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Now to learn more about Thorn, go to episode 323 of the Behind the Shield podcast with

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Joel Titoro and Wes Barnett.

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Welcome to the Behind the Shield podcast.

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As always, my name is James Gearing and this week it is my absolute honor to welcome on

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the show Joshua Rose and Dr. Jared Troutman.

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Now the reason why this conversation is so important is as you will hear, they are bringing

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an incredible solution to removing the non-emergent responses when it comes to the fire service,

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which in turn is not only providing better care to the people that call 911, but also

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the cost to that patient is greatly reduced and the added ripple effect is another ER

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bed stays vacant for a true emergency.

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So we discuss a host of topics from Josh's journey through EMS, the GMR response to Hurricane

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Helene, viewing 911 as a three tiered system and so much more.

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Now before we get to this incredible conversation, as I say every week, please just take a moment.

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Go to whichever app you listen to this on, subscribe to the show, leave feedback and

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leave a rating.

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Every single five star rating truly does elevate this podcast, therefore making it easier for

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others to find.

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And this is a free library of almost 1000 episodes now.

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So all I ask in return is that you help share these incredible men and women stories so

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I can get them to every single person on planet earth who needs to hear them.

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So with that being said, I introduce to you, Joshua Rose and Dr. Jared Troutman.

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Enjoy.

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Well Josh and Jared, I want to start by saying two things.

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Firstly, thank you to Rob Milano, who was the chief that connected us originally.

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And secondly, I want to welcome you both to the Behind the Shield podcast today.

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Thank you.

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Really excited to be here.

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All right.

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Well, first question for you, and I'm going to have to obviously point to each of you

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because you're sitting in totally different places and we'll get to why Dr. Troutman is

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in somewhere interesting at the moment.

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But Josh, start with you.

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Where on planet earth are we finding you today?

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So I am based right outside Pensacola, Florida, the beautiful panhandle on right on the Gulf

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Coast.

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And we obviously as a state just had two hurricanes recently, you know, and then, you know, one

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obviously went north and the other one, as I was saying, when we just hit record, tore

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through Indian River County and the tornadoes there were pretty catastrophic.

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The rest of us are very fortunate.

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So as that as a segue, Jared, where are we finding you and why are you sitting there

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right now?

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Yeah, so I'm actually in Asheville, North Carolina, which surprisingly enough, we all

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know a hurricane hit.

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So I'm out here supporting some of our deployed ambulance team members.

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So let's expand on that just for a second, because I saw when I was looking at the website,

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you have a state response.

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So before we dive into your backstories and the real reason why we're here, which is the

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nurse navigation, talk to me about the emergency response element that you have nationally.

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Yeah.

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So we are a primary national responder for disasters, certainly natural disasters.

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So for Hurricane Helena and Hurricane Milton, which, of course, we all know happened at

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almost the same time, we've had over 800 ambulances, over 2000 personnel deployed out to the front

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lines.

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And these are personnel from EMS agencies all across the US, literally as far away as

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Alaska and Hawaii, and all out here caring for patients.

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Even today, still have several hundred personnel and ambulances out there helping backfill

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the 911 systems here in Western North Carolina.

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What are some of the elements that were underreported to the average person that you're hearing

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now with the men and women that are boots on the ground in these places?

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So I think for everyone that comes out here, it really is just a rejuvenation as to why

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do we do what we do?

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Why did we sign up for EMS in the first place?

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Sometimes we get in a lull in our home jobs, but to come out here and to come together

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with people from across the US and really be able to impact somebody locally on their

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worst day, we know when people call 911, they're having their worst day, but this is the worst

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of the worst day.

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You really see a lot of new smiles and new rejuvenations and people actually leave refreshed

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after going out on deployment.

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Although it has all its difficulties, but there are so many positive stories and positive

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patient care things that happen at one of these.

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It really is just great to see all the positives that come out of this for our EMS providers.

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I think we've seen that even with the regular people, the neighbors and some of the volunteers

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that have come in with every tragedy like this, what I love is all the human stories,

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all the elements of community that I would argue is what America truly is, even though

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sometimes we get a little partitioned and divided by certain groups.

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You're exactly right.

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It really brings us all together and really is just a profound positive.

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I think it's refreshing and can be a reset for us.

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Absolutely.

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That's an interesting subtext to what we're going to be talking about later, which is

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really getting our responders back to real emergencies again.

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Before we go down that road though, let's start with you, Josh.

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Tell me a little bit about your early life.

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Tell me where you were born and what did your parents do, how many siblings?

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I grew up in Boston, Go Patriots, even though this isn't our year.

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I grew up right outside Boston.

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I have a younger brother and then my parents, both of whom who have passed now, were just

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in completely random industries.

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My mother was a writer primarily and my father actually was a sound engineer, created radio

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commercials and built some of the initial software for podcasts such as this.

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Your dad had probably appalled at my editing skills.

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So he never listened to the Behind the Shield podcast.

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All right.

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Then the same question to you, Jared.

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What about that?

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Where you were born, what your parents did, how many siblings?

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Absolutely.

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Born in North Texas, a town called Wichita Falls, Texas, my mom stayed at home with my

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brother and I.

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My dad actually buys and sells wrecked cars, which he still does today.

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That's probably a whole other podcast, but it's something that I like to do too in my

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spare time and not only wreck cars, but wreck motor homes and pretty much wrecked any kind

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of vehicle.

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I've probably fixed it and that's what we do and drive today, me and my family.

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My late brother was a paramedic for a number of years.

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Yeah, that's a little bit about my family.

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So Josh, let's go to your journey into EMS.

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I know you started working in your kind of home area as a paramedic.

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Absolutely.

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Thanks.

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So actually when I was an undergraduate student in college at University of Rhode Island,

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we had a student run ambulance program there, college based EMS.

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And I think like a lot of folks, I was intrigued by just the nature of this as an option.

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And so I started volunteering between classes and got to the point where it really, like

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everybody knows, once EMS gets in your blood, it's there to stay.

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And so it became something that I became really passionate about, that opportunity to help

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people to step in when people are at their worst moments and provide a real solution

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for them, get them to definitive care, whatever that might look like.

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It really spoke to me.

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And so I got my start back in the early 90s as a volunteer EMT with the college.

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And then I started volunteering for the town, took some advanced EMT program classes in

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Rhode Island.

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Of course, we have the EMT cardiac program.

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So I went to the cardiac school.

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And then when I graduated, looked at an option of, do I do something within my major that

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I went to school for and paid all that money to get a degree in or do I continue to stay

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in EMS?

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And obviously made the decision at that point to go to paramedic school and then started

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working in the 911 systems in Metro Boston.

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What have you seen as far as what you witnessed when you first especially became a full time

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paramedic and then what has been the evolution or devolution of the core volumes and some

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of the things that our responders are sending now?

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What have you witnessed?

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Because you've been in this for a long time.

