Webinar: Innovation in End-of-Life Care

Executive Director Michael Skaggs interviews Zac Willette, Lead Facilitator for Allay Care Services. A transcript of this webinar is available below and the slides seen within are available here.

Michael Skaggs:            Thank you everyone for joining us again for the first webinar here in 2019. We are very excited to have Zac Willette from Ascension joining us today. And I always mispronounce the name of the organization you’re representing. So, say it for me.

Zac Willette:                Allay. 

Michael Skaggs:            Allay. Okay, I want to say it like ally and elay and I know I’m going to butcher it, so Allay. Zac is joining us from Ascension in Allay Care Services. Zack is also involved in the Chaplaincy Innovation Lab as well, one of our project leaders. He just contributes so much to us in terms of thought leadership, so we’re so excited to have not only his participation in the lab but his time here today. So, Zac, I will let you take it from here because I know you have quite a bit to tell us about Allay. 

Zac Willette:                Yeah. Good afternoon or good morning everyone. It’s a pleasure to be with you. I was telling Michael that at Ascension we have a tradition of beginning every meeting with a reflection. Sometimes it’s a prayer, sometimes it’s a poem, sometimes it’s an image and just in silence. I thought because Mary Oliver passed away just recently, it might be great to just start with some of her words. I’m yet to meet a chaplain who doesn’t at least tolerate Mary Oliver if not outright adore her. And I was sharing with Micheal that I had the privilege of meeting her a couple of years ago and it was momentous occasion for me. Okay, so let’s settle ourselves in, and here are some words from the late Mary Oliver. 

                                    “When death comes like the hungry bear in autumn. When death comes and takes all of the bright coins from his purse to buy me, and snaps the purse shut. When death comes like the measle-pox. When death comes like an iceberg between the shoulder blades. I want to step through the door full of curiosity wondering, what is it going to be like, that cottage of darkness? When it is over, I want to say all my life I was a bride married to amazement. I was the bridegroom taking the world into my arms. When it’s over, I don’t want to wonder if I’ve made of my something particular and real. I don’t want to find myself sighing and frightened or full of argument. I don’t want to end up simply having visited this world.”

                                    I believe this is from her book, New and Selected Poems, published in 1992. It’s called When Death Comes. As chaplains we are there when people find themselves sighing, or frightened, of full of argument. Or we are there when they find themselves, as I believe Mary must have been, in amazement, ready to step through the door with curiosity. 

                                    A quick overview of what I thought would be good for us to spend our time with today, big part of it is going to be questions and answers at the end. But, Why innovate end of life? Why is it end of life that we innovated? What makes Allay unique besides our challenging to pronounce name, which by the way we are adding this week a little pronunciation guide to our website. We debated about 117 alternative names that we considered, this is the one we’re sticking with for reasons we can go to if you’re curious at the Q&A. What do our services cost i.e. how do we generate revenue? As you saw on the description, we are a not-for-profit but we are a revenue generating entity for a not-for-profit. So, that’s a big reason we exist, I was going into it just a little bit. 

                                    How might you innovate? I recognize that you didn’t just come on to this call to hear about the innovation that we’re doing but perhaps you got some ideas for yourself, so I’ve got a couple of lessons learnt to share. And then some time for Q&A and Micheal tells me you can type in the questions at any time. It might be mildly distracting to me but I’ll persevere and he will coordinate them and share them. He said also he’ll interrupt me, if there’s any time I need to be interrupted. 

Michael Skaggs:            Well, and you don’t need to be interrupted now, but I’m going to. I’m going to do so anyway, and that is the fact that I don’t want us to look at your point number three here, what our services cost and how we generate revenue? I really don’t want that to be a negative part of our conversation because I think this is something that every chaplain has to be aware of no matter what setting they find themselves in because these services, they represent a cost to somebody, whether it is an end client like with Allay, if it’s a system, if it’s an employer. They represent a cost somewhere and even though so much of what chaplains do is really so emotive and interpersonal, it comes at a cost. And if we don’t get a grip on that resource question, chaplaincy is not sustainable in the long-run. 

                                    So, I just want to set the stage that way and I’ll get out of your way. 

Zac Willette:                Yeah. As long as we’re on that, I don’t have this later so I’ll say it now, so in my role before this role, innovating by starting Allay, I oversaw spiritual care for all of Ascension. And one of the things that I was aware of was because Ascension is a Catholic health system, or a non-profit healthcare system that draws on the Catholic traditions, we have absolutely a floor for spiritual care. We will never go below this because we’re so committed, it’s so integral to our mission. But because, as Micheal waws saying, chaplaincy is not a revenue generating part of the hospital, there’s also a bit of a ceiling. We can’t really go beyond that. 

                                    And so this effort is a little bit of a way to break through that ceiling and say, “If you decision makers in healthcare can see that spiritual care is not just a cost center but actually can be a revenue center, even if we’re not yet budget neutral, Right? Paying for ourselves or generating revenue as Allay will be. Even if we’re not yet there, at least if we could move towards neutral, we’re giving ourselves a little bit of space.” And I think that space allows for creativity and it allows us to do what we know needs to be done. So, yeah, thanks for that little soapbox moment here. Should we dive back in? 

