Transcending Home Care

A financially viable home-based palliative care model is driven by appropriate practices, processes and logistics. A big part of establishing successful parameters comes from starting with a sensible staffing model. What are the right roles in a palliative care start-up? How should a provider schedule patient visits? What’s the proper mix of in-person visits versus support by phone or virtual video visits? How does the right level of patient care translate into manageable caseloads for clinicians and social workers? How can providers make sure services are covered by reimbursement? In this second episode of a two-part series, Mark Hendrix, president of nTakt, and Amanda Copeland, a palliative care nurse practitioner, join host Stan Massey of Transcend Strategy Group to discuss staffing, billing, telehealth and other smart palliative care practices. Mark’s company, nTakt, is focused on building sustainable palliative care programs by utilizing meaningful technologies, uncomplicating processes and providing hands-on training. Mark has over 35 years of experience in process improvement and business turnaround. He is trained as a Lean Six Sigma Blackbelt with over 10 years of experience applying Lean concepts in healthcare settings. Mark also has served as Operations Director for CMMI Palliative Care Grant and has had results published in the Journal of Palliative Medicine. Amanda Copeland, AGNP, has dedicated over 20 years to caring for seriously ill patients, primarily focusing on hospice and palliative care in home settings. She is passionate about supporting seriously ill patients and families during this difficult part of their life’s journey. Amanda played an integral role in building a successful home-based palliative program that has served more than a thousand families and continues to expand into new regions.

Most healthcare providers – especially providers of care at patients’ homes – started their organizations offering one particular service line. Whether that original service was home health, hospice, private duty nursing or something else, many organizations felt the need to expand their services and engage with patients for more needs over longer periods of time. When these organizations added even one more service, they often began to talk about their “continuum of care.” But how expansive should a continuum be? How can agencies know what service lines to add and when to make the expansions? How do you make margins on new service lines? And what about staffing when it’s challenging enough to keep current positions filled? In this podcast episode, Rhonda Sanders, chief mission access officer of Empath Health, joins host Stan Massey to share details of how her organization has built a very robust continuum of care that engages patients and families at different stages of life. Empath Health offers 10 service lines – and growing – including a sexual health program for adults of all ages. Rhonda and Stan discuss Empath’s business strategies for adding services, keeping up with staffing demands, the use of telehealth, appealing to managed care plans, different reimbursement models and more. Rhonda Sanders joined Empath Health in November 2021. Rhonda plays an integral part in helping Empath Health continue to evolve as a customer-driven organization and is responsible for driving growth and enabling access among consumers, payers and referral sources for each of the organization’s services lines as well as overseeing the agency’s managed care strategies. A seasoned executive in healthcare operations, business development and sales, Rhonda has succeeded in leading growth strategies for home-based healthcare providers serving large, multi-state regions. Most recently, Rhonda served as vice president of business development for Amedisys Home Health, Central Region, in Lubbock, Texas. She also served as area vice president of sales/operations for Kindred at Home in Texas, New Mexico, Colorado and Oklahoma.

Due to the historically weak reimbursement stream from CMS for palliative care, providers often have been conflicted with providing this undeniably helpful service and staying out of the red while doing so. Some hospice providers started their palliative care service line with the mindset that it would be a “loss leader” – they expected to lose money on the service but hoped to build relationships with patients and families sooner, convert them to their hospice care as early as appropriate, and make up for the loss through stronger hospice census and LOS. For most providers, things didn’t really work out that way. So how can providers deliver the comfort and quality of palliative care without hurting themselves financially … and build a program that can be sustainable? In this podcast episode, Mark Hendrix, president of nTakt, joins host Stan Massey of Transcend Strategy Group to discuss wise approaches to solving the palliative care dilemma. The conversation covers billing practices, the role of telehealth, a smart foundational model to build a strong palliative care program, the future of reimbursement and much more. Mark Hendrix has over 35 years of experience in process improvement and business turnaround. He is trained as a Lean Six Sigma Blackbelt with over 10 years of hands-on experience applying Lean concepts in healthcare settings. Mark also has served as Operations Director for CMMI Palliative Care Grant and has had results published in the Journal of Palliative Medicine.

