48. Todd Pang: "We had to do a lot of training and awareness building for what actually constitutes PHI."

Here's the full transcript of this episode.

 

Hannah Trum: I'm Hannah Trum, and this is the HIPAA Critical podcast.  Are organizations adjacent to healthcare, such as assisted living residential care homes, required to follow HIPAA rules and regulations? HIPAA compliance is a must for those who work in the healthcare industry; covered entities are expected to adhere to HIPAA rules and regulations. But how does HIPAA compliance work in the gray areas of health care?  Adult or senior care facilities aren't considered covered entities and don't need to achieve HIPAA compliance. These organizations don't always collect or process protected health information or PHI, but they deal with sensitive information. How can these organizations protect themselves and their residents from potential data breaches and accidental privacy leaks?  Today I'm speaking with Todd Pang, president and part-owner of Caring Manoa, a two-type expanded adult residential care home. Caring Manoa provides 24/7 assisted living services in a historical estate. Todd and I discussed how he took his business paperless, how the global pandemic affected this initiative and how HIPAA plays a role in his organization and their provided patient care. Hi, Todd. The first question I have for you today is can you provide us with some background on Caring Manoa and who are your ideal customers? Todd Pang: Well, firstly, I want to thank you, Hannah and Sierra, for having me on your podcast. It's a really important topic, especially for our part, our little corner of the whole spectrum of care for seniors and the elderly.  But some background on Caring Manoa. We are what's called an adult residential care home. And that's like a specific designation in Hawaii. They are usually small cottage industry, Mom and Pop facilities. With a handful like ourselves, we're actually bigger and run more like a company or as an organization. It's a nonmedical service. And it's purely just assistance with activities of daily living, medication management, monitoring and assisting our residents and offers 24/7. Caring Manoa started in 2001.  So this is our 20th year come October. Hannah: Congratulations! Todd: Thank you so much. It's been a journey. For us, it started as a small care home and what is called a type one care home in Honolulu, Hawaii. That means that we only had five residents at that time. And so we really fell into that category of like mom and pop facility. At that time, my family had been operating it while the kids had grown up and gone away to college.  In 2011, I had relocated back home to Honolulu and started our expansion to another three beds or to a total of eight residents. That might not seem like a lot, but for a small mom and pop, you know, to have 60% more residents was kind of a big jump.  Hannah: That's a huge jump.  Todd: Unfortunately, that's the only way that care homes do it here in Hawaii to expand or scale-up is to have these massive jumps in residents because we either have to build out a whole new section of the house or maybe build a whole new house. So there are quite a bit of risk and startup costs for a residential home here locally.  But we did it in 2011. So after running that small home for ten years, we then scaled up another eight residents. Then in 2014, I had done exactly what I just mentioned; we built a whole other wing of our home to have another eight residents, effectively doubling our capacity overnight. And that was all sorts of fun. As a small family-run business, a lot of us in the residential care industry really don't have much of a template to follow, or we're kind of just figuring it out as we go. We've been operating at 16 beds since 2014. That's been going very well for these many years now.  Finally, we are undertaking a whole new expansion again to add a whole other 32 beds or four homes of eight to our organization coming up this year and over the next few years.  Caring Manoa has been around for a little while. We really try to specialize in a group of seniors who don't have many other options. They might have come and gone through an independent or assisted living facility, or maybe they suffered some sort of injury and went to short-term rehab. And now the physician is telling them that it's not safe to go home.  We really are looking at our niche; it is for residents who truly don't have many other options either because of their mobility issues or because they have perhaps more of a moderate to severe dementia, something like that.  Care homes, in general, are a catch-all between assisted living, which we think of resonance as needing to be a bit more independent, and a skilled nursing facility, which is definitely providing that medical attention.  We fill a gap of residents who are too high acuity for assisted living, but they don't really need that nursing service 24/7 or even on a regular basis. That's our little sweet spot.  We are one of maybe about 400 care homes throughout the state. So definitely a small, or cottage industry of many small operators and care homes accounted for about 20% of all of the long-term care beds in Hawaii. That's a total of about 12,500 beds in Hawaii statewide for all long-term care. Hannah: Wow, that's amazing. I didn't realize that there were that many or few, depending on how you look at it. Todd: There's simultaneously many, but not enough. It's really an interesting conundrum. Because that just was such a fragmented part of the industry, plus a whole nother layer of another 20% of the beds is occupied by what's called Community Care, foster family homes, which are kind of like care homes but have a different license.  