                                    All right. So, why end of life? Sorry, I realized I had a slide before that and the slides aren’t advancing. There we go. I just wanted to clarify the relationship between Ascension and Allay. Ascension is the largest non-for-profit group operating 24 different states, about 150,000 associates, 2400 or so sites of care, maybe it’s more than that. Sorry if I don’t have my statistics right. And Allay care services is an innovation project powered by Ascension. It was designed by an Ascension chaplain, me, to fulfill Ascension’s mission and expand Ascension’s impact while at the same time generating new revenue in the process. 

                                    So, all Allay associates, right now there is just me, are Ascension associates, and all of Allay’s revenue is Ascension’s revenue. But just to put a sharp point on how innovation goes, if Allay fails to generate revenue, we will close up shop. So, a little grounding on the reality of high stakes is a phrase every now and then. But let’s go back and see, where did this whole notion come from? Why are we innovating at end of life? 

                                    And so, I have a story. I don’t have that much screens to pull up so give me one moment. Sorry about that, I thought I had that worked out. Yeah, this one’s going to tell you a little bit about why is it that we chose this particular way of being. Interesting, the document I’m looking for is not where I thought it was. Thanks for bearing with us, folks. 

Michael Skaggs:            Technology always works until it actually has to and then it doesn’t. 

Zac Willette:                Mm-hmm (affirmative). It’s true. Let me try one other way. 

Michael Skaggs:            While Zac is looking I’ll just reiterate. We typically wait until the end to do any sort of of Q&A, but if you want to type your questions into the box, you can do it now. It’ll store them all. It will keep them all, so if you something comes to mind and you don’t want to forget, just put it in there and we’ll keep it in there and we’ll get to it in the end. 

Zac Willette:                All right. Thanks for your patience. I found the document that I needed to have. We just moved offices and my printer doesn’t work, so I have this story on a piece of paper. We’re going to have it on the screen instead. So, this is the story, the why we are innovating at The end of life. It comes from when I was a full-time chaplain at Rush University Medical Center in Chicago, Illinois. Both rooms that night were on the same ICU in one, the families exhaustion was a heavy cloak they couldn’t take off. It made their movements slow and their anger quick. They wanted to do the right thing and so did the frustrated doctors and frazzled nurses, but no one knew what the right thing was. 

                                    The patient had never said anything about his wishes or even what made his life meaningful in the first place. The same kind of ventilator rattled and the second room but was outdone by some Sam Cooke albums on repeat. This family had the same sadness as the first room but right next to their heavy exhaustion was a quiet kind of joy. She said, “This time would come. He told me.” She told us what to do and she told us why we had to do it. “I’m going to miss her with every bone in my body but we’re going to send her on wrapped in love.” 

                                    Both patients died that night, well loved and well cared for. As chaplains that I had the privilege of holding hands in both rooms, hearing stories in both rooms, handing out Kleenex and terrible hospital coffee and cups of cold water in both rooms. We signed the same paper work and discussed the same practicalities, but I noticed that the walk to the elevator was not the same for these two families. “Did we do the right thing?” Was etched on the face of the first family. They knew there were more tough decisions to come. 

                                    The second family had different questions, “What do we do with here tomato plants? That’s basically the only thing she didn’t tell us.” One of the hardest things that I saw when I was a full-time chaplain was also one of the most preventable. Families wracked with guilt because they didn’t know what to do for someone who suddenly or sometimes not so suddenly couldn’t speak for themselves.

                                    We launched Allay to prevent that. We listened to people, young, healthy, old, sick or anywhere in between. And we helped them name not just their wishes, medical wishes, logistical wishes, personal wishes, but also the values behind those wishes. Because sometimes wishes can’t be honored, but values always can. The people that we have served so far tell us it is making a difference for them and for their loved ones. It turns out that even just talking about the reality of our someday death helps us to live this day more alive, more present, and more at peace. 

                                    That’s the long and the short of why and now we have to change screens again to this one. See if I can make this work, thanks for bearing with me. Here we go, slideshow, good, so now you’re able to see that. So, you might be able to tell from that story that Allay is both the head and the heart. We really believe in combining all of these things and that’s not the only both end that we endorse. We’re interested in what someones wishes are and what’s the why behind those wishes. We’re interested in the person, the person who we’re serving, the person who we are helping them name their wishes for end of life and for their care after they’ve died. But also for their people, we don’t believe in just treating people in isolation but really let’s look at the bigger picture, the system that they’re in again. This comes from my work as chaplains. 

                                    We’re interested in the living that happens at the end of life as well as the details that begin with death. One person campaigned so far to start a new three letter acronym of DBD, details that begin with death, so far it’s going very slowly. And then what else we’re interested in, the way we plan stuff and the way that it actually happens. As chaplains, you know it doesn’t always happen the way you think it’s going to. And that’s one more reason why it’s so important to know the why. 

                                    I like to clarify right from the beginning, there are some things that Allay’s services don’t cover. So, we don’t cover wills. We don’t cover financial planning. We don’t cover estates or heirlooms, but we absolutely ask people if they have covered those things on their own. And if not we encourage them without any particular… when they prefer all of the recommendations that we say, that’s really important. We’ve seen how having those things taken care of can really reduce stress for your loved ones at this point of your life. 

                                    These next statistics you I’m sure have seen before, 90% of people say that talking with their loved ones about end of life care is important. This is from the Conversation Project in 2013. 27% have actually done so. 82% of people say it’s actually important to put their wishes in writing, 23 have actually done so. This from the California Health Foundation in 2012.