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Yeah.

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When I first started in EMS, we were a BLS ambulance squad when I first started as a

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volunteer.

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And paramedics and advanced life support were fairly rare in the community that I was operating

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in.

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And then as I progressed and became a paramedic myself, we started to see this big transformation

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in EMS systems towards this two tiered model where you would have BLS providers and then

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ALS providers and the advent of emergency medical dispatch where the dispatchers would

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screen the call and make a determination based on that call as to the acuity of that patient.

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And it would either be an ALS call and we'd send the paramedic unit or it would be a BLS

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call and we'd send the BLS unit.

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And of course, BLS could get on scene and determine that ALS wasn't necessary.

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ALS could get on scene and say BLS wasn't necessary or we could move the patients around

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as we needed.

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But it was this big emerging trend back in the late 90s, early 2000s to start tiering

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EMS systems.

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And as a provider working in those systems, we thought it was great.

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As a paramedic provider, I knew that most of the calls that are going on, we're going

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to be operating sort of at that higher end of my skill set and require interventions

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for sick patients.

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And that's what I went to school for and that's what I was passionate about and what

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I really wanted to do.

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Then we started to see as EMS contracts evolved and cities and communities started to look

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at what was out there and available, this movement towards all ALS systems.

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And so I think the cities and the community leaders probably rightfully so felt that,

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look, paramedics are trained at a higher level than an EMT rather than having separate EMT

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ambulances and paramedic level ambulances.

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Let's combine them.

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That's right around the time when we started to see a lot of paramedic basic staffing on

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most ambulances out there.

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And it would make sense.

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So you'd have one of each in the same ambulance and then if it was a low acuity call, the

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basic could handle it, get that good patient care skill set, develop their skills and abilities

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to manage patients in the back of the ambulance.

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And of course, if it was a higher level patient, more acute patient than the paramedic could

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work in the back and practice at the upper end of their skill level.

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And then that model I think worked really well for a really long time.

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And we still today, most of our systems out there are that all ALS system staffed with

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a paramedic and a basic in the same ambulance.

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The other thing that happened though, back in the early 90s, mid 90s, 2000s and so on

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is as an industry, we got very comfortable with saying to our patients, look, if you're

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not sure what you need, call 911.

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We're happy to respond.

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We're glad to take care of you.

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We want to make sure that you're getting the care that you need.

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It is better for us to be there and be safe rather than for us to miss a potential emergency

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because you didn't know what to do and you didn't think it was serious enough to call

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911 and then something bad happened.

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And so as an industry, I think we got really good at educating people to call 911 in the

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event of an emergency.

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We never really defined what an emergency was.

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But I think most people kind of knew that an ambulance was for these life-threatening

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conditions.

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Well, the last 10 years or so, and this isn't really a pandemic thing.

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I think it started much prior to that.

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We started to see this shift and lots of other reasons for it outside of our little world

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within the 911 space, but more and more patients, more and more people started to call 911 regardless

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of what that emergency was.

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And we can go on and on talking about culture wants instant gratification.

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We can talk about the change in these high deductible health plans.

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And so people become more reticent to use health care, to use primary care because they

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don't want to pay out of pocket.

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And as a result, they have unmanaged chronic conditions that exacerbate and so on.

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There's a lot of factors that push to this.

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But what we started to see probably about 10 years ago was this increase in call volume

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across 911 systems across the country focused primarily on the lower priority calls.

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Now that's not to say that these are not quote unquote emergencies, but we see people using

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911 today for scenarios that 10 or 15 years ago, they probably would have just called

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their primary care physician for or managed some other way.

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The net result of that is our ambulance systems, our paramedics and EMTs out there in the field

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are getting called more and more often for cases that are not at the upper end of their

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skill set and instead are things that are really could potentially be treated elsewhere.

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And probably the best evidence of that is when you look at any EMS system across the

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country, in most cases, we see this rise of what we call dry runs.

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And so those are the calls that a unit responds to, went lights and sirens and got there as

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quick as they could and they got on scene.

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And then the patient, the 911 caller said, you know what, I changed my mind.

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I really don't want to go to the hospital.

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And they signed a refusal and then the crew leaves.

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I think that's a big dissatisfier just across the industry.

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I think it's bad for the patients who didn't know what to do.

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So they called 911 and then had a second thought afterwards and said, well, maybe I don't want

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to go spend the next 10 hours sitting in a waiting room in an emergency department.

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And if there was only some other way that I could get care, I think it's a dissatisfier

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for the individual EMTs and paramedics that have to respond to that call who frankly put

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their lives at risk to respond lights and sirens to what they're anticipating to be

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an emergency.

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And then they get there and discover that the patient changed their mind and didn't

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want to go to the hospital.

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And I think it's a dissatisfier for the system in general, because every time that that ambulance

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is tied up on one of those dry run calls, it means that they're not able to respond

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to higher priority emergencies that really need a rapid response and an intervention

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as quickly as possible by trained EMTs and paramedics.

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And so those are just some fundamental underlying challenges that I saw as a provider.

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And of course, I think every provider that's listening to this would recognize and agree

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that when we get that call at one in the morning for the person who twisted their ankle three

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weeks ago, and it's now throbbing in the middle of the night and they don't know what else

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to do.

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And maybe they've called their doctor's office and got the message, if this is an emergency,

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hang up and call 911.

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We've all responded to cases like that.

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I think individual providers recognize that this is a growing problem.

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And I think system administrators, EMS directors, hospital directors, healthcare folks, public

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health leaders, elected officials, I think everybody's starting to recognize that unless

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we do something different than this traditional model of sending the most expensive form of

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transportation and the most expensive type of emergency healthcare out to individuals

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for every single time they call 911 and then taking them to an emergency department for

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the most expensive resource for their care can end up becoming really just not an effective

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way to manage these situations today.

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And so that's why I'm excited about our nurse navigation program.

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Absolutely.

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When I look back at most of the time, ironically, it was when I was in Florida, when I worked

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out in California for a few years, they had a great relationship between the hospitals

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and FD and they hardly ever held the wall.

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But that aside, all the transport units, all the rescues I worked on, when the pandemic

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hit there were these reporters saying, there's people in the hallways and it's so terrible.

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And I just remember going, and of course it's a real thing and it was having an impact,

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but that was my entire career, hour, hour and a half, sometimes two, three hours holding

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the wall, especially if you had a low acuity patient because they were getting jumped over

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and over and over again.

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So through your eyes, through your career, before we get to Dr. Troutman and within the

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hospital, what were you seeing as far as that very element, the inability to provide beds

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for patients because of the increasing calls and the low acuity of a lot of them?

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Absolutely.

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I think it's just frustrating, period.

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I think there's frustration for the patient who, let's face it, our ambulance stretchers

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are not very comfortable.

