years and evolve in the way that you have. You know, you talk about the care and the numbers. What excites you most today, John?

John Sory:
Well, maybe you can sense it. I mean, I do think that we’re on the right set. And there was this is where health care is going. This is exactly what we did. I was I have had the benefit of being in population management and chronic disease management. I worked for Pfizer for a number of years, which in the news a lot these days. But these guys are making each in their own way, make a huge impact on people’s lives and on the health care community. I feel that this area, what we do with the rise, the aging of the population, the rise of that portion of the population, the fact that we can keep quality of life better for longer, that there is demand for our work because it is so good. And I will tell you, it’s superior here than it is anywhere in the world. So we have opportunities to share some of what we’ve learned elsewhere, which I think is gives us just that sense of having made a difference. And I think at the end of the day, the people in our organization feel that they are making a difference and that when we hire physicians, one point that really resonates with many that we talk about is they can see the impact of their actions.

John Sory:
The words you can physically invert, you can visually see the as the wound heals and when you can see what you’re doing and see the impact of it, you know, you’re a part of that. It’s very rewarding. And I think that’s what drives a lot. So there’s opportunity ahead. We’re still, which is still relatively small in a growing market. We’re seeing that even with what’s happened in the last year with COVID, what have you, that the people have not been going into nursing homes at the same rates as before. Occupancy rates have been declining in part because it was concern over what would happen. We’re seeing that turn around now. I mean, for folks to get vaccines for covid, we’re nursing homes. So some people are saying it may soon be the safest place in America to be because they’ll be so well vaccinated. So we’ll supported it. So we’ll see that upturn again and we’re continuing to grow. And that’s very rewarding. So we like what we do.

Saul Marquez:
That’s fantastic. John, your passion is palpable and just kind of considering your experience and kind of what you’ve done, what you did with the university, and expanding these programs internationally. I mean, the care that you provide, I mean, it’s without borders. So this is something that could be meaningful across the globe and is certainly exciting to hear and see the work that you guys are making such a difference with. This has been fun. I’ve truly enjoyed spending time with you and I’m sure the listeners have to. So, John, give us a closing thought and then tell the listeners that are interested in learning more where they could get in touch with you.

John Sory:
First, if there are physicians who are listening. If this sounds interesting, know, we like I said, we’re growing. We’re in twenty-eight states. Maybe if you’re one of the communities where we’re looking for support, I can tell you that we have a sense of urgency as there is demand. And we’d love to talk to you. We can talk about primarily surgeons, say a general surgery or surgical subspecialty, the family medicine. Internal medicine is the primary areas. But we have covered many different specialty groups that join our practice. So if you’re interested, that’s one thing. The second is if anybody has a family member in a nursing home, go see them. I mean, it’s a very I’ve been into a number of nursing homes and it’s the place where you make sure you take a few minutes to see and give some care to the person that’s there. And the third is that so much of our health is somewhat controllable. You know, they talk about how much is connected to genetics and how much is connected to the environment and how much it’s connected to behaviors. If you don’t take care of yourself, you might find yourself suffering from somewhat would have been avoidable causes long term. And some of the drivers we talk about are things like obesity or other chronic diseases that if you act now, maybe you won’t you won’t suffer from those.

John Sory:
But we see the effect of that many years later. And I just encourage us all to be mindful, know we have a chance to think hard about it. And it just feels like we see in the stuff that comes back to haunt people. And I would be remiss if I didn’t think that we all have a sense of responsibility to ourselves and to our family to take care of ourselves and try to make sure others do the same. Maybe that’s not my place to say, but I guess it feels to me like when you see it. But it’s like it feels important if you do have a family member who’s going into a nursing home, there are some high-quality ones out there. We’ve actually identified some as we’ll call it, wound care centers of excellence, which are very, very good at taking care of patients with wounds. I encourage you to look for those kinds of nursing homes for those that you’re treating or taking care of. And I think that we’re we’re on a good trajectory in terms of being really, really wise with what we need to do to take better care of people all across the health care continuum. So I’m very positive, optimistic that way.

Saul Marquez:
John, thank you. Some great closing thoughts there and certainly great message, I think well in line. I mean, we all have that power to make the decisions that are going to make us healthy, those behavior, those health, those lifestyle choices that ultimately matter. So appreciate you calling that out. And also, if you do have somebody in a nursing home, by all means, you know, just visit them, take care of them. I think John’s message just is awesome. It’s spot on with all of us. And so, John, I just want to say thank you. And it’s Vohrawoundcare.com. Anywhere else that you would suggest the listeners reach out to you guys?

John Sory:
Well, if this resonates with anybody, you can always email me. My initial jsory@vohraphysicians.com.

Saul Marquez:
0utstanding. And we’ll leave that in the show notes for everyone, including the links to their website. And certainly looking forward to seeing how you guys evolve. John And we appreciate all the insights you’ve shared today.

John Sory:
Very well. Thank you, Saul. So I really appreciate the invitation, the opportunity.

Saul Marquez:
My pleasure.

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