                                    So, what Allay dos is we give people the opportunity and the ability to have these conversations. Because it turns out that just having opportunity is not enough, just having the ability is not enough. Which we’ve heard from a lot of them,  our clients, who were like, “I tried. I tried to have the conversation, just didn’t go anywhere. Or it fell apart because of X, Y or Z reason.” So, that why facilitated conversations, a board certified chaplain or a licensed social worker is the person who’s going to facilitate your conversation to give you both the opportunity and the ability. 

                                    When we know what people want personally and medically at the end of life, two really important evidence-based goals can be accomplished. These two aren’t always combined and we think it’s worth noting them for that reason. The first is to reduce human suffering, the anxiety, both for the client and for their loved ones. And the second, and this is what tends to get the attention of healthcare systems, is to right-size the end of life costs. Most people, not everybody, but most people want less aggressive care than they end up getting. Some people want the aggressive care, some people want more aggressive care, but in the aggregate, enough people want less aggressive care that it can lead to some really important savings especially at end of life. 

                                    So, we also see that what we do is to help people see that death is not a medical event but a natural part of life that can be discussed in a genuine and honest way. So, we think about those 90% of people who say it’s important to do this but haven’t yet, 68% of them haven’t yet done it. We’re interested in helping them. We’re actually interested in helping everybody name their values, name their wishes and then have the conversation actually with their loved ones. 

                                    So, let me go into a little bit of what makes Allay unique. Our guided conversations that we facilitate and the process that we have has been developed from years of experience on the front line in hospital ICUs, trauma centers, and the ER, as well as palliative care, hospice and grief support. Our facilitators are master’s-level educated board certified chaplains and licensed social workers at the top of their field, in my humble opinion. It’s a little immodest to say that when we’re one of the two facilitators but that’s what we’re going for and we help people articulate their own values,  of course never imposing our own. I’m talking to chaplains, you know that already but for everyone else, it’s important for them to hear that. 

                                    We are, as you know, expert at listening for “What’s the question behind the question or the comment behind the comment.” That’s a little bit about our process in our facilitators. Let me give you some high level stuff. As I’ve said we go beyond just the medical, to integrate the personal and logistical aspects so that we really have a holistic and interconnected conversation. Again, not just about how you want to live at the end of your life but what happens after you die, right now our continuity of care falls off a cliff the moment someone dies and we don’t think it has to be that way. 

                                    Our process builds in time to reflect between conversations and prompts that reflection with custom educational materials. And from the beginning, the client’s wishes and preferences are documented in their own words to create a fully customized portfolio. We really think that using the actually person’s words matter. We’ve had some of the children of some of our clients say, “Oh my gosh, I can totally hear mom. That’s exactly how mom talks. I love that you got the exact wording.” 

                                    Other important things, each client, and this is a really radical idea, each client chooses family members or other loved ones, often their healthcare agent to join the conversation, both to hear the decision straight from the horse’s mouth, so to speak, and, when applicable, to help them make that decision. Let me tell you, if nothing else is accomplished through Allay’s work, we are radically increasing the number of really excellent health care agents. We’ve all been there in the hospital is like, “I don’t know. They never told me what they want.” Or “I can’t think in this moment because I didn’t think this was going to happen.” And with Allay, with this process, the healthcare agent was like, “Well, I was there when mom said she wanted this.” Or, “I was there when dad and I decided that the best thing for him was going to be X, Y or Z.” 

                                    Travel is not an issue, as all conversation can be done via phone or video conference. And everything happens at the client’s preferred pace, whether it’s complete in two weeks, two months, it can even be over two years. We put their relationship with it front and center. 

                                    So, what is the actually package? What is a person getting when they buy our services? They’re getting three sessions that involve three hours of focus conversation and supportive educational materials that we don’t overwhelm them with. We have a process for learning what they want to learn about and then we give them that information when they request it. It ends up with a customized CareDecisions Portfolio that’s written in their own words as well as all the official forms that their medical team will need. It’s delivered digitally so they can have it as a PDF and share it with whomever they want and then we also deliver print ones on request. 

                                    We have served a number of millennials who are like, “Oh my gosh, do not send me anything in the mail. I don’t want anymore stuff.” And we’ve also served a lot of boomers who are like, “You’re going to give me a hard copy, right?” So it’s really interesting to see generational differences. 

                                    I won’t read these all to you but I just want you to have a little flavor of what actually ends up in the CareDecisions portfolio. I got permission from these three people to share these little quotes of what their own words look like. You’ll see it covers a lot of different bases. I do have slide coming up on what we actually covered so you can see that but I’ll just take a brief moment so you can read that. I mentioned millennials, often when end of life they automatically think people who are a certain age or older, that certain age is not a young number. It’s usually, “Well, once your 70 you should be thinking about this.” 

                                    Well, we made a point of searching out in our pilot phase people who are in their 30s and providing a service to them when they reach you. This next quote is from a woman named Lauren who lives in Florida who’s age 31. She said, “Wow, this process really made a difference. Now I know what I want, and it’s recorded.” And she made a copy for everyone in her family. 

                                    So, let me just give you this highest level overview of our process. Because I don’t want to get too into the weeds here but we start with the survey. It’s online, takes about less than 10 minutes for people and that gives us a ton of data that we can start correlating the process already to that person. One of the fundamental questions, a lot of them are multiple choice questions, but one of the most important is, “How would you name three enduring values?” And that is really the launch pad for so much of our conversation. They’re not locked into those three. They can add more and be like, “I said this but actually now I’m thinking more about this.” But it’s super helpful for us to have that from the very beginning. So people really feel heard and they see that their volition and their values is what’s driving this whole process. 