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And for that patient that we've had to pick up and transport and then sit with them in

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the hallway of the hospital, well, they see nurses and doctors and technicians and everybody

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running past, dealing with other patients and we're just sitting there.

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I think it's frustrating for them.

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They called 911 with the expectation of being able to get to the hospital and be treated

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relatively quickly.

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It's obviously a tremendous frustration for the paramedics and EMTs who are listening

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to the radio and hearing dispatchers screaming for units saying, hey, we need somebody to

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clear up ASAP.

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We have a chest pain on the other side of town and we can't.

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And we get stuck there and then that gets very frustrating.

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It's obviously a frustration for the hospitals as well.

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They recognize that having these patients in their emergency rooms, again, it's a finite

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resource.

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And those hospital beds ideally should be filled with the patients who have the higher

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acuity, higher priority needs and should be treated.

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It's not first come, first serve.

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It's treated based on the degree of need.

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And if there are people who don't have as high a priority, then the hospitals are really

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stuck and they don't have too many other options of what to do with them.

302
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And so this challenge and to your point, James, right?

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Some parts of the country, this has been a challenge for years, not just triggered by

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the pandemic, but I think across the country, it's ubiquitous now that in 2024, we simply

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don't have enough paramedics and EMTs on the road.

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We don't have enough ambulances out there.

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We don't have enough hospital beds to keep pace with this growing number of lower acuity

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911 callers that are flooding the system.

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100%.

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Well, speaking of hospitals, let's go to you, Jared.

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I'd love to walk through why you chose medicine and then again, the front door perspective

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that you've had and either evolution or devolution through a physician's eyes.

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Well, so certainly found myself in emergency medicine because I realized I like just seeing

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everything.

315
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I like that element of not knowing what's coming through the door next and being able

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to take care of anything and everything.

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So that drew me to the specialty of emergency medicine very early in my med school career.

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If you asked before I was going to med school, I wanted to be a pediatrician and I can tell

319
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you now, I would not have been happy doing that.

320
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I love kids.

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I love taking care of kids, but I could not do that all day in and out.

322
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Now interestingly enough, so finished with residency, ended up back in Lubbock, Texas

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and I got to say guns up and go Texas Tech out there at the big university level one

324
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tertiary care trauma center.

325
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Was there just a handful of months and literally got a, Hey, you're the new guy.

326
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Our ambulances, we need an EMS medical director.

327
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Since you're the new guy, why don't you do that?

328
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And I said, Oh, that sounds fun.

329
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I have no idea what that means.

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That was goodness about 13 years ago, I think now.

331
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So I found myself as an EMS medical director and found out real quick one, I had no idea

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what I was doing.

333
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And fortunately fast forward a few years, met a lot of great mentors, really became

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really engaged, certainly in the state of Texas EMS scene, if you will, and learned

335
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a lot those first few years and gained some good mentors and just learned about EMS and

336
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certainly learned about all the high acuity stuff.

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And even if we talk today, I'm a big proponent of doing things like whole blood and pre-hospital

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and RSI, DSI, all those fun things, but there'd always had been this overarching, whether

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in practicing medicine in the hospital or talking to our EMS crews and ultimately looking

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at the patient, are we really doing the right thing for some patients that have real low

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acuity complaints?

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They just don't know what to do.

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So what do they do?

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They either come to the emergency department because they show up there or they dial 911.

345
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They can't get into their doctor.

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They don't know if it's okay.

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And that's the easy access.

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So I found myself really struggling with what is the right plan?

349
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What is the right thing to do with this?

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So I left the hospital-based practice and me and another couple of doctors actually

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built three freestanding ERs, two in one city, one in another.

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I operated those as our CEO.

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I've always kind of liked the business side of medicine and how all the economics and

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such works, but really viewed that as an alternative for a place for patients to access quick care.

355
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Now we could get all into why today I'm not certain that freestanding ERs are the right

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solution.

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I think they probably have a role, but ended up out of that.

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Kind of didn't do much for a year other than really focus on EMS.

359
00:27:01,800 --> 00:27:08,120
A few other agencies that I worked with became board certified in EMS and then essentially

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was approached to working with global medical response as our national medical director

361
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and really with a focus on we need to be healthcare.

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That's what EMS provides.

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Even still today, we know that transport is where the world lives, but we know, and I

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00:27:25,200 --> 00:27:28,320
think the needle's moving a little bit, we are healthcare.

365
00:27:28,320 --> 00:27:35,200
EMS is an important integral part of providing healthcare to patients and part of that healthcare

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system.

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And how do we get there?

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How do we get recognized?

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Everything from funding to our healthcare partners, et cetera.

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And part of that is what do we do with those low acuity patients?

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And really it was a realization that, you know, look, patients call 911 just looking

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for a solution to a problem.

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You know, the issue is in the EMS world, our solution to every problem is what it's sending

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fire engines, fire trucks, and ambulances, maybe a helicopter.

375
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But is that really the right thing to do for the system, for the healthcare system?

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Is that the best way to provide healthcare for every patient?

377
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Is there a safer, better way to do it?

378
00:28:15,040 --> 00:28:19,440
And that's what really also drew me into the nurse navigation program, which we've had

379
00:28:19,440 --> 00:28:25,320
a lot of growth in and I know we'll get into that a little bit more, but how we are ongoing

380
00:28:25,320 --> 00:28:32,440
every day showing the safety and efficacy on how we can really connect patients to really

381
00:28:32,440 --> 00:28:36,880
the right type of care that they need, even though they called 911, but it doesn't need

382
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to be an ambulance.

383
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And we, it has so many positives.

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I always say that with nurse navigation type program, it's like every rock we looked under

385
00:28:46,040 --> 00:28:50,240
is a positive, whether it's for the patient, whether it's for the operations, whether it's

386
00:28:50,240 --> 00:28:56,120
for the personnel, whether it's the finances for the patient, every single thing is a positive.

387
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And I just love that obviously from a physician perspective.

388
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And I know we kind of kicked it off.

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Josh wants to kick on that operation centric stuff, which I get as important, but also

390
00:29:06,240 --> 00:29:09,560
I got to be the doctor and bring it back patient centric.

391
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It really all becomes patient centric and which to me also directly relates to the fact

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that EMS is healthcare.

393
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That's what we do each and every day.

394
00:29:18,320 --> 00:29:23,160
Well, I want to go to the proactive conversation for a second when it comes to people even

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getting sick.

396
00:29:25,080 --> 00:29:29,120
What I've realized now through this career and then obviously this podcast and learning

397
00:29:29,120 --> 00:29:32,280
from literally this is more than a thousand interviews now I've done.

398
00:29:32,280 --> 00:29:38,380
So a lot of very, very smart people is there's areas where at the time, obviously people

399
00:29:38,380 --> 00:29:41,800
thought it was the right thing to do, but there's a certain point where you've got

400
00:29:41,800 --> 00:29:43,980
to have the humility to go, it's not working.