Most providers of home care are struggling with major staffing shortages – especially among nurses, CNAs and social workers. The COVID-19 pandemic ushered in a new era of professionals reevaluating their careers, resulting in massive job changes and even “the Great Resignation.” Turnover among many healthcare providers is at record levels. Recently, Transcend Strategy Group and MAC Legacy partnered in a national research project to explore what healthcare workers look for in their careers so employers can be more effective with recruitment and retention. According to the research results, 30 percent of healthcare workers say they are likely to change jobs during the next year. Yet, not many have home care as their destination of choice. For instance, fewer than half of RNs say they would consider opportunities in home care. In this podcast episode, Marcylle Combs – president and CEO of MAC Legacy – joins host Stan Massey and Transcend CEO Stephanie Johnston to discuss details of the research findings and insights gleaned. The conversation covers what the home care workforce cites as their top reasons for leaving a job, as well as the priorities they’re seeking from a new position. By unlocking these motivators, home care organizations can promote their current attributes or build new ones to be more attractive to workforce recruits – and help reduce turnover of their staff. Marcylle Combs, BS, MS, RN, CHCE, has shaped MAC Legacy to turn complex problems into simple solutions for home health and hospice providers. With more than 30 years’ experience in these home care categories, Marcylle has held many roles, including field nurse director, administrator and owner/president of a successful home health and hospice company. She also serves on the board of directors for the Home Care and Hospice Financial Managers Association (HHFMA) and chairs the Women in Leadership Committee for HHFMA.

It’s no secret that most seniors in America want to maintain their independence for as long as possible. In fact, according to the Disabled Living Foundation, the majority of seniors say they fear losing their independence more than they fear death. For many, a main hallmark of independence is being able to age in place. A survey by AARP revealed that 90% of Americans age 65 and over want to stay in their home and 80% believe their current residence is where they will live until they die. Other statistics show 27% of seniors currently live alone – and that number is projected to keep growing as Baby Boomers age. So, a crucial key to empowering seniors to maintain their independence, especially if they live alone, is the use of technology to monitor their health and well-being. Ryan Herd – founder of Caregiver Smart Solutions and CEO of 1 Sound Choice (a company specializing in smart home automation) – joins host Stan Massey of Transcend Strategy Group in this engaging discussion on remote monitoring technology and its increasingly important role in caregiving. Whether you’re a professional provider of home-based care or a concerned family member wanting to keep tabs on a senior loved one, existing and emerging technologies are making remote monitoring easier and more effective. Ryan and Stan cover a variety of significant factors for remote monitoring, including fall detection, looking for changes in living habits, tracking clinical vital signs and much more. With 30 years of experience in smart home technology, Ryan consults with the home building and healthcare industries and is a sought-after speaker. Because of his expertise, he was selected by the National Kitchen & Bath Association to be a 2019 NKBA Insider to assist in educating its members about the importance of collaboration between technology integrators and the design community. Ryan offers unique insight into smart home technology, the Internet of Things (IoT), and the significance of technology in the home today. He also is the author of “Join the Smart Home Revolution,” Amazon’s #1 best-selling smart home book.

COVID-19 magnified the need and desire for patients to stay out of hospitals if possible. A national survey conducted by Transcend Strategy Group revealed that more than 60% of family caregivers had greater confidence in the quality of care provided at home during the pandemic versus care in a facility. Plus, the repeating surges in COVID cases across the country pushed many hospitals to the brink – and sometimes beyond – when it came to inpatient beds available. Cooper Linton – associate VP of Duke HomeCare & Hospice – is at the forefront of helping a major healthcare system rethink how certain patients can receive care at home instead of in a hospital. In this discussion with host Stan Massey of Transcend Strategy Group, Cooper discusses the pioneering efforts of Duke University Healthcare System in starting a COVID Care-at-Home program and examining the option of starting a Hospital-at-Home program. The conversation covers a variety of issues related to these programs, including patient criteria to identify candidates for home care, the different demands on providers for managing higher acuity patients at home, and the growing imperative for remote patient monitoring and other technologies to enable the efficiencies necessary for a larger home patient census. Cooper has deep expertise in managing home-based and community-based care. Before taking his current role at Duke HomeCare & Hospice in 2018, he was VP of marketing and business development at Transitions LifeCare (founded as Hospice of Wake County) for 13 years. His career also includes experience with home health providers. In addition, Cooper is co-host of his own podcast “Edge of Aging” – a series that asks, “What if we reimagined how we provide care for older adults and their caregivers?” and explores the possibilities.