That’s almost 50% of all of the beds in Hawaii. There's something like 1,038 foster family homes as well. So put together, there are so many, and yet, it's very fragmented. Hannah: So many and yet not enough. Todd, could you give us some information about your background and your focus as president and part-owner? Todd: I joined in 2011, as I mentioned, and prior to that, I was living abroad in China. I had been involved with the luxury travel and luxury tour operations industry there. So I was working with a local Beijing company that was part British, part Korean American couple called Imperial Tours. We were really focusing on the high-end luxury travel market there. We would have Americans or Europeans or Australians primarily come in and have a really wonderful experience.  I did that in Beijing for about five years prior to then being called home, by my family, in this family business. And it really actually wasn't a far stretch from what I was doing in China, with luxury tours and luxury hotels, to then be operating a residential care facility. I see what I do is kind of like a boutique hotel, plus some caregiving. There’s, well, quite a bit of caregiving that's involved. But it's really a focus that I've brought to this work.  My background in hospitality. I'm always using it as a competitive advantage, I suppose, over others in the market who might be primarily just focusing on the care by itself. I really try to focus on more of the holistic experience that my residents and their families can have while they're here, for however long that might be.  We may have some residents who are here for a short term, maybe for hospice, or I have one resident who has been with us now for nine years. Through that period of time, I'm really looking at you know, what is it that would be a special kind of zinger or special sort of experience that they could have either each month with our family parties or maybe throughout the day, that would just be a little bit more than bathing, eating. Hannah: You're adding more fun things to do, which definitely connects to your luxury background because that's what you did but just a different demographic, and maybe slightly different activities. Todd: That's right. Very different activities; we’re not hiking on the great wall here. We're playing balloon volleyball or doing a lot of games.  It's actually very interesting, though, to see our families getting involved with those activities, and people who might otherwise be very stoic in the business community or whatnot are really letting loose, doing relay races with their parents. It's really nice to see. Hannah: I bet it's incredible to see.  Todd: It’s one of those things that we want our families to feel like this is beyond something depressing or beyond basic care. Our vision that we established some time ago was to elevate and transform life. And what that means to us is, you know, wherever our residents came from, or their families, and whatever their personal situations or their personal relationship dynamics, we really want to be adding to that and elevating it for them to, to look back at this last chapter of their lives here. And really feel like that was something they could be proud of that they had closure. We aim for that. Hannah: It sounds like it; it sounds like something that's truly incredible to witness and to be a part of. So I definitely commend you for that.  Switching gears a little bit, the pandemic affected each of us differently. And early on in the pandemic, adult residential homes and care facilities seem to be hit the hardest. How did your organization prepare for this pandemic, If anything? Todd: I have to say, admittedly, we didn't prepare for the pandemic before it happened. It really was one of those things that blindsided us early on. I wanted to emphasize with my team that we have to stay ahead of it, whatever it might be. We don't want to have to be playing catch up after the fact.  We saw things slowly developing, and back in January of 2020, we started thinking, “Okay, gosh, like, maybe we should start buying more face masks.” I would buy about one case of face masks for like a year previously. Then we started having to buy so many more. We started amassing PPE as the first cases started occurring in the US. There was a very notable facility in Washington [affected hard], and we really started to think, “okay, we have to take action with this, not wait for something to come back around and bite us in the butt.”  So we closed our doors at the end of February and beginning of March to all family visitations to the physicians to providers, all of our volunteer hours and that program. We really had to work fast as many facilities did, to respond quickly or even try to be proactive about it. Through that process, it took a little while for our families to understand why we were doing that and to feel like we weren’t just kind of draconian about our cautions.  It really was a challenge because it's very different from what we were used to. Here at Caring Manoa, we welcome our families with open arms. But as you mentioned, all facilities struggled with this. We had to really scramble to develop new policies and procedures that we hadn't previously really needed to focus on. [We also had to] address caregiver anxiety and fear about what this new virus is, how we might get it. It was a big deal for us to convince our employees and our caregivers that PPE works.  