                                    Then we have what we cleverly call Conversation One. I got it in my next slide. It gives a little bit of detail on Conversation One. Then they get a roadmap. We’re like, “Okay, we’ve had enough conversations to be like, ‘this seems to be the direction you want to go.” We are a checking whether they reviewed some of information we sent them and then the big thing is really Conversation Two, again, very clever name. And then that one is when they actually bring in their loved ones. I did one with a gentleman who lives in Tennessee. He had his spouse. His one child, adult child, who lived also in Tennessee and another adult child who lived in Peru. And she was a part of the process, the distance didn’t matter. It’s through the joy of the technology available to us. 

                                    All of that ends up with this comprehensive care decisions portfolio. So what do we cover in conversation one? Here’s a slide that gives a high level overview. We have six sections. The first is describing how you want to live at the end of your life. The second is naming someone to be your voice for healthcare if ever you can’t be your own voice, that’s classic healthcare agent. We always make people name two alternates as well even though some states remarkably don’t require that and some states don’t enough space on their form. We’re going to sure point it in. 

                                    The third section is clarifying your views on treatments at the end of your life. I’ll pause here say that what’s typical or conventional advance care planning could result in section two and some of section three, but not all of what we cover in section three. One good example is, we asked people in section three, “What’s your preferred balance between awareness and pain relief in your last days, as you imagine your last days?” And it’s interesting, nobody’s neutral on that. Everybody is like, “It’s so important for me to know who’s there.” Or, “Oh my gosh I’ll get champagne. I don’t care if I’m asleep and I don’t get a visitor. I don’t know who’s visiting me. I’m okay.” It’s really interesting. 

                                    Section four, five, and six are the details that begin with death. So deciding what to do with your body when you’re done with it, guiding how your loved ones gather to remember you. Notice that it says, “guiding.” We think that it’s the dose that makes the poison and we don’t want to give people a chance to micromanage something that’s really not for them. When you’ve died your memorial service if you choose to have one, whatever you call it, is really for the survivors and part of that is for them to actually get to create it and be generative in their grief. 

                                    And then six is settling important logistics for after you’re gone. Those are the ones that require outside experts like a financial planner, a lawyer, or a agent. You see that typically what’s covered in conventional preneed funeral planning is all of section four and part of section five. So, this slide more than anything gives you a sense of what we’ve ventilated really is unique. That you can’t really go anywhere else and get all of these things at once and get them facilitated by someone who’s been through it a million times before, who’s trained to listen, and to do this process with your loved ones being involved. 

                                    So, again, I won’t read all the slides, I’ll just say there’re some cool stuff here on the screen about what the CareDecision Portfolio does, can be updated anytime on their own. We give them instructions on how to update it on their own or they’re welcome to engage with us again, so you’re updated. Another person that we served in Tennessee said, “Hey, this was actually really good exercise of communication with my spouse.” He also said it’s a relief making his wishes known. 

                                    I’m looking at the time and I don’t want to go into too much detail, but we’ll just highlight… I won’t read the slide but we designed this to bring about peace of mind, clarity, and confidence for both the patient and for their loved ones. And that I think is something unique and it really grows out of our experiences at chaplaincy. So, pricing, none of this is free. So, let’s actually pause on that. Someone could go and get the advance care planning stuff, the typical advance care planning done for free and there’s lots of online resources where you could on your own go about and take care of these things and have the decisions documented.

                                    So, what you’re really buying when you’re hiring Allay is that there’s that facilitation as well as you’re getting it all put into one place. It’s really these three hours of focused conversation with a professional. And so the price is higher than most people think it’s going to be. We’ve had a lot of people say it’s lower than they think it should be, but most chaplains I’ve talked to are like, “Oh, that’s a pretty high price, $650.” But think about it as three hours with a trained professional. If you had three hours with a lawyer, just the time alone would probably be more than that and the document creation might be separate from that as well. 

                                    Again, we’re not lawyers just saw we’re clear. I’m comparing myself to that service but we don’t pretend to be lawyers. And because we are so committed as an organization, Ascension is to caring for those who live in poverty and caring for those who are vulnerable in other ways. We’ve created a number of ways to reduce those rates. So, you can get a reduced rate through a chaplain referral but within the Ascension system. A referral from the financial planner, those are again people who are very eager to have these conversations and help it happen. Employers, we’ve talked to a number of employers who are making this a benefit that they can offer to their people, say, “Hey we care about you, not just for the 40 hours you’re with us, but we really care about you and your loved ones. And we want to help you give peace of mind to your loved ones.”  

                                    First responders, teachers, veterans, are groups that we’re considering creating special discounts for. If you work for Ascension, I mentioned 150,000 folks do, they get a special discount and I’ll give them a special discount for hardship. And on all of these it’s the honor system, we’re not going to make you prove that you’re a first responder. If you tell us you are then you get that discount. 