COVID-19 ushered in an overwhelmingly stronger preference for patients to receive care at home rather than in a facility. A national survey by Transcend Strategy Group revealed that 60 percent of family healthcare decision makers are now more confident that quality care can be provided at home versus 33 percent feeling more confident in the quality of care at a facility. This preference, along with the growing demand for care as the huge demographic of Baby Boomers continues to age, is opening new opportunities and challenges for providers of home-based care. In response, Bill Dombi – Doctor of Law and President of the National Association for Home Care & Hospice (NAHC) – has said that providers of home-based care must demonstrate “a willingness to not only embrace change, but to lead it.” Through this important discussion with host Stan Massey of Transcend, Bill offers his insights to three key areas of necessary change: 1) Widening the understanding of what home-based care can provide; 2) The role of technology and other innovations in meeting the demands of home-based care; and 3) Developing a bigger and better workforce to handle the growing volume of home-based patients. Bill has served at NAHC for more than 30 years, including his role as president since 2017. He also serves as executive director for the Home Care & Hospice Financial Managers Association. Bill specializes in legal, legislative and regulatory advocacy on behalf of patients and providers of home health, private duty home care and hospice care. With nearly 40 years of experience in healthcare law and policy, Bill has been involved in virtually all legislative and regulatory efforts affecting home care and hospice since 1975.

When most people think of “home care” or “home health,” they think of clinical or skilled therapy services at home. However, as the “Silver Tsunami” of Baby Boomers continue to age, there’s an exponential need for nonclinical home care. By helping with activities of daily living, providing personal monitoring and supervision, serving as a companion, running errands and much more, nonclinical caregivers help seniors age in place with greater independence. Jeff Salter – founder and CEO of Caring Senior Service – has been leading his company for 30 years to meet these needs. In this discussion with host Stan Massey of Transcend Strategy Group, Jeff delves into the lack of awareness and understanding about the availability of nonclinical home care, as well as key opportunities and challenges of this important service. The conversation covers the details of the crucial role nonclinical home care serves. Jeff and Stan also talk about the gaps custodial care can help fill in partnership with clinical providers, the current lack of reimbursement or tax breaks for nonclinical care at home, the impact technology will have on home care innovations, and the career opportunities for home caregivers – including workers being displaced by technology in retail and food service. Jeff began his career in home health and quickly saw a glaring need for greater custodial home care. He started Caring Senior Service in 1991, launching the company in Odessa, Texas. After expanding across the state for 12 years, the company began offering franchises in 2003 and today has 45 locations in 20 states. To celebrate Caring Senior Service’s 30th anniversary – and to bring national attention to the outstanding needs in senior care – Jeff is embarking on a 9,000-mile electric bike journey starting April 1, 2021 (no foolin’!). He will ride to each of his franchise’s 45 locations and begin a dialogue with each community on how they can join him to Close the Gap in Senior Care.

Many physicians view palliative care and hospice care as the same service – pain and symptom management for the very end of life. By not referring patients to palliative care early in a disease progression, the patients and their families may be missing out on valuable relief from physical, emotional and spiritual suffering. Annette Collier, MD, FACP – and a medical director for palliative care – has invested more than a decade in educating her physician peers about the many advantages of earlier referrals to this specialty. In this conversation with host Stan Massey of Transcend, Dr. Collier shares her insights on successful approaches she’s had for partnering with physicians and greatly enhancing their understanding and appreciation of palliative care. The key? Working with physicians one-to-one and having them experience palliative care “the right way” starting with just one patient. Dr. Collier discusses how she demonstrates palliative care as a very collaborative effort with the referring physician, working clearly in tandem with the doctor’s curative treatment plan. The conversation also covers the role of palliative care in different care settings, CMS’ shifting views on better interdisciplinary care for seriously ill patients, and advice for communicating with patients and families. Dr. Collier has been the palliative care medical director for Hospice of Northwest Ohio and their Sincera Supportive Care service line since 2008. She is board-certified in Internal Medicine as well as Hospice and Palliative Medicine. Dr. Collier also has served as an assistant professor at the University of Toledo Department of Medicine since 2016.

