Inner Circle: A Conversation on Long-Term Care

Chris? 

Christopher KOENIG: We are not a formalized CCRC. We are a little bit different, but we have kind of the same concept. We’re a continuing care community. We have independent living for folks who are still up in age but require help with some of the activities that they do. We have different levels of assisted living. We have memory care assisted living, as well as enhanced assisted living. We have seen that change quite a bit, even in the past year. We went from having quite a few open beds to a waiting list that is quite deep. We also have a skilled nursing facility with a very busy subacute unit. Our campus kind of centers around Greenfield Health and Rehab Center. Our patients at times on this campus will transition to this facility as they need higher levels of care. Our goal is to get them back to their residence, to make it a short stay as much as possible, and we have been doing a pretty good job of that.

Peter, tell us more about Brothers.

Peter EIMER: Sure. The Brothers came into Buffalo in 1924, so it was almost 100 years ago. They came in at the request of the bishop of Buffalo and they came in for home care. So they would ride their bikes around Allentown and visit people in their homes for tips. That’s kind of the legacy that’s left and still holds. In 1952 they moved out to Clarence. They bought 126 acres for $50,000. And the fresh air was the attraction. In the early ‘80s, the Brothers were really the first in Western New York to start subacute rehab in their Clarence campus. It’s been a journey and over the last eight years or so, we’re really on a new track where we are putting almost $45 million into the campus for new independent living. We opened our Montabaur Heights all-inclusive independent living about a year and a half ago and it’s full with a three-year waiting list. That was a very successful project and it’s a niche that will feed other areas on our campus which includes skilled, of course the rehab, assistive living. A year ago the Brothers merged with a different order in Germany. The order is out of Trier, which is next door to Luxembourg. We’re a nonprofit. You know, sometimes that can be a little bit different than having to earn every last dollar to pay shareholders and we really have the compassionate quality and price that people are looking for.

You all have talked about how your operations have changed over the years. What pushed that change?

McGUIRE: I think it’s market-driven. It’s a recognition that health care has to become more efficient. But you can’t become more efficient by sacrificing quality.

EIMER: Patients are becoming much more medically complex, so the patients are driving care, in some respects. And then, of course, regulations are putting the framework around how you can address those needs. But certainly I think in the old days it was hips and knees, things like that, orthopedics. Now it’s much more complex with strokes and cardiacs and all kinds of things that probably used to be in the hospital.

How has that affected your workforce and the investments you needed to make to be able to manage those types of patients?

RUBIN: It involves a truly comprehensive plan about how to go about treating these higher-acuity residents. We took the approach that we started from the top, which meant the physicians and physician extenders. We hired a corporate medical director to supervise our physicians and physician extenders. We are extremely diligent and put a tremendous amount of effort in recruiting different physicians and their extenders, so there is a lot of emphasis on that. The next focus, or whatever you want to call it, the pecking order or the skill set, is the nursing component. We created an educational center for our company so that we have a level of control vis-a-vis onboarding and quality regarding our staff. We have moved to more of an RN model, a registered nurse model, versus the traditional LPN model. All our buildings have RN coverage 24/7. Wherever possible, we try to hire RNs as LPN positions open up. There is a strong emphasis of having RNs, specifically on the higher-acuity units such as the subacute units. Our buildings are always looking at being centers of excellence in a certain clinical diagnosis. We are trying to truly distinguish ourselves specifically clinically in our various sites.

All of you have some expanded investments in bringing in more skilled workers to manage those patient populations. What are you seeing in terms of getting return on those investments?

RUBIN: The return is a result of additional patient throughput. It allows us to drive volume for those patients. And as long as the volume is there, there is a level of profitability. We believe that if you are able to distinguish yourself clinically, you are able to collaborate in the various initiatives that sit out there in the marketplace. One initiative is obviously preferred-provider relationships with hospitals, payers, referring physicians and the community-base referral sources. So we’re a strong believer that investing in the individuals, in these skilled individuals, in technology, in training allows you to have those collaborations and be successful at them. One of the most important focuses today in health care is the rehospitalization rate. Everyone is looking at how you are performing. And the government is going to eventually ding you if you have poor rates. But all the providers that have any sort of financial risk, whether it’s the traditional Medicare, managed care payers or even the hospitals that are pursuing bundle payment rates, they want to be sure that there is minimal in the way of rehospitalization rates. And having these higher-level clinicians, both the physicians and the NPs and RNs allows you to perform better and prove yourself to the payers and to the community and show how you are a value proposition to the payers and the referral sources.