401
00:29:43,980 --> 00:29:47,640
And if you look at the first responder professions, it's not working.

402
00:29:47,640 --> 00:29:52,760
You know, we have a recruitment crisis, we have 911 abuse, we have all the things.

403
00:29:52,760 --> 00:29:56,960
When you talked about residency, one of the big things I'm very passionate about is sleep

404
00:29:56,960 --> 00:30:00,560
deprivation and getting our responders more rest and recovery.

405
00:30:00,560 --> 00:30:07,480
Dr. William Halsted was the physician who was behind the residency program.

406
00:30:07,480 --> 00:30:12,120
And people always ask your community, why do they work so many hours as a resident?

407
00:30:12,120 --> 00:30:16,680
But when you go to the origin story, Dr. Halsted was also a cocaine addict.

408
00:30:16,680 --> 00:30:19,520
And so, you know, he was awake for hours and hours and hours.

409
00:30:19,520 --> 00:30:25,020
His students obviously were expected to do the same and that kind of bled in forward.

410
00:30:25,020 --> 00:30:30,040
So looking back and realizing that maybe a 56-hour work week for firefighters and paramedics

411
00:30:30,040 --> 00:30:32,740
is pure insanity, we need to change that.

412
00:30:32,740 --> 00:30:34,280
Same with residency.

413
00:30:34,280 --> 00:30:39,120
But another area with your profession specifically that I hear over and over again from physicians,

414
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I don't know if you ever cross paths with Dr. Chris Colvin from Texas, but he's been

415
00:30:44,520 --> 00:30:47,000
one of the ones on the show a couple of times now.

416
00:30:47,000 --> 00:30:54,280
But the absence of education on sleep, nutrition, exercise when it comes to med school versus

417
00:30:54,280 --> 00:30:57,320
pharmacology.

418
00:30:57,320 --> 00:30:58,880
You know, great point.

419
00:30:58,880 --> 00:31:04,240
And I'll segue a little bit into that on a personal story of mine.

420
00:31:04,240 --> 00:31:11,280
When you talk about good sleep, good exercise, eating right, etc.

421
00:31:11,280 --> 00:31:17,480
I'm sitting here before you about 115 pounds lighter than I was about four years ago.

422
00:31:17,480 --> 00:31:23,920
At the start of COVID, I was large and I was a bit unhappy with my weight.

423
00:31:23,920 --> 00:31:25,680
And I got with a health coach.

424
00:31:25,680 --> 00:31:30,040
And because it was frustrating to me as a physician because I knew what I needed to

425
00:31:30,040 --> 00:31:32,440
do, but I just couldn't do it on my own.

426
00:31:32,440 --> 00:31:38,280
But work closely with a health coach to really have a better understanding things that really

427
00:31:38,280 --> 00:31:40,900
weren't learned in medical school.

428
00:31:40,900 --> 00:31:43,560
What is the appropriate diet and stuff?

429
00:31:43,560 --> 00:31:45,980
What is the appropriate way to work out?

430
00:31:45,980 --> 00:31:49,520
Literally this morning, I walked about two and a half miles around downtown Asheville.

431
00:31:49,520 --> 00:31:52,880
I tried to, you have to prioritize exercise.

432
00:31:52,880 --> 00:31:58,360
You have to prioritize appropriate diet and you have to prioritize sleep.

433
00:31:58,360 --> 00:32:02,780
And when you bring those three together, you end up as a healthier version of you and a

434
00:32:02,780 --> 00:32:07,200
healthier version of you, I think is a better productive person out there.

435
00:32:07,200 --> 00:32:12,000
So it is absolutely a gap in all of medicine.

436
00:32:12,000 --> 00:32:17,200
It's a gap, of course, as you pointed out in the physician world, it's a gap in the

437
00:32:17,200 --> 00:32:19,040
paramedicine world as well.

438
00:32:19,040 --> 00:32:21,960
We just don't do a good job at educating and teaching it.

439
00:32:21,960 --> 00:32:26,520
Yeah, well, I think as well, whether it's crushing residencies, whether it's shift

440
00:32:26,520 --> 00:32:31,200
work in doctors and nurses, whether it's, again, we mentioned the insane firefighter

441
00:32:31,200 --> 00:32:33,360
work week and add in mandatory overtime.

442
00:32:33,360 --> 00:32:37,360
Now you've got these men and women working eight plus hour weeks sometimes.

443
00:32:37,360 --> 00:32:41,240
And then you look at their physical health and the outside, you're like, well, they see

444
00:32:41,240 --> 00:32:42,240
people die every day.

445
00:32:42,240 --> 00:32:46,340
Why are they not in great shape and not smoking and all these things?

446
00:32:46,340 --> 00:32:50,080
But you've got to factor in the work environment, which I think is one of the conversations

447
00:32:50,080 --> 00:32:55,720
of solving the recruitment crisis is simply investing in your people and using, you know,

448
00:32:55,720 --> 00:32:59,520
seeing them as your most important resource.

449
00:32:59,520 --> 00:33:02,760
Absolutely.

450
00:33:02,760 --> 00:33:03,760
You know, I'd agree.

451
00:33:03,760 --> 00:33:11,480
And you look at and certainly in the EMS world, what we potentially take a rather young person

452
00:33:11,480 --> 00:33:16,920
from a life experience standpoint and put them on an ambulance and what they potentially

453
00:33:16,920 --> 00:33:23,400
could go experience on that first call is unbelievable when you really lay that out

454
00:33:23,400 --> 00:33:25,280
to the general public.

455
00:33:25,280 --> 00:33:29,800
And of course, I could lay out a number of examples, but anybody in EMS knows what those

456
00:33:29,800 --> 00:33:30,800
are.

457
00:33:30,800 --> 00:33:36,120
And how do you do that on day one, but let alone on day 10 years or day 20 years?

458
00:33:36,120 --> 00:33:40,560
And how do you process that all in between and remain successful?

459
00:33:40,560 --> 00:33:44,680
And oh, by the way, I know that call just finished, but we also have this holding that

460
00:33:44,680 --> 00:33:47,800
you need to get to because we don't have another truck available.

461
00:33:47,800 --> 00:33:53,840
And I need you to show up mind game, ready to go, be ready to perform that DSI perfectly.

462
00:33:53,840 --> 00:33:58,520
And I need a smile on your face and treat the patient with respect.

463
00:33:58,520 --> 00:33:59,640
That's tough.

464
00:33:59,640 --> 00:34:02,400
And I wish I knew a magic answer to get over that.

465
00:34:02,400 --> 00:34:04,200
But that is the big question.

466
00:34:04,200 --> 00:34:05,200
Absolutely.

467
00:34:05,200 --> 00:34:09,560
Well, I would argue enough rest and recovery so they get close to baseline and then a high

468
00:34:09,560 --> 00:34:10,560
standard.