                                    It’s available for gifting. This has actually been an innovation within the innovation that some of our earlier doctors were people my age, I’m 45, buying it for their loved ones, for their aging parents. And giving it as a gift, which is of course a gift for the whole family. Importantly I want to highlight, when someone does gift it, the gift recipient, so the person it’s for does not get an email about it. The email goes to the gift giver so that… If were to buy this for my parents, it comes and then I print out the certificate and I talk to them about it. There’s no random emails or like, “Congratulations. People who you love are thinking about how you’re going to die one day.” 

                                    How do people sign up? It’s all down online at allaycare.org. This has been another lovely innovation. The code that people can use for a reduced rate gets entered right there. It’s a seamless, easy system. If someone already has an appointment taken that’s not available, that time isn’t available, and they just can pick the times that work for them. 

                                    All right. I’m going to switch gears and… my screen and I are not agreeing, just so you the action. I’m a human being here, talking. I’m going to switch gears here, just do a couple slides on what innovation could be like for you guys. We’re at the halfway mark. So, I’ll go in that… unless Micheal you want to take some questions now. 

Michael Skaggs:            Actually, I would like to ask a question ask it because it gets asked of me a lot in some of the other settings that work in, not just in healthcare. I don’t say we as in chaplains but the Chaplains Innovation Lab. As you were going through that, you mentioned a couple of times that part of the reason that this is a useful thing to do is that you are trained to listen for the question behind the question, the comment behind the comment. So, my question, and there’s no question behind it, but my question-

Zac Willette:                The noises, the noises, Micheal.

Michael Skaggs:            … my question is, how are chaplains uniquely positions to help facilitate these conversations? That’s a question that I get all the time because people say it could be a social worker, it could be clergy person that’s part of a [inaudible 00:32:03]. How are chaplains uniquely positioned to help do this? 

Zac Willette:                Yeah, your video froze for a second but you’re back, so I heard the question. Yeah, a number of reasons because we say that death is not a medical event even though it’s treated in our systems so clearly like a medical event. Chaplains are uniquely positioned to bridge the medical and the non-medical world. When you talk about a ventilator, when you talk about a PEG tube, we know what that is. So, we don’t answer the questions on a level that a doctor would answer, but it’s because you’re thinking ahead. It’s not like, “You need this right now, get the opinion from a chaplain.” No, you’re getting your opinion from the doctor, but the chaplain can help you understand that. 

                                    But also we think, chaplains think, holistically, social workers do to, clergy people do too, but they don’t have the particular training that we do to bridge that world. But that’s it, social workers do and so that’s why we made the decision to hire both board certified chaplains and social workers, but we’re looking at social workers especially who have that experience in the medical setting. The one consultant we’ve hired, I can’t wait until we hire her as an associate, right now she’s a consultant, did some great work with end of life care. So, that’s a long answer for a short question.

                                    And I can go longer if you want, but let me keep going with the other slides here. I believe they’re shared again. So if wanted to innovate, this is my first ever start-up so I’ve learned some things the hard way and I don’t know everything. It’s very important to acknowledge what you don’t know. There are whole libraries are full of things I don’t know. But if you were asking me, “How could you innovate?” I would say, “Well, what problem are you trying to solve?” That’s the first thing you got to get really clear on. And the next slide goes into a little more detail.

                                    Who else sees it as a problem and who doesn’t? So, this partially came from my experience in that ICU at that night that I was the on-call chaplain, seeing these striking differences in these two rooms. For some people that’s not a problem, that’s just normal, right? So it’s important to get a lay to land of who are your allies and who just doesn’t see it as an issue. 

                                    Who else is trying to solve it? Don’t spend too much time on here, because you can endlessly talk yourself out by saying, “Well everyone’s trying to solve it.” And I had to get coaching from… So, Ascension actually has a chief incubation officer, and Jason Dinger who is a brilliant, brilliant human being who’s a great coach to me. I’m one of 11 different innovation projects that Ascension’s incubating at the moment and he often has reminded me that your innovation might be your approach or actually it might just be that you bundled things together that didn’t used to be bundled. Or it could be the pricing, how you price this, could be the innovation or could be something else entirely. 

                                    So, don’t be spooked when you find other folks are doing similar things, you might your innovation yet. And this then this is a really important thing, interview everyone you can about the problem. I think I did at least 50, probably close to a hundred interviews, patients, doctors, social workers, people in the funeral industry, you name it. And it’s really important that the conversation be about the problem. As soon as you start talking about your solution, they’re like, “Well, what are you thinking of, Zac?” And I’m like, “Well, here’s this really great idea.” At that point actually the most useful part of the conversation is over because we need to really understand the problem we’re trying to solve, not just pitch this really cool idea that we have, that’s a major shift. 

                                    And what are the next… the next part. And then get really honest about could you, do only this and all of this for much longer than you think it will take? I’m astonished it’s been almost a year since the beginnings of Allay when we were born and I really thought it would not have taken this long to be where we’re at now. I’m thrilled where we are but I’m surprised how long it has taken. 

                                    So, let me dive into a little bit of that. These are some slides from a presentation I did for some students at Portland State University about making change in a large institution or really anywhere but they apply here as well. Don’t fall in a love with a solution, fall in love with a problem. If you only get one thing from this webinar about innovation, let that be the thing. And this I learned directly from Jason Dinger. Falling in love with a solution means that you’re a hammer looking for a nail but falling in love with a problem means the more you learn about how tricky it is, the more enamored you become and that’s going to serve you really well in innovation because it turns out everything is trickier when you think. 