Jim, follow up a bit about the preferred-provider programs.

McGUIRE: We are very proud to be the preferred provider for the Catholic Health system and for Kaleida for their bundled program, and for Highgate Medical, Envision Health and Infinity Health, a number of physician groups. And as I listened to Dr. Rubin’s approach of starting with physicians at the top and working down, I see that in contrast to our approach of starting with the direct caregivers and inspiring them, investing in them, creating career paths and opportunities so that they can continue to grow in their clinical skills and sophistication. We have done our best to create the clinical outcomes and the single-digit rehospitalization rates and the quality metrics that are measured by the state. We think that that’s been the means by which we have been able to establish those preferred-provider relationships and cultivate and grow them. And, in fact, we have been able to help other organizations. Like the Catholic Health system has competing nursing homes with our own, but we’re able to use our educational programs to help train their staff.

We talked about the return on investment. But that is different in the nonprofit sector. So how are you addressing that?

KOENIG: Well, it’s different and it’s the same. We have the same hurdles as the for-profits do. The regulations don’t change just because we are not-for-profit. The only difference is the composition of our board. Luckily, my board is vast but very understanding. They’re mission-driven, Christian-based. Christian values go into every decision that they make. So the bottom line still exists regardless and we have to keep the doors open. Return on investment is not immediate and I can tell you it’s not going to be tomorrow. There are a lot of new things happening in the industry such as value-based payments, bundles, etc. A lot of that hinges first on your quality, to make sure you can be at the table. Everybody here is at a five-star level. There are geographic regions around the country that can’t even participate because they don’t have three-star facilities. So that adds to a level of competition in Western New York. I’ve consulted across the Northeast and I can tell you Western New York is pretty competitive. And I’m sure that everybody else in the room can tell you it’s the same. We have two large, competing hospitals. It’s important that we all stay at the preferred providers and we do that through the quality. But the microscope is shifting from just your star status, so the hospitals and payers want you to be smart statistically. They want you to know what’s going on in your facilities in terms of rehospitalization.

McGUIRE: Because our industry has been traditionally a fee-for-service industry, it was perhaps counterintuitive to many providers to work to reduce their length of stay. It’s no coincidence that other providers would typically have a 20-day length of stay because the first 20 days are typically fully covered by Medicare and there is no co-pay. There is not that financial sensitivity to the patient and facilities perhaps had an instinct to maximize their revenue by keeping a patient for a full 20 days. For many years we have been cannibalizing our own business and working to reduce our length of stay. And as I talked to providers around the state over the course of the years, it was more shocking to them years ago that you are reducing your own revenue. It seemed counterintuitive to them. The shorter length of stay means an overall lower cost per case. The goal is to have a shorter length of stay and then hope to make up in volume with more patients.

EIMER: The statistics show, nationwide anyway, there’s been 40 percent less revenues and a 30 percent paid length-of-stay drop since the government put in all their new regs. And it goes to what Jim says: It’s a little counterintuitive for an organization to move their customers, if you will, out of their system quicker. But that’s the best way to do it for the patient. So you have to keep things positive and in black. Again, that’s not our main focus. Our main focus is still the patient.

Let’s talk about post-acute services such as rehab. Where is that heading?

EIMER: It seems like the hospitals of, let’s say, the ‘70s are now the nursing homes. And the nursing homes of the ‘70s are becoming assisted living and so on. So I totally believe that the paradigm has shifted. And for a bunch of us, we have multiple facilities on the same campus which can allow for those different levels. But I think the hospitals are becoming more outpatient and that’s part of the overall industry trend.

KOENIG: A lot of that is what we are seeing in the increase in health care costs in the United States. That means that we have to continue to invest in the training of our staff. Hospitals have RNs, we have RNs, so it’s important that the nurses have the confidence in their clinical skills so that when they are getting a patient who is sicker or sooner in their stay, because they are moving out of the hospital quicker, that they have the ability to treat that patient. They have the assessment skills, they have the support of physicians and administrative executive staff in the facilities to be able to do that. To Peter’s point, having all the services located on campus, I can tell you that our assisted living residents are more complex and their length of stay has actually increased, too. We have increased the clinical competence of all levels of assisted living. The memory care is not traditional memory care anymore. It’s focused on the 24/7 care. These are the folks who would have been in memory care, in skilled nursing, five years ago. We are seeing them at these specialized assisted living residences. So it really is affecting all levels beyond just subacute.