469
00:34:10,560 --> 00:34:13,440
You know, when you create a healthy work, you can put that bar back where it needs to

470
00:34:13,440 --> 00:34:16,600
be and then most of the time you're going to get that result.

471
00:34:16,600 --> 00:34:18,240
Yeah, I agree completely.

472
00:34:18,240 --> 00:34:24,920
You know, having resources, having mechanisms in place, which we try to do that when there

473
00:34:24,920 --> 00:34:29,020
is a tough call that, you know, there's a phone call or something, hey, let's come in,

474
00:34:29,020 --> 00:34:34,480
let's sit down at the table, let's chat before we just put you back on that next call.

475
00:34:34,480 --> 00:34:40,760
And so that is absolutely important for resiliency and mental health and being able to process

476
00:34:40,760 --> 00:34:41,760
that.

477
00:34:41,760 --> 00:34:44,000
I think things can be processed.

478
00:34:44,000 --> 00:34:48,920
We can get over that, but we have to as a profession engage and do it in a healthy way

479
00:34:48,920 --> 00:34:54,840
in order to protect our workforce and to be able to be good providers of health care.

480
00:34:54,840 --> 00:34:55,840
Absolutely.

481
00:34:55,840 --> 00:34:59,360
Yeah, I think that's what I've said a lot about the mental health conversation is the

482
00:34:59,360 --> 00:35:05,040
hope that's in post-traumatic growth that you can take a struggle, find your own personal

483
00:35:05,040 --> 00:35:06,760
toolbox, which is not really discussed too.

484
00:35:06,760 --> 00:35:07,760
We're all different.

485
00:35:07,760 --> 00:35:11,360
We've all got, you know, different, you know, ways of losing weight, ways of exercising.

486
00:35:11,360 --> 00:35:15,280
It's the same with our mental health, but I truly, truly believe that on the other side

487
00:35:15,280 --> 00:35:20,200
is a more resilient version of you and therefore you will be an asset on that rig once again.

488
00:35:20,200 --> 00:35:25,980
Well, I want to go to the kind of origin story of the telehealth before we really dive into

489
00:35:25,980 --> 00:35:27,440
nurse navigation.

490
00:35:27,440 --> 00:35:32,720
I had a guest on the show, a former firefighter that was in a company that was doing a similar

491
00:35:32,720 --> 00:35:35,600
thing but on a much smaller scale.

492
00:35:35,600 --> 00:35:40,400
And he was kind of explaining how much red tape there was when it came to telehealth

493
00:35:40,400 --> 00:35:46,000
pre-COVID and then how some of those shackles were kind of broken as they progressed through

494
00:35:46,000 --> 00:35:47,000
that.

495
00:35:47,000 --> 00:35:48,000
So what were the restrictions?

496
00:35:48,000 --> 00:35:49,320
I'll go to you, Josh.

497
00:35:49,320 --> 00:35:55,360
What were the restrictions as far as the ability to deliver this, say, in 2019?

498
00:35:55,360 --> 00:36:01,800
And then what has changed to allow this metamorphosis of medicine that we're going to talk about?

499
00:36:01,800 --> 00:36:07,120
Yeah, you know, that's a great question, James.

500
00:36:07,120 --> 00:36:15,760
And when I first got involved in my role at American Medical Response at the time, now

501
00:36:15,760 --> 00:36:21,720
of course we're Global Medical Response, it was about 11, 12 years ago.

502
00:36:21,720 --> 00:36:26,280
And one of the things that I was responsible for when I first came aboard was trying to

503
00:36:26,280 --> 00:36:34,120
expand and grow this fledgling mobile integrated healthcare concept, MIH.

504
00:36:34,120 --> 00:36:39,640
And lots of various elements that were part of that, telehealth being one of them.

505
00:36:39,640 --> 00:36:45,760
Really it was around trying to find alternative ways to use our paramedic and EMT resources

506
00:36:45,760 --> 00:36:49,720
in addition to the 911 system and transporting patients.

507
00:36:49,720 --> 00:36:54,580
But as Dr. Troutman pointed out, at the end of the day we're healthcare.

508
00:36:54,580 --> 00:37:00,640
And how can we deliver better healthcare to this constituent of patients that are in the

509
00:37:00,640 --> 00:37:03,240
out of hospital environment?

510
00:37:03,240 --> 00:37:11,360
And so we developed a number of different programs related to MIH, community paramedicine,

511
00:37:11,360 --> 00:37:16,920
telemedicine, various elements and permutations of that.

512
00:37:16,920 --> 00:37:24,440
And where we kept getting hung up, especially pre-pandemic, was trying to find an appropriate

513
00:37:24,440 --> 00:37:27,160
funding source for these.

514
00:37:27,160 --> 00:37:32,880
And it came down to one of those things where, look, this is a great idea.

515
00:37:32,880 --> 00:37:35,640
We're very capable of doing it.

516
00:37:35,640 --> 00:37:44,240
Paramedics, EMTs, they know how to go into somebody's home and deliver care in an unscheduled,

517
00:37:44,240 --> 00:37:45,660
unplanned format.

518
00:37:45,660 --> 00:37:49,080
That's what we're really good at.

519
00:37:49,080 --> 00:37:56,760
But if we can't find somebody to pay for it, then it becomes a non-starter.

520
00:37:56,760 --> 00:37:58,640
It's not sustainable.

521
00:37:58,640 --> 00:38:05,160
And the challenge that we had and still have to a certain point today is that the funding

522
00:38:05,160 --> 00:38:10,760
for emergency medical services, as you probably know, the primary source of funding is based

523
00:38:10,760 --> 00:38:17,320
on transports, not taking care of patients in their homes or providing alternative options

524
00:38:17,320 --> 00:38:19,180
for care.

525
00:38:19,180 --> 00:38:21,120
We get paid by the mile.

526
00:38:21,120 --> 00:38:26,360
And if we don't transport a patient, then there's no revenue associated with that in

527
00:38:26,360 --> 00:38:31,080
95% of the systems out there across the country even today.

528
00:38:31,080 --> 00:38:39,520
And so while we had developed a number of innovative approaches to this and identified

529
00:38:39,520 --> 00:38:46,160
stakeholder groups, whether it was on the far end of the spectrum with hospice and palliative

530
00:38:46,160 --> 00:38:53,400
care or with the subacute patient or recently discharged patient from the hospital and managing

531
00:38:53,400 --> 00:39:03,720
that readmission process and so on, ultimately, we could not find a sustainable payer source

532
00:39:03,720 --> 00:39:10,200
that was willing to fund the cost associated with that type of service.

533
00:39:10,200 --> 00:39:17,000
And again, I don't want to speak for the payers, but the traditional model of, hey, you call

534
00:39:17,000 --> 00:39:21,360
911, we'll pay for you to bring somebody to the hospital.

535
00:39:21,360 --> 00:39:22,780
That's what we've signed up for.