                                    And by sticking with the problem you’re going to find other people who are also intrigued by that problem which is way more useful than finding other people who are interested in your solution. Make sure that the problem you fall in love with is a problem that your organization, whatever that organization is, cares about, sees that can change and derives some benefit from solving. So, it’s not full-on Machiavellian but you do have to keep in mind that people, these horses are tight, and Micheal already made a reference to that. People will not get on board if they don’t see that there is some benefit that can come from actually solving the problem. 

                                    Talk about the problem and the problems behind the problem. Again, use your chaplain super skills to look at the issue behind the issue, fight the urge to pitch the solution. I learned the hard way. I had interviews that were going great, learning tons of stuff and then I started pitching my solution and it was so a fun conversation, the person I was talking to was thrilled but it stopped being useful to me because I wasn’t learning about the problem. There’s always more to learn about the problem. 

                                    People will want to tell you their ideas about the solution that you have in mind and unfortunately you’ll just get ungrounded data, what Jason calls well meaning noise. They say people have a good heart and they’re like, “Oh, I have an idea for your idea.” And you’re like, “Oh, the best thing you can do is tell me more about the nuances of the problem that I’m not seeing because of my blind spots. Talk to people about the problems that they’re facing and you get very grounded data, that’s the difference. 

                                    Be rooted to the problem that you’re solving during all the pivots because there will be pivots. They will test your resolve as a change agent. But if you’re in love with the problem, then those pivots will be mostly energizing. I’ll admit they’ve been some pivots that have not been energizing for me. Okay, a couple of more points then actually… this is…. So, if you’re having the [inaudible 00:39:18] for too slides, the first was to remember to fall in love with the problem, don’t fall in love with the solution. And the second thing to remember is this, change is slow except when it isn’t. 

                                    So, I’ve given up predicting how long things will take. To operationalize you have to have a sense but you have to hold it really lightly because some things are slow and some things are not. I’ll give a couple of heads up and then we’ll move into… a couple of slides and then we’ll go into Q&A. It will be slow, I already said that, and not in the ways you expect so some real humility is called for. I’ve learned that lesson daily I think. Like, “Okay, I didn’t see this coming but I’m going to role with it.” 

                                    Innovation will require partners and you don’t always know which partner you need before you need them. So, again, a little bit of humility of like, “Wow, hi, you should have called me two weeks ago.” And I didn’t know that I should have called you two weeks ago, “Can we talk today?” And Discern, good chaplain word, that which you can surrender and that which you orient yourself to. Those are two really important things for you to be like, “Okay, I can surrender all these things.” And, “Okay, I’ll only be oriented towards this.” Because everything else is mud, it really is muddy. As the son of a farmer I can tell you it’s good fertile mud, but it is messy. 

                                    So, in conclusion, going back to the later stuff, many people aren’t sure where to start conversations about end of life of they’re overwhelmed by these conversations but they do want to have them. What Allay does is we make that possible. So, think, which ICU room would your patients want their family to be in?

                                    Before we go to Q&A, I get a lot of Q&As that I have learned to head up with a pass by getting some FYIs. We are headquartered in Minneapolis, Minnesota where yes, it is currently… let’s see, current temperature is 18 degrees below zero. It’s warmed up now that the sun is out. It is colder here than in Antarctica. I like to point out it is summer in Antarctica. Allay will be hiring board certified chaplains and licensed social workers locally here in Minneapolis. And ad hoc we have a strong desire for Spanish speakers. 

                                    Depending on demand, we might get to expand 2020 or 2021 to wherever the demand is strongest, potentially officing where Ascension already has existing space that’s a good use of existing resources. But that… probably you would want to expand because a small percentage of clients actually do prefer this process in person. The phone has some pros and cons and the person has some pros and cons.

                                    So, with that, I’ll turn it over to Micheal to see if there’s any questions that have come in. 

Michael Skaggs:            Yeah, so we do have a couple of questions that have come in. The first question has to do with basically the sources of payment for services like this. I also want to ask, they say that… I’ve heard that there is Medicare reimbursements for a qualified practitioner to do this work. So, I want to hear your answer and then I want to follow that up with a little bit of research as well to talk about. So, anyway, take that. 

Zac Willette:                Yeah. Micheal, your computer froze. Listening in on my side we got to the actual question, so [inaudible 00:42:45] does have this qualified professional. And the questions that… the onset question was… You know what? You froze again. 

Michael Skaggs:            Yes, you’re freezing for me as well. Maybe it’s the ice outside that’s getting between us. 

Zac Willette:                Maybe, yeah. 

Michael Skaggs:            Okay, so Medicare reimbursement, how does that work with Allay? 

Zac Willette:                Oh, sure. So the Center for Medicaid… CMS, Center for Medicaid Service, has not ruled yet on who actually is a qualified professional. So, we have not touched that with a 10 foot pole because it is all of our compliance officers tell us if the ruling comes out against us, it could technically be considered Medicare fraud. And no hospital ever wants that on their record. So, we’re being super, super cautious. I do know that different hospitals had chaplains be a qualified professional and have successfully been paid. I know that my colleague from when I was in Rush, Ethel Lee, at Oak Park in Chicago published a really great little research letter, is that what it’s called? Research letter which was outstanding.