Whatever your opinion of the BLM movement, it has thrust the topic of true equality into a searing national spotlight – and has prompted many of us to reflect more deeply on the issue. In addition to risk factors regarding COVID-19 and minority populations, equality considerations have sparked renewed discussions on glaring disparities in healthcare across key demographics. Hospice and palliative care professionals have recognized for decades that minority populations greatly underutilize their valuable services. Recent Medicare data shows that of their members who died on hospice care, only 37.1% of African Americans received the service, 38.8% of Hispanic/Latino descent and 34.5% of Asian descent (compared to 51.2% of Caucasians). In this special podcast episode, Ronit Elk, PhD – Professor in the School of Medicine, Division of Geriatrics, Gerontology and Palliative Care at University of Alabama-Birmingham (UAB) – talks with host Stan Massey about an important research project and pilot program she has been leading. The subject is developing culturally based protocols for palliative care and hospice, with the goal of better engagement and access for minority populations. Dr. Elk and Stan discuss why the origins of traditional hospice care in America may not be an ideal fit with minority populations, the disconnect that can happen between the medical world and cultural beliefs, the influence of community in minority populations – and how such factors informed her process to develop protocols based on individual cultures. Protocols developed from her research currently are being applied through a pilot program in Beaufort, South Carolina, a rural area with a significant African American population. In addition to her position at UAB, Dr. Elk is associate director of the Southeast Institute for Innovation in Palliative Care and Supportive Care. She also served as guest editor on “Palliative and End of Life Care for African Americans” in a special issue of Journal of Palliative Medicine. Dr. Elk was born in Israel (but moved to many countries during her youth because her father was an Israeli Ambassador to Turkey, India, Uganda, Kenya and South Africa). She has been a U.S. resident for more than 30 years yet maintains a global perspective on serious illness, death and dying.

Palliative care may be the Rodney Dangerfield of healthcare. More accurately, palliative care does get major respect from those who know its value when properly applied – but too few truly understand the power of this specialty. In this conversation with host Stan Massey of Transcend, Melanie Marien, RPA-C – a nationally certified Physician Assistant and palliative care specialist – discusses how we may overcome challenges to make palliative care a routine part of treatment regimens. Melanie and Stan talk about persistent obstacles of distinguishing palliative care from hospice care in the minds of referrers, patients and families. Their discussion also includes her thoughts on educating referrers about starting palliative care early in the disease progression, the use of telehealth in furthering palliative care and how COVID-19 may have opened people’s eyes to the benefits palliative care can provide. A longtime practitioner of palliative care, Melanie currently runs her own healthcare consulting firm advocating for patients, caregivers and seamless care. During her career, she also has gained vast experience as the VP of Operations, Northeast Region for Aspire Health (a national palliative care specialty organization) and as the Director of Clinical Relations at Center for Hospice and Palliative Care in Buffalo, New York.

Providers of home health services, palliative care and hospice care often express disappointment and confusion regarding referral patterns by physicians. Many providers feel physicians don’t refer to them as early as they should or may be missing the full benefits they can provide to patients and families alike. What are common key barriers that get in the way of physicians making referrals to home-based care providers? How can providers better educate and communicate with physicians to break down those barriers and enhance the care patients receive? Special guest Michael Paletta, MD, FAAHPM, is Chief Medical Officer and Senior Vice President for Hospice of Michigan – the largest provider of hospice and palliative care services in that state. As a physician with a background in a wider range of healthcare, Dr. Paletta has decades of experience in collaborating with other physicians and understanding their mindset. Dr. Paletta joins host Stan Massey (lead consultant of Transcend) to discuss physicians’ perspective on supportive care versus curative care and how to overcome barriers in gaining physician referrals. Their conversation covers intriguing topics, including Dr. Paletta’s view on “buyer’s remorse” in today’s healthcare environment, the challenges of accurately predicting life expectancy with the interventions of modern medical, educating physicians on the full truth about palliative care and hospice services, and his hope for the new generation of physicians in seeing palliative medicine as the specialty it is – with referrals being the norm rather than the exception.