RUBIN: Regarding skilled nursing homes being more hospital-like, we have already seen that. As we have started to renovate our facilities, just the physical environment is more hospital-like from an infection- control perspective and finishes and even hospitals today moving to private rooms. As we renovate our facilities, we are trying to create those private rooms. Clinically, we are moving to more intensive MD, NP, RN services. There is just more in quantity and more in quality. Finally, there is a whole different level of collaboration. Care plans, our care pathways, are being shared between the discharging hospital and our facilities. There is a lot of sharing of information through technology, through the EMRs. It is very much with a hospital mindset how they are being treated in our facilities.

Let’s talk about what’s happening at the federal level with cuts that probably are coming. Can you prepare for some of them?

McGUIRE: I don’t think you can prepare specifically for any of the cuts that might be contemplated because we really don’t know what the impact will be. We can anticipate that New York state is likely to have continued budget challenges in the way of health care because their Medicaid spending is so high. We currently lose a substantial amount of money on servicing those Medicaid patients because we haven’t been willing to cut our costs or the quality of our care in order to keep it in line with the reimbursement the state offers. But we try to reduce our dependency on the Medicaid population by growing those other services, those higher-value, more clinically sophisticated services. So from our standpoint, our hope is that if we position ourselves as a cost-effective, high-quality provider, that when the dust settles sooner or later, whomever is making those purchasing decisions or spending health care dollars – be it the state, the health care system, the insurance companies – that they recognize us as invaluable members of that health care continuum and will pay us fairly for our services.

EIMER: If you can continue to diversify your revenue sources, that’s one strategy for what we already have been dealing with, all of us, for years anyways. The reimbursement for Medicaid is far less than all of our costs on a daily basis. So you are dealing with, in our case, 60 percent Medicaid patients. And we are already underwater on each one daily by $60 to $70. So we have already dropped the tip of the iceberg there with diversification on the campus with other services and independent living, things like that. And that’s been the business model for many of us for quite a while. So when you see $800 billion on the Senate bill which didn’t go through this time, you are dealing with the most vulnerable patients that any of us have. And, again, I think we will all agree, it doesn’t seem to be the right thing for government to be doing and we are glad this one, this time, it didn’t happen. But we are all trying to prepare for further cuts.

KOENIG: It’s difficult to forecast. I’m sure nobody is forecasting next year an increase in their Medicaid rates or anytime in the future. I think statistically it’s important to understand whatever is on the political agenda doesn’t necessary get wiped away when a bill doesn’t go through. So diversification, as everyone has talked about it before, is also important to look at operational expenses, efficiency, because we know we can’t change some of our reimbursement rates. And we know we can’t go to an insurance company and say, hey, these guys are paying us less, you have to pay us more. We don’t have that kind of leverage as skilled nursing providers. I think it causes us to look at other pieces of our business to increase our efficiencies, whether it’s through costing payments, but I’m sure nobody here is looking at that from a staffing perspective. So our staffing costs are going up. So are there other areas we can find these deficiencies or can we increase our relationships with other providers in the area? I think that’s one of the largest strategies that we have to look at.

EIMER: I was thinking the other night, if you are a car dealer, you have an idea what you are going to sell your cars at next year and the price. We don’t have that. We don’t really know what our price will be next year. So it’s a very difficult industry to operate.

RUBIN: Elderwood has a similar mindset regarding diversification. We are doing a lot more in the way of assisted living and hopefully independent living. We are looking at efficiencies. There are two specific areas that we’re looking at: One is electronic point-of-service documentation. We believe that there is an efficiency and level of accuracy both from a compliance perspective that allows the aide to spend more time with the individual and, likewise, with the nurse. And the other, what I hope will be an innovative practice pattern is multi-dose packaging of pharmaceuticals. That would allow the nurse to really spend a lot more time with the resident regarding assessments and treatments and taking significant amount of time away from the actual med task. So those are two, hopefully, productive and creative ways that we will see better efficiencies in the operations of the facility.