                                    But, yeah, if that does come, we would love to explore that. That said, if what Medicaid and Medicare are paying for is just the medical slice. And so we would have to be really careful about being clear saying, “And now that is over, and now we’re beginning a new conversation that we’re not charging for.” And that doesn’t really appeal to us, we really like the holistic, warm conversation because one of our operating theories is that only 30% of Americans have any sort of advanced directive in part because it’s all the thanatophobia and fear of death and death denying culture et cetera, et cetera. 

                                    If you’re going to push passed all of that, all that discomfort to actually have the conversation. You don’t want to have just part of the conversation or you don’t just want the medical slice. You want the whole enchilada. 

Michael Skaggs:            And actually just for the participants, I dropped in to chat the link to Transforming Chaplains. It talks about Ethel’s research letter. Because this is actually a really important part of seeing how chaplains are integrated into the entire process. Now, I know that you’re coming at this from the other side of viewing this very holistically but at the same time I think it’s important that we begin to understand chaplains as an even more integral part of the medical side of things as well. You mentioned that phrase earlier of bridging that divide. I think that’s so important but of course we need to focus on really clearly seeing that chaplains do have a foot in both sides. It’s not like one side or the other but it’s medical and everything else at the same time. 

Zac Willette:                Yeah, well, to go with the metaphor, a bridge is only reliable if it is solid on both sides. 

Michael Skaggs:            Exactly, exactly. Right, right. Someone asked, how did you arrive at the name of Allay Care Service? 

Zac Willette:                Yeah. Our first name was Spirar, S-P-I-R-A-R.

Michael Skaggs:            As a focus group of one I will say I’m glad you didn’t pick that. 

Zac Willette:                Yeah. It’s great etymologically. It’s the route of the word spirituality. It’s the route of the word inspiration, expiration. It’s an amazingly, in my humble opinion, great word and it’s terrible because people don’t… because it’s a new word and a lot of start-ups do makeup a word or they do a portmanteau where they put two words together. So, we tried that for like a nano second and then we’re like, “No, people are stumbling over on how to say it.” Which ironically still happens with Allay, but most people are familiar with the phrase, allay your fears. 

                                    And etymologically, I don’t have it in front of me, it will be up on our website soon, but etymologically it actually was related to letting go of a burden. Like literally laying down a burden and letting go and we see that so much of the death denying in North American culture is this grasping and holding on and, “I’ll live forever.” And chaplains we’re always asking people to let go. We have to let go of things ourselves. So, that’s part of where it came from. It also our lawyers did the search and there is a home hospice that uses the name but what we used different enough from them that we think we’re going to be friendly with them and not competing with them. So, it was a word that was available. 

                                    I literally had a list of a 117 potential names, some which I loved but were already taken and so we ended up with Allay. 

Michael Skaggs:            Another question, this is really interesting because just looking at the attendance list right now I see so many names that I recognize up for various healthcare chaplains in sight. And someone asked, when does the relationship look like between you and Ascension, you’re at Ascension directly before and now you’re with this, so you mentioned a little bit about Ascension’s incubation mindset. How does that work? 

Zac Willette:                Yeah. So, like I mentioned, we’re one of eleven incubates. We’re the only ones so far that’s coming out as spiritual care. And the reason I that that’s important for as we were talking about at the very beginning to show that spiritual care isn’t just a cost center, that we can actually bring something to the table, a lot of the things to the table including capacity generating revenue. So the way that I explain it is that Ascension is about $20 non-profit and about $4 billion of that depending on your definition is care for people who live in poverty or care for people who are undocumented or otherwise vulnerable.

                                    And we are looking at the next five and ten years, we are recognizing that we will not need less care for people who live in poverty. So, how can spiritual care while still upholding our mission and expand our impact by generating new revenue to help meet that. So, yes, as I… I had that slide in the beginning, Allay is Ascension in the Venn diagram where a tiny little part of it… but yeah, all the revenue directly goes to keep ascension doing the good work that we’re trying to do. 

Michael Skaggs:            Sure. This a really interesting question that I hadn’t thought of before. This question says, we deal frequently with unique cultures here in New Mexico. We have cultural and spiritual beliefs that make these kinds of conversations more difficult to have, the level of avoidance when it comes to death makes it very challenging to engage in these future oriented or present oriented if they’re right at that stage conversations and decision making processes. So how have you dealt with that kind of diversity of approaches to death? 

Zac Willette:                Yeah, this is great. So, we’re actually doing research right now into whether or not the language that we have on our website and in our process is as culturally competent as we think it is because that’s not something you can hubris of that. You’ve got to be humble and learn it if it is or if it isn’t. But what I’ll say is two really important things that run our process, it is centered on the volition of the person… We use the term principle for the person that we’re serving. And it includes their loved ones, whomever they decide is their loved ones. 

                                    So, for example, I live in Minneapolis. We have a very large, robust community here of immigrants from Somalia and decisions… I’m speaking the aggregate here, so using some generalizations but in general medical decisions are made by elders. So if I have a medical situation, I won’t make it myself, I’ll have an elder make it, either in consultation with me or I’ll just defer. This process 100% works for that because the person’s volition is, “I want said decision to be made by this trusted person in my community.” 

                                    And so the fact that we don’t say, “Oh, no, no, what do you want?” You just told us what you want and guess what? We’re going to have a conversation too where you get to bring whoever you want to the table. So, there’s a lot of… We believe, we hope, we intend to have lot of respect for the cultural diversity that’s present in our world today. 