And even then, at that point, we didn't know if it worked, but we had to put some faith in the CDC to say, “if you have a mask, and gown up, then you'll be safe.” Luckily, those early actions help us to weather most of the storms throughout 2020.  We could really fall back on a lot of the strides that we made in going paperless over the last few years, prior to so we didn't have to reinvent the entire wheel but kind of chisel away to make it more round and roll more smoothly. Hannah: So how else has COVID changed your organization? Do you see any of the changes that you made in 2020 becoming permanent or continuing in 2021? And beyond? Todd: As I mentioned earlier, there hasn't previously been a huge emphasis on infection control in this residential setting. We would have some procedures to isolate residents if they seem like they had a cold or something. But of course, with COVID, now, it becomes much more deadly.  We really had to tighten up our policies and procedures, and I think all residential care homes had to do that. In addition, with the Department of Health here locally beginning to adopt new legislation to require that, it's been a very good thing.  And I think overall, in Hawaii, we don't have the same kind of case counts in the long-term care industry as there are in other states. It's very widespread already in acute care hospitals or in nursing facilities. But now, with trickling down into the residential care field, there are required policies and procedures for infection control.  PPE is just through the roof now. As I mentioned, I buy 300 facemasks maybe a year, and now that would last me, you know, less than a month. We've had to add a whole new line item to our budget. Getting the employees and the residents to be using [PPE] more frequently is a common practice now.  The other issue that we've now since worked with is to have to tell our families that there are certain restrictions on how they can visit and deal with their loved one that was, again, previously a very open, laissez-faire, come whenever you can. Obviously, during the pandemic, but even after the pandemic, we'll have to be a little bit more restrictive on either the time or how families might bump into each other on-site until we're really past this pandemic.  But on a more macro level, there are so many seniors that need this type of service. I have found during the pandemic that many of them are less willing to move into facilities for that COVID risk. Of course, it's understandable. It's been in combination with perhaps high unemployment that families are not really connected sitting or reconsidering the stage to which they want to consider moving into a facility. And it's been a trend anyway, for the last few years.  A lot of families are staying home for longer and trying to, or their loved one is staying home for longer and trying to accommodate and care at home. So when they really move into a facility, that's when they truly are incapable of providing the care for their loved one or maybe the family is so burned out that they've had it, and they need to find something they need.  Then there's the overall telemedicine and remote communications that are definitely here to stay. We've been able to have PCP visits with our residents, providers and other providers via their own HIPAA compliant portal that the residents and we sign on. [Communication] through telemedicine and through communication with the families on things like FaceTime and Zoom, I think that's here to stay. Hannah: I totally agree. We've talked to other people, and they all say that telehealth is here to stay. It's only made everyone's lives easier.  Todd: It actually is because, and especially on the individual level, we can make it really worthwhile for a provider to come and see maybe like ten people at a time. But it's been a real nascent growing thing where the local geriatricians are trying to do more house calls. I think it's called like the milk man's dilemma or something where, how do you go through all of these different places and fit it within your schedule?  So now, with telehealth and telemedicine that providers here locally can have a bigger reach, especially to remote areas or remote islands in the state now, where they might have to take a plane to see their patients.  We've also been able to connect with our residents’ family members who are on the mainland or other locations where they weren't able to join us for our parties. Now they can. They can see their loved ones more easily because, other residential facilities, and we have evolved and bought iPads now. Hannah: Video calls have really changed the way we communicate with everyone.  Going paperless is an ideal situation for almost every company, and it is something that you are trying to do. How and why did you make this decision to make Caring Manoa a paperless organization? Did you find that the pandemic made that easier or harder? Todd: It had to happen. When I started ten years ago, I thought there had to be a better way to do this. So back then, phone and fax were the only way for us to get in touch with a provider.  The Department of Health really would come to inspect it; it was kind of like a sport for them to look through all the paper records and look for something we called pukas, which is Hawaiian for holes. Pukas in the medication administration record of you know, did they record it, then? Or did they do this? Is the order missing? The same for something as silly as did the facility use black ink versus blue ink?  It had to take a really large proportion of the Department of Health's annual inspection of facilities. It's important, but that was really not a reflection of the core service that we were providing or the core value and performance that we were operating at.  