You mentioned independent living. Is that something that you are moving into with the company?

RUBIN: We are always looking at it; it’s something that we’re interested in. Obviously market-driven. Our company today is growing in the North Country. We are not just purely Buffalo-based and we have facilities in our markets. We are strong believers in the continuum of care and wherever we have a facility, whether it’s AL, SNF, we are always looking at opportunities to develop other levels of care in conjunction with those facilities.

When you look at continuum of care, which you have on your campuses, Jim, is that something your company is looking at?

McGUIRE: In the mid ‘90s we purchased land and spent a fair amount of money on beautiful architectural plans for an assisted living facility. We ultimately came to the conclusion that we had so many great relationships with other assisted living operators that if we were to get into that business, we would likely alienate those relationships. And while I’m sure we would have done a quality job of it, I can’t say we would have done any better of a job than many of those assisted living operators, that we today, 20 years later, still have great relationships with. So our personal choice was to complement other people in the continuum and to work closely with them but to not necessarily vertically integrate our own organization. Because to do it effectively, you have to have so many more assisted living beds than skilled nursing beds. The proportions have to be in the right numbers in order to keep each facility full. And I think those proportions have probably changed as the acuity levels and patient patterns have changed. We decided to just focus on our skilled nursing facilities and grow the subacute clinical offerings and outpatient services because they complemented our other relationships with both the hospital systems and the existing assisted living communities.

When you look at what’s coming next for your organizations, forecast maybe five years down the line, when you look at who you will be serving and what services you will have at your facilities, what do you see?

EIMER: Technology-wise, I have to say this because I saw it. You probably all saw it. It’s a great little snippet here about an Italian research company that has been able to create a wearable robotic device designed to sense a senior’s impending fall within 350 milliseconds and apply torque directly to the stumbling limb.

So they have to wear this thing all the time?

EIMER: It’s worked on their sample. There are some crazy innovations coming. I think a lot of people can speak to a lot of future dynamics. It’s incredible what we don’t know is coming. But fall prevention is huge; it’s so important to prevent them. Well, now you have technology involved instead of wondering where a wire is or a rug is or things like that. I don’t think any of us can predict five years, technology-wise, what’s coming. It’s just so rapidly changing. And that’s just technology. I know others can speak to financials and regulations and patient outcomes and length of stay. But from a technology side, it’s unbelievable.

McGUIRE: From a technology perspective, one of the things that we’re excited about and advancing forward since we solidified a relationship with VestraCare and other nursing home operators across the state, they have a restorative care unit and a technology they call Telestat, which we’re implementing in our facilities. It’s what I would refer to as Star Trek stuff. It’s a Wi-Fi and cellular-enabled wristband, has a sensor on one finger and another patch sensor that you can put on patients and leave on patients 24 hours a day, comfortable enough to wear. It’s not impeding their ability to go anywhere in the facility, inside, outside, etc. But it monitors hemodynamic functions and cardiac output. It actually uses technology that was in part licensed from the Israeli military and developed to monitor soldiers in the battlefield and to assess how badly are they injured and how quickly does help need to be rushed to them. But in our setting, it’s being used to look at things like the cardiac output of a patient. And the physician who can see their data on their cell phone or on big screens in a war room monitored by nurses or on every nurse’s cart in the hallway. It can help staff predict problems with patients. So two days before somebody goes into congestive heart failure, the physician can see the fact that their cardiac output is declining and their heart rate is increasing and then you make adjustments to that patient’s plan of care. I think the technology is amazing and this Star Trek stuff is going to become more common. And, in fact, we have seen sustained rehospitalization rates in the low single digits, less than 5 percent. And compared to industry, the averages might be 20-some percent. So those types of technologies are going to be a great benefit to patient population in the future.

RUBIN: Five years from now … that’s a fascinating question. People are living longer. People are living well into their 90s today. We also have the cohort of baby boomers hitting our industry. I believe that they will hit significantly in five years. We will all survive the next five years and all the changes coming our way through marketplace or regulations. I believe we will see a lot more patient population. And if I had to venture a guess, I believe that, obviously, most people will try to stay home; that would be the goal and objective. But people who require care will get that care in the most cost-effective setting. So people who could be in ILs (Independent Living) will be in ILs. People who could be in adult homes will be in adult homes. People who need more in the way of medical services will require enhanced assisted living. I have to believe that the Alzheimer’s patient population will be a significant cohort of patients in five years. And so these special-need facilities, SNALRs, in New York state will be in high demand. And so I think in five years, that would be how I see the vision. The technology that Jim mentioned probably will improve the quality of care in the subacute units. Length of stay will always be extremely important, as Chris suggested. Everyone is going to be looking at value, so there has to be a value proposition, whatever level of care we are at.