                                    Now, that said, I also heard a little bit in that question of cultures that are just have a cultural prohibition against talking about death. And that is a particular challenge, those people probably wouldn’t come into our door but if they did we would hope that our culturally competent programs, their effort would be useful. 

Michael Skaggs:            Sure, sure. And now this next question, I am not familiar with the content of it so I’m just going to ask it and let you take it away. I think I know what they’re asking but in any case this person says, “How are your services different from the honoring choices project here in Minnesota?” I would say that question is, how is this different from just advanced directives in general? 

Zac Willette:                Yeah, great choice. I love having choices. I am so proud to be a Minnesotan because having looked in a lot of different state forms, honoring choice is one of the best out there actually. And I like that our state legislature here in Minnesota has deferred to honoring choices in a number of ways, not always but there’s been a great potential for partnership there. So, what’s different is that honoring choice is not by its nature a facilitating process whereas ours is and it’s facilitated by a chaplain or by a social worker from beginning to end. 

                                    So, you can absolutely… sometimes honoring choices has been facilitated for someone but it’s also available to be used individually just bring it out on your own. And if we think back of that and I can pull it up if you’d let me too but that slide of the six different sections, honoring choices makes a little bit of space available for, “Hey, if you have particular wishes for the care of your body after your death, put them here.” If you have instructions for memorial service, there’s a little space for that of you can always attach more pages. 

                                    But honoring choices does not get into the specifics of what we do about, for example, who has the passwords for all of your online accounts that need to be wound down. Don’t give them to Allay, just tell Allay so it can be in your document, who has them and Allay by the way is going to remind you to update them. I’m telling people to update them on Groundhogs Day because what else is there to do on Groundhogs day, update your passwords. 

Michael Skaggs:            As we get to the end of time. I want to be respectful of everyone’s time but what really strikes me is that you had those couple of slides up earlier and I’ll remind everyone then we’ll have those connected to the Allay section on the Chaplains Innovation Lab website. But this is useful for basically anyone because you had those slides on how to innovate where you are and know that especially for chaplains who are working in hospital setting or other sorts of health care settings, things are very often done in a very specific way. This is system we have setup, this is the hierarchy, these are the methods. You show up for work and you do your job.

                                    And in a lost of ways that’s beneficial there needs to be protocol. There needs to be a safe and effective way of just operating without having to figure out what you’re going to be doing every day. But I think that the pieces that you mentioned earlier on innovation and how to identify problems, what can be done about it and how to partner with people, I would really encourage everyone who’s watching this to take a look at that and think very hard about that. because all of us we have various parts of our jobs of locations, however you want to view it. When we see friction points, areas of tension, very often it feels like this is just an intractable problem because this isn’t how we do things and what can I do about it? 

                                    But I think that what you have given us on how to innovate, just to think in that kind of mindset has been really helpful so thank you for that. I will give the last word here and then we’ll wrap up. 

Zac Willette:                Sure, thanks. I was going to expand on that, that chaplains are… We talk a lot about coping, right? We talk a lot about resilience. One of the  ways I describe what chaplains do to people  who don’t understand this is say we reorient to their own resilience, right? Micheal’s making a really good point but too often as chaplains because we thing of ourselves as the forgotten step-child in the healthcare setting, we have this narrative in our own head, we use our coping to jut suck it up. And be like, “Well this is just how it has to be. We’re never going to get the positions we want. The research that we want to do prove that we are necessary, that’ll take five years. I’m probably going to lose all the funding we in the meantime between now and when five years is finally over.”

                                    We can have a little bit of what in Minnesota we call as winter fatalism. And I think it doesn’t serve as well as a profession. It doesn’t help people take us seriously. It doesn’t help people recognize the many gifts that we bring and I think it doesn’t help us take ourselves seriously. So, we have a really unique perspective on what is broken in healthcare and how it can be fixed. 

                                    I got into the position I’m in now because after five years in the emergency room of seeing how our healthcare was broken, I needed to be part of the solution. I think about the trauma surgeons that I worked with at Cook County at Stroger in Chicago who said, “I can’t just stitch people back up and send them back onto the street. I need to be also out in the streets helping do whatever I can do to prevent the violence that’s getting them into my theater, my trauma bay in the first place.” And I think chaplains we have a similar opportunity. We see what’s broken and we are called in the spirit of justice to innovate and aggregate for things. 

                                    The world as it is is not yet the world as it should be and we have a million big and small ways every day to make it more that way. And I think innovation is one of them.

Michael Skaggs:            Very good. Well, thank you for ending us on a very positive note. It was an entire webinar built around preparing for the end of life can seem a little grueling from one perspective. 

Zac Willette:                Clients are like, “I didn’t think I would be laughing during this conversation.” 

Michael Skaggs:            Yeah, yeah. Well thank you for bringing us up here at the end. This has been really, really great. I’ll just remind everyone this is being recorded so we’ll have it up on the website here pretty soon as soon as we can get it processed. We’ll have the slides up so you can take a look through those at will. And if you have any questions get in touch with me, I’ll pass it along to Zac. We would love to keep the conversation going. Thank everybody for coming. Zac, thank you of much for your time. This has been wonderful. It’s always a pleasure to talk to you and so I look forward to staying in touch. 

Zac Willette:                It’s a privilege. Thanks everyone, have a great rest of the day and if you’re in a place where it’s cold, stay warm. 

Michael Skaggs:            All right, thanks. Have a great afternoon everyone. Bye, bye.