536
00:39:22,780 --> 00:39:29,040
That's our responsibility, whether it's Medicare, Medicaid, private insurance, et cetera.

537
00:39:29,040 --> 00:39:31,040
That's what the fee schedules are based on.

538
00:39:31,040 --> 00:39:37,060
Again, it's based on reimbursement per mile plus a base fee.

539
00:39:37,060 --> 00:39:40,680
And that's the way that that system had been built.

540
00:39:40,680 --> 00:39:48,640
So fast forward to 2016, 2017.

541
00:39:48,640 --> 00:39:59,200
And city in particular, Washington, DC, was having tremendous issues with their EMS system.

542
00:39:59,200 --> 00:40:05,560
I think in many ways they were a leading indicator for what's going on with a lot of the EMS

543
00:40:05,560 --> 00:40:11,780
systems across the country today, not just urban systems, but large suburban and even

544
00:40:11,780 --> 00:40:13,580
some rural systems.

545
00:40:13,580 --> 00:40:20,160
And the challenges that they had were really just one compared to supply and demand.

546
00:40:20,160 --> 00:40:27,840
There was a growing demand for their resources within the district and not enough supply

547
00:40:27,840 --> 00:40:34,280
of their available fire engines and ambulances and paramedics and first responders in order

548
00:40:34,280 --> 00:40:36,160
to meet that demand.

549
00:40:36,160 --> 00:40:43,920
And so with Fire Chief at the time, Chief Gregory Dean engaged with AMR and said, hey,

550
00:40:43,920 --> 00:40:48,560
you guys, you know how to run ambulances, but what else do you know?

551
00:40:48,560 --> 00:40:54,440
Are there ways that we can come up with some type of innovative workaround to help reduce

552
00:40:54,440 --> 00:40:58,760
and decompress the pressure that is on my department?

553
00:40:58,760 --> 00:41:06,120
Because they were having issues with ambulances that would go out the door first thing in

554
00:41:06,120 --> 00:41:11,640
the morning as part of their shift and then would not return to the station until past

555
00:41:11,640 --> 00:41:16,560
the end of their shift because they're literally running call to call to call.

556
00:41:16,560 --> 00:41:21,400
And that left no time for the members to do any training, to do any type of repair and

557
00:41:21,400 --> 00:41:23,440
maintenance on the vehicles.

558
00:41:23,440 --> 00:41:27,280
Just it had gotten to this crisis point.

559
00:41:27,280 --> 00:41:35,160
And so we worked with Chief Dean, developed this concept of nurse navigation.

560
00:41:35,160 --> 00:41:42,280
He called it at the time, Right Care Right Now for Washington, D.C. and ended up launching

561
00:41:42,280 --> 00:41:50,720
that program in 2018, which was really prophetic in a way, two years before the pandemic and

562
00:41:50,720 --> 00:41:56,720
allowed us to not just with nurse navigation, there are certainly some other things that

563
00:41:56,720 --> 00:42:02,520
we did as part of that launch in D.C. being able to decompress the workload with additional

564
00:42:02,520 --> 00:42:07,880
VLS units and things like that that are obviously critically important, especially for these

565
00:42:07,880 --> 00:42:13,660
metropolitan fire departments that are facing these resource challenges.

566
00:42:13,660 --> 00:42:19,160
But nurse navigation, Right Care Right Now became a fundamental part of that program.

567
00:42:19,160 --> 00:42:25,120
And I think it showed, especially when we got into the pandemic, that wait a minute,

568
00:42:25,120 --> 00:42:32,160
we can be successful in introducing what I like to call a third tier of EMS.

569
00:42:32,160 --> 00:42:36,380
So we have the ALS tier, we have the BLS tier.

570
00:42:36,380 --> 00:42:41,040
And now when that caller calls into the 911 system and the call taker does the initial

571
00:42:41,040 --> 00:42:47,880
EMD screening, the call taker can identify, hey, this call might be appropriate for a

572
00:42:47,880 --> 00:42:52,280
nurse to do some additional screening on.

573
00:42:52,280 --> 00:43:00,120
And so that third tier of sending those calls over to a nurse that the ones that, certainly

574
00:43:00,120 --> 00:43:06,120
not every call, you know, 85, 90 percent of the calls that are coming into the dispatch

575
00:43:06,120 --> 00:43:12,320
center are still going to go out for an immediate either ALS response or BLS response.

576
00:43:12,320 --> 00:43:20,240
But for those other 10 to 15 percent, we can screen them and determine is an ambulance

577
00:43:20,240 --> 00:43:23,360
really going to be clinically required on this?

578
00:43:23,360 --> 00:43:27,680
And if so, absolutely, let's get them into the queue and get an ambulance sent over to

579
00:43:27,680 --> 00:43:28,860
them.

580
00:43:28,860 --> 00:43:34,120
But maybe there's some alternate options where they can get care outside of the emergency

581
00:43:34,120 --> 00:43:35,120
department.

582
00:43:35,120 --> 00:43:39,440
And that's where that nurse navigation really comes in.

583
00:43:39,440 --> 00:43:45,200
Was there any element of rules being changed during the pandemic that made it even easier

584
00:43:45,200 --> 00:43:46,200
though?

585
00:43:46,200 --> 00:43:51,560
Or was that purely just that the creation of this happened to be a couple of years prior

586
00:43:51,560 --> 00:43:53,600
to it?

587
00:43:53,600 --> 00:43:59,840
So for the most part, I don't think it's really been an issue with rules and regulations.

588
00:43:59,840 --> 00:44:06,640
You know, certainly as we go bringing these systems into new parts of the country, they're

589
00:44:06,640 --> 00:44:10,800
looked at very closely by regulators.

590
00:44:10,800 --> 00:44:14,440
You know, we're in the process right now of launching a number of programs out on the

591
00:44:14,440 --> 00:44:20,560
West Coast in California and California, as you well know, James, from working out there,

592
00:44:20,560 --> 00:44:26,480
that's a very unique EMS system and a very heavily regulated EMS system down to the county

593
00:44:26,480 --> 00:44:29,560
level with different LEMSAs and so on.

594
00:44:29,560 --> 00:44:34,880
And so that becomes part of those discussions, certainly, and we need to make sure that the

595
00:44:34,880 --> 00:44:41,720
medical directors and LEMSA directors and other parts of the country, the state or local

596
00:44:41,720 --> 00:44:46,740
regional EMS directors are all aware of and supportive of this program.

597
00:44:46,740 --> 00:44:50,000
It's not something that we do in a vacuum, certainly.

598
00:44:50,000 --> 00:44:56,760
But we really haven't run into scenarios where state regulations or statutes need to be changed

599
00:44:56,760 --> 00:44:58,400
for this.

600
00:44:58,400 --> 00:45:05,320
I think the bigger thing that we saw shifting primarily during the pandemic, but again,

601
00:45:05,320 --> 00:45:11,280
with DC, it was prior to that, it's really the mentality of EMS providers.