If there are any upsides to COVID-19, catapulting necessary change is one of them. Healthcare already needed innovation before COVID-19 if providers are going to indeed achieve value-based care – and COVID-19 gave a kick in the pants to make some of these changes gain traction. In this conversation with host Stan Massey of Transcend, Devin Griffith, MPA, MSW – vice president of development and innovation for AuthoraCare Collective – talks about innovations he’s seeing in home health, hospice and senior care … as well as areas where the need to innovate are still ripe for development. The discussion covers a range of topics. including the evolution of provider and community partnerships, integrated care continuums, payer relations and the growing role of remote care technology. AuthoraCare Collective is a regional nonprofit hospice and palliative care organization based in Greensboro, North Carolina. In his role, Devin leads strategic development and partnerships, service diversification, payer strategy, medical and community outreach, innovation and value-based care initiatives. Prior to joining AuthoraCare, Devin was vice president, home health and regional development for Advanced Home Care, a nonprofit organization owned by 12 health systems across the southeast, where he led the strategic development of the organization’s home health, home infusion, clinical respiratory, and home medical equipment services as well as integration, population health and value-based care initiatives.

COVID-19’s lockdowns and quarantines magnified America’s awareness of social isolation – especially among our seriously ill and elderly populations. Yet social isolation has been a challenge for many seniors long before this pandemic. One valuable tool in overcoming isolation among seniors is adult day care – if it’s available and affordable. In this conversation with host Stan Massey of Transcend, Kara Harvey, co-founder and CEO of Elder-Well® Adult Day Program, talks about the positive impact of adult day care on participants and their families. Along with the discussion on combating social isolation, topics include the benefits of cognitive engagement, music therapy, emotional well-being, the advantages of respite for family caregivers and other issues. Kara co-founded the franchise-based Elder-Well® Adult Day Program with her husband, Ken Harvey. Together, they have a long history of providing services in the elder care industry. Starting in 1998, they began an independent home care agency serving local seniors. To expand that company, they purchased a national home care franchise and continued to provide home care and hospice services. Then, in 2014, they developed a unique social-supportive adult day program to fill a need in their community. This innovative program quickly became a trusted resource for families and senior care professionals seeking day care services. Now, they are offering these services in communities across the country under the name Elder-Well®.

Months and months of preparation, training and concern went into preparing home health agencies for the change to PDGM. Now that providers have been using PDGM for more than a full quarter, how are they adapting to the new system? In this conversation with host Stan Massey of Transcend, Jess Stover, principal, and Erin Masterson, consulting director, at BlackTree Healthcare Consulting dive into what the first quarter of data is reporting – even though some of the numbers admittedly have been skewed by COVID-19 circumstances. The discussion covers a range of topics and insights from BlackTree’s distinct perspective. BlackTree provides the strategies, resources and knowledge that healthcare agencies use to fulfill their vision. The BlackTree team is made up of clinical, operational and revenue cycle staff to support its clients. They have both the technical expertise and the real-world experience to implement seamless solutions that assist agencies in a rapidly changing operational and regulatory environment. With a career almost exclusively in home-based care, Jess has helped organizations improve their daily operations by taking a consultative approach to reimbursement and strategy. Jess has more than 13 years of experience providing extensive revenue cycle and operations consulting to organizations of all sizes. Erin’s work has focused on operational and accounts receivable engagements with an emphasis on project management and leadership surrounding increased cash flow, accounts receivable reductions, revenue cycle redesigns, and interim management for home health and hospice agencies.

With the no-contact demands of COVID-19, telehealth and other remote care tools were thrust into the national spotlight. CMS started to relax certain restrictions regarding telehealth, and the use of video conferences skyrocketed for remote care and communications among clinical teams, patients and their families. A common perception, however, is that telehealth mostly consists of video chats – and remote care technology has the existing performance and future potential to offer many more functions to elevate overall care, as well as the patient/family experience. In this conversation with host Stan Massey of Transcend, Robin Stawasz, LMSW and program development executive for Acclivity Health Solutions, provides a range of exciting considerations for the emerging use of telehealth and other remote care tools. Starting as a Hospice Social Worker in 1990 and dedicating her professional life to hospice, Robin has held a variety of clinical, leadership and administrative positions within hospice and palliative care, often specializing in innovation and program design. She has served on many regional, state and national Boards and hospice related organizations, and has written and presented on a wide variety of topics focusing on serious illness care. Robin’s work with Acclivity Healthcare Solutions helps deliver the technology providers need to ensure patients with advanced illness receive the right care at the right time in the right setting – while honoring the patient’s dignity, goals and values. The company’s Connected Care platform utilizes analytics, machine learning and workflow management to uncover insights needed to avoid unnecessary emergency department and hospital stays. By further empowering home-based care’s effectiveness and efficiency, such technologies help improve quality and reduce spending for America’s sickest and most costly patient populations.