So in 2016, and I just started thinking, this has to happen. There are very few applications, or there were few applications back in 2011 for this kind of residential market. Most of the kind of paperless systems are geared more towards the acute industry or nursing facilities.  But in 2016, there were two big things that I did. One was signing on with Paubox, which was really great. And two was to get our medication administration record onto a paperless system. It had to start with that because the majority of our Department of Health inspections really focus on the MAR.  So we joined on with something called Quick Mar, which is now purchased by Point Click Pair. They really focus more on the long-term care industry and less so on the acute side. It was night and day for us in terms of our compliance, our reporting, our care management.  We could really use exception-based reporting to be able to see what was a trend for our resonance conditions to be able to catch if a caregiver had missed some medication or hadn't recorded, you know, even if they did give the medication, they forgot to write their little initial in the square box on the MAR. So it was just an overnight improvement. Well, I should say, it took us quite a bit of time to get a caregiver used to a computer. Some of them were not very computer literate. But we’ve pushed ahead, and over about six months, we really got everybody on board.  There's no turning back. There's no need to, and it's really helped us within our niche of the market to shine. I think that the Department of Health now feels very comfortable about what we do. And with that, it's helped us to also think about scale and how we can expand.  Over the next couple of years, we will be growing by 200%. The only way we can grow is to grow by these big jumps. And with that, we can have better communication across locations; we can have more accurate reporting for the residents’ PCPs and their families.  All of that boils down to being very reliable and trustworthy because we're working with people's parents and their loved ones. Hannah: Exactly, the more reliable and trustworthy you are, the better that they feel leaving their parents and, I'm sure, the better the residents feel about their care. Todd: Absolutely. As I mentioned, we never want to find ourselves behind the ball and trying to explain why something had to happen or, you know, why somebody’s mom seems to be declining and not be able to have any documentation about it.  With our paperless system, we've really been able to amass that much better to stay ahead of COVID. We really want to try to stay ahead of conditions that could be preventable for our residents and be able to show data on a more longitudinal level that these are some flags for your provider to look at and think about offering some sort of treatment for them or vice versa to their family.   We have an activities program report card to be able to tell the kids, “your mom has not been participating with the morning activities as much as she used to” and “do you want to talk to her about that.” We find ourselves in that situation quite often as well. It all helps to really be able to reassure families that this is an environment that we're not cutting corners, and this is a team that we are really trying to be very open, transparent and collaborative with them.  Hannah: My next question is about HIPAA, HIPAA compliance. Your organization is not a medical care provider, so HIPAA compliance is not necessarily at the top of mind for you or your staff. However, y'all do deal with your residents’ medication; how do you ensure that your team keeps that sort of sensitive information secure? Todd: It's been a journey, and as I mentioned, with just getting a caregiver who might not otherwise be very tech-savvy or understanding of computers, or what exactly PHI is. We've had to do a lot of training, and a lot of awareness building for what actually constitutes PHI, and what they can and can't be doing with the medications, what can or can't you do when you leave the computer. Like, click the button so that it minimizes the medication information.  All of that has required initial and ongoing training constantly for them to understand that this is information that we have rights to and that we have the right to have it be private. We've had to continually oversee how our caregivers operate, how they communicate with each other. It's been an ongoing thing that I think will always have to continue, as we get new employees over time.  The other aspect of it is that we've been able to rely very heavily on apps like Paubox. With the encryption side of it, I don't have to think about “is this gonna be safe, when I communicate with my managers, or if we're sending information to the families,” and then with Quick MAR, they also have that encryption control and internal controls.  It's an option for our caregivers to know that they can minimize or not just go about how they normally would not think about keeping that PHI safe. We're really relying quite a bit and heavily on what, you know, organizations like Paubox offer. Hannah: Alright, Todd, my next question for you... your organization relies on Paubox for email encryption, as you mentioned. What were some of the must-have items that you thought you needed to look for in your email encryption solution? Todd: Definitely the reliability and not knowing what's in the backend, but knowing that it works. That's where I come from, with my limited understanding of technology, but we didn't want ourselves at the care home to be the weak link in the overall chain of communication between family and provider, or between the, you know, facility to facility if we were sharing information.  