KOENIG: In addition to all the technology, I think what we are starting to see today is a stronger move toward population health management that is encompassing post-acute care, that’s not just primary care and acute care, and that’s going to extend even further. So with the population health management, it’s going to become a predictive analytic and I think that’s going to help drive the patient into the most efficient and cost-effective level of care. Folks are still going to need nursing homes but we know that the level of complexities will increase. The areas that I think are going to change, as Dr. Rubin pointed out, are the assisted living, the memory care units, and I think even the independent living. I can tell you our independent living, it’s still at a level of complexity. Those folks, they support each other just as much as our staff does and they understand. If you ask those folks, they say, “I want to stay where I am, I don’t want to go to the hospital. If I have to, I want to go to the health center, but I would really like to stay here.” That’s where the predictive analytics tie into all this telemedicine. We want the changes to happen much quicker than a patient waiting weeks sometimes to see a specialist. Telemedicine can be nearly instantaneous, but that information transmission has to be much quicker. Five years from now, I think we are going to be there. I don’t think we can wait much longer than that. So I think the information transmission between the levels of care but also with our partners is going to be much tighter than it is today.

You all are partnered with different educational providers. Some of you have people rounding in your facilities from the hospitals, you have med students, you have programs through the nursing school at UB. Can you talk about what it’s like having stronger partnerships with those educational providers?

EIMER: We started years ago with D’Youville College School of Pharmacy and that’s been going on seven years or so now. They do rounds and do their clinicals and so on, but we benefit, as well. I remember when they first came in, we had X amount of pills per patient from various doctors prescribing and probably not knowing what some of the other doctors were prescribing. So they came in and they were able to reduce some of these cross-over prescriptions. And for the patients, that was a big improvement. From a cost perspective, obviously it’s better for us. It’s better for everybody. So that was a neat thing to start and it has continued. I know there’s been talk about education, as well. We have a program with Trocaire now where our aides and LPNs can get further educated, basically tuition-free between our assistance and Trocaire’s. So there are some career ladders for some of our people. And by the way, old people love having young people around, so it’s great for everybody. One of our new buildings going up is involved with UB’s School of Architecture. So all these things, I think we are blessed to be in a community with such a strong educational system. And we’re probably all working with them to benefit the students and patients.

McGUIRE: I agree with all of what Peter said – that it’s inspirational for the staff to have those career ladders and to be able to grow in their educational experiences. It makes them better staff. It makes them more likely to stay with the organization and gives them the ability to offer better care. Those collaborative relationships with the universities are fabulous for everyone involved and mostly for the patients.

Are universities or colleges coming into your sites, as well?

McGUIRE: We have great relationships and clinical rotations with D’Youville and Trocaire because of their nursing and health care programs. We do things with BOCES and some of the LPN programs, trying to cultivate those relationships while people are early in their careers and trying to identify what segment of health care they want to work in, trying to help make a positive impression on behalf of the long-term care community and our organization. So that people can understand that working in long-term care and working with the elderly might be a very rewarding career path for them.

KOENIG: From an educational perspective, it’s very important to all of us. So tying into schools and the educational programs is important for a lot of different reasons. One of them is for a circular feedback loop. Just as much as we benefit from universities allowing the students to do their clinical rotations and partake with us, they let us know what’s the newest and the best, what’s the clinical research showing us. From our perspective, I think we can show them what does the industry need, what are the changes. We need graduates to be strong clinicians and I think our benefit to them is we can let them know what’s changing in the regulations, what’s changing from a financial perspective and what do we, as future employers, need from folks we’re going to be recruiting from these colleges. We all have the same issues with recruitment and retention. Western New York, compared with the rest of the state, we’re a little behind, so it’s important for us to make relationships with these folks as they come out of school but also so they want to stay in Western New York and want to work with us. I think that’s where the mutual benefit is to having these partnerships.