602
00:45:11,280 --> 00:45:14,520
You know, I love EMS.

603
00:45:14,520 --> 00:45:17,080
I've been in this my entire career.

604
00:45:17,080 --> 00:45:19,180
It is going to be my entire career.

605
00:45:19,180 --> 00:45:23,200
This is what I really enjoy doing.

606
00:45:23,200 --> 00:45:30,000
But let's face it, there are many, many things that we do because we've always done it that

607
00:45:30,000 --> 00:45:31,240
way.

608
00:45:31,240 --> 00:45:39,520
And we get into our own habits and mentalities of, well, this is the right way to deliver

609
00:45:39,520 --> 00:45:44,280
EMS because it's what we've always done and it's how we're going to continue to do it.

610
00:45:44,280 --> 00:45:54,720
And it can take a significant paradigm shift in order to start to get the decision makers,

611
00:45:54,720 --> 00:46:00,480
the regulators, the people, again, not to change regulations or develop new laws or

612
00:46:00,480 --> 00:46:06,160
anything like that, but just to understand that there is a potential outcome of somebody

613
00:46:06,160 --> 00:46:10,200
calling 911 and us not sending an ambulance.

614
00:46:10,200 --> 00:46:16,640
And that's okay when we can determine that this is a low priority call that doesn't require

615
00:46:16,640 --> 00:46:19,680
an ambulance.

616
00:46:19,680 --> 00:46:28,040
And for so many people, not just the authorities and EMS directors and folks like that on our

617
00:46:28,040 --> 00:46:32,860
side of the house, but for the public at large, that becomes something that takes a while

618
00:46:32,860 --> 00:46:34,780
for community acceptance.

619
00:46:34,780 --> 00:46:39,960
When we put these programs into a community, one of the things that we do is work very

620
00:46:39,960 --> 00:46:45,160
closely with local media to publicize this program, make sure that people are aware that

621
00:46:45,160 --> 00:46:49,200
this is an additional outcome that could now occur when you call 911.

622
00:46:49,200 --> 00:46:53,520
It's an additional set of resources and really a benefit for the community.

623
00:46:53,520 --> 00:46:58,940
But for the person who's not aware of that, when they call 911, they have an expectation

624
00:46:58,940 --> 00:47:02,960
that an ambulance is going to be at their door six to eight minutes later.

625
00:47:02,960 --> 00:47:08,980
And when they call 911 and the dispatcher or call taker says, you know, this sounds

626
00:47:08,980 --> 00:47:13,360
like something where you might benefit from speaking to a nurse before we send an ambulance.

627
00:47:13,360 --> 00:47:16,160
Would you like to speak to one of our nurses?

628
00:47:16,160 --> 00:47:18,680
That can catch a lot of people off guard.

629
00:47:18,680 --> 00:47:23,040
And we do get those folks who say, no, no, no, just send me an ambulance.

630
00:47:23,040 --> 00:47:27,880
I want one because I pay my taxes and I demand an ambulance and that's how it's going to

631
00:47:27,880 --> 00:47:29,960
be.

632
00:47:29,960 --> 00:47:37,840
But we start to see a shift in the community's mentality as these programs get underway,

633
00:47:37,840 --> 00:47:43,560
as they start to gain adoption in the community and neighbors start telling neighbors about,

634
00:47:43,560 --> 00:47:45,160
yeah, you know, I didn't know what to do.

635
00:47:45,160 --> 00:47:51,080
I called 911 and instead of sending an ambulance, I got to talk to a nurse and she got me connected

636
00:47:51,080 --> 00:47:53,880
to the urgent care center and I went in and had an appointment.

637
00:47:53,880 --> 00:47:56,920
It was great and only cost me 200 bucks.

638
00:47:56,920 --> 00:48:01,760
I didn't have a big ambulance bill and I didn't have a big ER bill and I didn't have to wait.

639
00:48:01,760 --> 00:48:07,760
And as people start to talk about that, then we see that shift in adoption in the community.

640
00:48:07,760 --> 00:48:15,880
Going back to you, Jared, you mentioned about the young medical EMT and their first call.

641
00:48:15,880 --> 00:48:19,900
The first call I had at Hialeah, the very first one is a firefighter EMT.

642
00:48:19,900 --> 00:48:22,500
We go into this gentleman's house and you're obviously hoping you're going to get some

643
00:48:22,500 --> 00:48:25,560
ripping structure fire or something on your first call.

644
00:48:25,560 --> 00:48:29,720
And there's this older gentleman and Hialeah was like 98% Cuban.

645
00:48:29,720 --> 00:48:34,360
So it was the call was in Spanish and he's got this tiny little condom looking thing

646
00:48:34,360 --> 00:48:35,640
on his finger.

647
00:48:35,640 --> 00:48:38,200
And he starts talking to the medics and I hear him say the word caca.

648
00:48:38,200 --> 00:48:41,920
I'm like, I'm not Spanish, but I know what that word means.

649
00:48:41,920 --> 00:48:46,200
And what he wanted one of us to do was to put this little condom on our finger and fish

650
00:48:46,200 --> 00:48:51,340
around and get whatever was stopping him from completing his bowel movement.

651
00:48:51,340 --> 00:48:54,640
When I think of that kind of person, I had another one that was, he called us because

652
00:48:54,640 --> 00:48:56,620
he didn't like the taste of his new dentures.

653
00:48:56,620 --> 00:49:00,460
So you've got your Alpha Omega call, which we see over and over again.

654
00:49:00,460 --> 00:49:05,360
And depending on where you are, like for example, Hialeah, a lot of immigrants, there was, you

655
00:49:05,360 --> 00:49:07,360
know, it's just, it is what it is.

656
00:49:07,360 --> 00:49:12,600
There was clearly some sort of sub conversation that you use as magic card and you call 911

657
00:49:12,600 --> 00:49:14,960
and they'll take you wherever you want to go.

658
00:49:14,960 --> 00:49:18,760
So I would argue it's probably more abuse in some areas, less than others, but it's

659
00:49:18,760 --> 00:49:24,040
a real thing that absolutely is continuing to wake up our first responders.

660
00:49:24,040 --> 00:49:29,160
So as you mentioned, you know, Josh and I obviously understand the station life element,

661
00:49:29,160 --> 00:49:35,280
but where I see so much value in what we're about to talk about every single patient that

662
00:49:35,280 --> 00:49:37,200
shouldn't have gone to the hospital.

663
00:49:37,200 --> 00:49:40,240
And I'll even put, you know, medical directors on blast too.

664
00:49:40,240 --> 00:49:41,360
I've worked for agencies.

665
00:49:41,360 --> 00:49:42,920
They said, just take everyone.

666
00:49:42,920 --> 00:49:45,000
Don't, don't, you know, question it.