Physicians are trained to cure, or at least treat illnesses to stabilize patients and help them enjoy the highest quality of life possible. Perhaps that’s why many physicians struggle with difficult conversations when the prognosis isn’t good … especially a terminal condition. Timothy Short, MD, has been a practicing physician for 33 years – 21 years as a family doctor and a palliative/hospice specialist for the past 12 years. During that time, Dr. Short has developed a deep passion – and compassion – for communicating effectively with patients and families despite situations that are difficult to process. In this conversation with host Stan Massey of Transcend Strategy Group, Dr. Short shares very practical yet profound advice on turning difficult discussions into productive goals-of-care conversations. His explanations of tactics and techniques to focus on the person first and their medical condition second may transform your approach to “having the hospice talk” with patients and their families – all while supporting a new definition of hope for them. Dr. Short is Associate Professor of Palliative Care at University of Virginia Medical Center. In 2019, he was honored with the Leonard Tow Humanism in Medicine Award – an annual recognition of one University of Virginia faculty member chosen by the students for exemplary humanistic and compassionate care. Well-deserved, Tim!

Accurate diagnosis and prognosis are crucial in determining a patient’s plan of care. Many look at a prognosis as an “event” – a moment in time when a prediction about a patient’s illness trajectory is made – when it’s really an ongoing process that typically changes over time. Especially because of these changing dynamics, how can clinicians be more accurate about prognoses? Christian Sinclair, MD, AAHPM, provides intriguing information and considerations about the impact of prognoses – particularly on hospice and palliative care – and offers suggestions on improving prognoses going forward. In this conversation with host Stan Massey of Transcend, Dr. Sinclair discusses some of the challenging factors that go into making a highly accurate prognosis. He also talks about the need for unified research and prediction technology present in other businesses to be applied in improving the accuracy of clinical prognoses. In addition, the discussion explores the role of big data in the future of prognoses, along with the importance for clinicians to apply more tangible metrics to their observations. Dr. Sinclair is Associate Professor of Internal Medicine at University of Kansas Medical Center. He is the organizer of a popular weekly TweetChat on hospice and palliative care (#hpm), as well as editor-in-chief of Pallimed, a widely read hospice and palliative medicine blog. His deep expertise and passion for hospice and palliative medicine makes listening to this episode time well invested.

When a loved one is afflicted with a serious illness or a debilitating chronic condition, the family is often thrust into a new role of caregiver at their loved one’s home. Although a labor of love, the job can be very demanding, emotionally draining and physically exhausting. And many family members begin without the knowledge of where to turn for help. According to Nicole Clagett, founder of Transitions GuidingLights – a nonprofit agency dedicated solely to supporting family and professional caregivers – the confusion begins with the very definition of “caregiver” and when the duties begin. In this conversation with host Stan Massey of Transcend Strategy Group, Nicole discusses several important facets of family caregiving. Topics include navigating resources for assistance, family dynamics as different members pitch in to help, the impact of caregiving on the caregivers’ personal lives, and the changing face of family caregiving as younger generations assume the mantle of caring for their elders. Nicole’s vast experience in caregiver support and her candid approach in talking about the challenges of caregiving make for an intriguing conversation.

A basic requirement for any organization granted 501(c)3 not-for-profit status by the government is having an active Board of Directors. Traditionally, many organizations have built their boards by going down a checklist of desirable skills board members will have based on their careers. An attorney? Check. Financial guru? Check. Marketing professional? Check. But is this the best way to build a Board? Bill Musick, founder of Integriti3D – a company focused on improving hospice care across the country – offers a different perspective. With decades of experience in the entire continuum of health services, Bill has a passion for working with CEOs and Boards of Directors to achieve new levels of effectiveness. In fact, Bill has even earned Certified Governance Trainer credentials from BoardSource. In this conversation with host Stan Massey of Transcend, Bill explores the desirable traits of high-performing Boards. He shares insights about taking Boards of Directors beyond being partners in problem-solving with an organization’s executive team. In addition, Bill encourages Boards to be highly involved in setting an aspirational vision for their organization, championing the agency’s culture, modeling behaviors of integrity, connecting to the community in meaningful ways and other impactful activities.