With Paubox, it really was that security angle and knowing that there's an extra piece of mind to give to our families and providers. Again, I mean, we really aren't defined as a provider in HIPAA, but it seems like an industry standard that we really want to adopt and try to follow and keep up with on our end too.  So that extra peace of mind is huge; it’s like a currency in what we do. Families are willing to pay a premium or to be able to trust us. And that's how we were really drawn to what Paubox had to offer. I'm hoping that we are leading the way in other residential homes of all those 400 care homes, really adopting something like Paubox just to maintain a standard that I don't know if is being followed or not. Hannah: Definitely, I think it would be. Obviously, I work in healthcare, so I think the more HIPAA compliant providers or non-providers there are out there, the better. And on a more personal note, how do you keep up with industry trends and best practices? Todd: Well, we are part of a couple of associations here locally. And definitely during COVID, we've relied heavily on them to try to understand what are some best practices for infection control, but because this is such a fragmented industry and such a cottage industry, what I like to think is we're at the forefront of forging new trends are best practices within the industry.  There can't be more than a handful of other care homes that do paperless systems, especially for the medication record. I see that as an opportunity for us to be a vanguard in this, not just with paperless systems, but with our activities program and the service that we provide to our residents. It's kind of, not the Wild West, necessarily, but there's a lot of creativity that can happen.  I've found that being the owner of the company and not having to work with a very large vertical organization, we can really see something that looks cool on Facebook or Instagram and say, “you know what, we want to do that. Let's try it out.” Many of those things have worked quite well for us.  There's the opportunity to be creative. Some facilities are just trying to struggle with the day-to-day or fill vacancies and that kind of thing. I think over time, here locally in Hawaii, there's going to be a lot of consolidation for what we have in this market. Hannah: Todd, my very last question for you, I saw on your website that Caring Manoa hosts about 15 parties a year for residents and staff; which ones are your favorite? Todd: I'm very proud of that because it's a lot of fun. And a lot of work, tons of work every month. I think actually the staff parties are really special. That's because my caregivers, as any caregiver, have to work so hard. They are busting their butts here day and night, working with dementia and behaviors and all sorts of physical taxing things. So to see them let loose and really enjoy themselves while at work is just really special.  There's always some sort of dance contest that’s happening. There's always some major giant spread of food and games. And so that's really special to me, for the family parties.  I think the holiday season for everybody tends to be a really fun time. It's always gratifying when I see that my families are just exhausted by the end of December, you know, January 1, they're thinking, “Okay, we need to take a break from seeing our loved one at the care home because we've been there.” Well, now it's on Zoom, unfortunately. But we've been having a party in succession, every few weeks at the end of this year, that now maybe we'll take some time away from having to visit mom or dad at the home until springtime comes back around. Hannah: I love hearing all about that. Thank you so much for sitting down with me today and answering some questions about your business and about yourself. I really appreciate it. Todd:  Yeah, thank you so much. It's been very special to share what we do. And I really appreciate having the opportunity to be HIPAA Critical, of course. Thank you so much.  Hannah: Todd, thank you again so much for being on today.  Our next webinar will be on July 21, covering the topic of HITRUST certifications and how to pick the right assessor. This webinar is free to attend and will feature Cathlynn Nigh, CEO of BEYOND LLC, and Michael Parisi, VP of strategy and solutions at HITRUST. If you’d like to attend, please email me at hannah@paubox.com or head to paubox.com/webinars. Are you looking for a place to network with others in the industry? Come join our next social mixer on July 29. Each mixer is about one hour, 100% virtual, attendance is free and includes a free beverage of your choice. Please send an email tohannah@paubox.com if you’d like to attend. Have you scheduled Paubox SECURE on your calendar? This year’s event will take place in person at the Park MGM in Las Vegas. Join us on September 29th and 30th for our 4th annual healthcare and cybersecurity innovation conference. Jane Harper, Senior Director, Information Security Risk Management and Business Engagement at Eli Lilly and Company, will be a keynote speaker.  Head to pauboxsecure.com for more information, early bird pricing, and to book your hotel. If you’re looking to sponsor or speak, please email hannah@paubox.com . As a reminder, you can listen to every episode of the HIPAA Critical podcast on paubox.com or subscribe via Apple Podcasts, Spotify, iHeartRadio, Stitcher, and Amazon Music. Thanks for tuning into another episode of the HIPAA Critical podcast; I’m your host, Hannah Trum, signing off.