RUBIN: Elderwood has clinical rotations for LPNs, RNs, pharmacists throughout all our facilities in the company, even in our facilities out of state. I want to emphasize a point that Chris made. There is such a shortage of health care staff out there today of all levels, RNs, LPN’s, even CNAs. And these clinical rotations allow us the opportunity to market to these individuals and to encourage them to think of a career in geriatrics. And that is invaluable for us to have that exposure to these individuals and see if we can’t encourage them to pursue a career in geriatrics. And I think that’s a tremendous benefit and something that we just have to keep doing. Because as America ages, we are going to need more and more of these individuals. And even today, already there is a shortage. I can’t imagine what it’s going to be like in five years. I think these clinical partnerships with academic institutions are truly invaluable.

Is there something you see happening in the industry that we have not touched on that you want to ask each other about or that you want to share with us?

EIMER: I just think the staffing is a huge challenge in our industry. It’s the No. 1 challenge for us, anyways, and at all levels. And it has to be addressed. Our costs are increasing with minimum wage changes and things like that. I don’t know if that’s a function of Western New York having such a strong employment situation right now or if it’s a bigger issue nationwide. One of my daughters, she just got her NP and she is over at DeGraff with the geriatric group. But there is not enough of that. There are not enough students, I think, looking at careers in long-term care and geriatrics. We need more of that.

RUBIN: Staffing is our greatest hurdle today. And we spent a lot of time trying to be creative in how we can market to the millennials. We have to think out of the box regarding scheduling. What’s the value proposition to the millennials? They are as much our customer today as is our patient population or our current staff. We are going to have to speak to them and attract them in thinking about a career in geriatrics. To me, that is the most pressing issue currently. I don’t know if this is the right forum or not, but CMS is looking at a whole new way of paying for Medicare Part A services in our space. They are talking of an alternate payment model. Not sure if it will happen or not. If it does, I’m not sure when it will happen. So that’s something we are going to have to think about.

KOENIG: I’m on a workforce redevelopment committee in Western New York. One of the things that’s important is this, you ask what’s difficult in long-term care and when we say staffing, there are jobs available. There are jobs with good benefits and good pay. But it’s not a hurdle that I think we can handle as long-term care providers alone. So there has to be extensions in the community. There has to be a reinvestment in Western New York. There has to be a collaboration between the schools, not just the colleges but the vocational programs. And it really can start in the high schools. So it’s an industrywide thing throughout the state. It starts in primary care. We are having a shortage in primary care. That actually extends almost all the way through all health care professions. And when it hits our front line, that’s the most difficult. Maybe we can get the support of some legislators to sit down and talk with us so we can say you have constituents that need jobs; we have jobs. And here’s some hurdles that we have, such as public transportation, ease of access to schools or support for the folks going through school. There may be some social services components that need to kick up. But I believe as it stands today, it’s bigger than the folks in this room. We could use help but we also have resources to provide back to the community. The jobs are there. We have them.

McGUIRE: Our industry as a whole needs to connect with and inspire young people and help them realize that health care can be a very rewarding career. It’s not likely a job that will be replaced by atomic driving vehicles and robots and IBM Watson. So people used to think that being a lawyer was a safe job. Now, IBM Watson will answer many of the questions we might have called you for. In the future, lawyers will still be necessary but they will be affected by technology. And truck drivers will and retail store clerks. There are so many industries that are hard to predict what the employment opportunity is going to be in the not-too-distant future. But health care is not only something that can’t be exported, those jobs won’t be offshored. They are here. They are in the community. And more important than that stability is the fact that it can be such an emotionally rewarding and satisfying job and career path for people because of the relationships they build – not only with each other but the patients they serve. If we begin with young people in high school, as they do their community service-type of work or interaction and come into nursing homes, to have them understand the positive impact they can have if they choose that as a career path and how they can find it personally rewarding in building those relationships and helping people with health care issues. Once they get beyond some of the less-than-desirable tasks that are involved in personally caring for individuals, it’s a challenging job but they can understand and appreciate the tremendous and positive impact they can have. I think we can’t motivate people simply with wage rates and benefits. Those things are necessary and you need to be able to give staff stability and security in life, but people need to choose a health care career not because they are making 50 cents more than at a fast-food restaurant; they need to choose a career in health care because they are passionate about it and they appreciate the emotional connection and the positive impact they can have.