667
00:49:45,000 --> 00:49:47,520
And then also ask them which hospital they want to go to.

668
00:49:47,520 --> 00:49:48,520
Like really?

669
00:49:48,520 --> 00:49:53,360
This is 911 and oh, I want to go to the one, you know, 40 minutes away, you know, so it's,

670
00:49:53,360 --> 00:49:58,600
I see again, this kind of broken system versus being available and ready for a true medical

671
00:49:58,600 --> 00:50:00,400
emergency.

672
00:50:00,400 --> 00:50:04,060
But you've got this patient being taken to the ER.

673
00:50:04,060 --> 00:50:09,920
So now you are using a bed that could be used for a chest pain, for a stroke, for a shooting,

674
00:50:09,920 --> 00:50:12,520
whatever facility you are.

675
00:50:12,520 --> 00:50:17,980
You've got a first responder crew being woken up and in the less intelligent fire departments,

676
00:50:17,980 --> 00:50:19,360
that means the entire station.

677
00:50:19,360 --> 00:50:22,240
If they haven't figured out, you don't need to wake up everyone for two guys to go on

678
00:50:22,240 --> 00:50:23,880
a call.

679
00:50:23,880 --> 00:50:28,440
And then from the patient, which again, going back to the patient centric element, you know,

680
00:50:28,440 --> 00:50:32,480
it might be a child who's worried parents and they've got a fever and they threw up

681
00:50:32,480 --> 00:50:34,840
once and they think they're going to die of dehydration.

682
00:50:34,840 --> 00:50:39,240
And now that child's in the ER between a drunk and a psych patient all night with the lights

683
00:50:39,240 --> 00:50:41,700
on and you know, screaming and everything.

684
00:50:41,700 --> 00:50:45,760
And then you've got the patients getting a bill for thousands and thousands of dollars

685
00:50:45,760 --> 00:50:50,280
on top of the fact that the fire department bills them for the ER ride.

686
00:50:50,280 --> 00:50:55,820
So I see all these different layers and how this is going to be such an incredibly powerful

687
00:50:55,820 --> 00:51:01,980
tool to eliminate, as you said, that bottom tier, empower these people to start learning

688
00:51:01,980 --> 00:51:07,840
that there is another option and then go back to having units available with well rested

689
00:51:07,840 --> 00:51:12,900
crews that now will respond to that wreck and extricate a child and then do pediatric

690
00:51:12,900 --> 00:51:15,400
algorithms as they rush into the hospital.

691
00:51:15,400 --> 00:51:21,080
Well, so one thing on the whole thing you explain there, and this is another paradigm

692
00:51:21,080 --> 00:51:22,160
shift.

693
00:51:22,160 --> 00:51:28,560
I don't like the word abuse of 911 because I really think what the problem is, is we

694
00:51:28,560 --> 00:51:33,360
have failed the 911 system because our only offering has been an ambulance.

695
00:51:33,360 --> 00:51:38,600
So you know, I think we have to remain that patients are going to call 911.

696
00:51:38,600 --> 00:51:44,720
We can't stop that and we shouldn't stop it, but we shouldn't view it as we only send

697
00:51:44,720 --> 00:51:45,720
an ambulance, right?

698
00:51:45,720 --> 00:51:50,680
I mean, that's an overarching theme to those patients, all those patients you just described

699
00:51:50,680 --> 00:51:56,080
in their world, they had a problem and they did not know what to do and they were legitimate

700
00:51:56,080 --> 00:51:57,080
problems.

701
00:51:57,080 --> 00:52:01,200
They weren't legitimate problems that maybe needed an emergency department, but they were

702
00:52:01,200 --> 00:52:09,160
problems to those patients and we fail them by thinking or having only in place an ambulance

703
00:52:09,160 --> 00:52:11,280
and ER as a solution.

704
00:52:11,280 --> 00:52:15,920
And it's back to, we have to provide them the appropriate level of healthcare, whatever

705
00:52:15,920 --> 00:52:22,600
that is, from nurse advice to send in a helicopter for that rural ejection patient that we need

706
00:52:22,600 --> 00:52:26,240
to get to level one trauma center and everything in between.

707
00:52:26,240 --> 00:52:29,600
I think, you know, you're absolutely right on correcting me on that.

708
00:52:29,600 --> 00:52:35,120
I think it's a lack of education and what I've underlined a lot recently is fire and

709
00:52:35,120 --> 00:52:37,160
EMS, which is my world.

710
00:52:37,160 --> 00:52:40,800
We've just done a horrible job at even educating the public on what we do.

711
00:52:40,800 --> 00:52:43,240
You know, why is there a fire engine in my medical call?

712
00:52:43,240 --> 00:52:45,400
You know, what are we buying you when we're in the store?

713
00:52:45,400 --> 00:52:46,400
You're buying me nothing.

714
00:52:46,400 --> 00:52:47,480
I'm just borrowing money.

715
00:52:47,480 --> 00:52:49,600
You know, we haven't told the story very well.

716
00:52:49,600 --> 00:52:54,840
So before we dive into nurse navigation, what does, you know, what do the first responder

717
00:52:54,840 --> 00:52:59,400
professions need to start to do to actually tell the real story?

718
00:52:59,400 --> 00:53:01,680
What we do, what is an emergency?

719
00:53:01,680 --> 00:53:06,180
And as you said, you know, using 911 in a tier system.

720
00:53:06,180 --> 00:53:11,160
So I would say that we cannot tell a person what an emergency is.

721
00:53:11,160 --> 00:53:16,080
You know, I very much believe in the prudent lay person standpoint and none of us here

722
00:53:16,080 --> 00:53:17,880
are prudent lay person.

723
00:53:17,880 --> 00:53:21,920
Prudent lay people are the house painter, the vice president of the bank, the school

724
00:53:21,920 --> 00:53:23,320
teacher, the mayor.

725
00:53:23,320 --> 00:53:28,360
So if they believe it's an emergency, I don't think we should restrict them from contacting

726
00:53:28,360 --> 00:53:32,440
911 and getting a solution to their problem.

727
00:53:32,440 --> 00:53:39,240
And I think that's a dogma we have to stand by because trying to educate a patient on

728
00:53:39,240 --> 00:53:42,880
what's an emergency or not, it's a failure, right?

729
00:53:42,880 --> 00:53:46,720
I mean, at the end of the day, an emergency physician is probably the tip of the spear

730
00:53:46,720 --> 00:53:49,440
for defining an emergency.

731
00:53:49,440 --> 00:53:50,440
Paramedics even not, right?

732
00:53:50,440 --> 00:53:55,080
I mean, sure, they have a much better understanding than a lay person, but they're still not

733
00:53:55,080 --> 00:53:57,160
at the tip of the spear for that.

734
00:53:57,160 --> 00:54:02,600
Nor can I often figure things out without x-rays and lab tests and physical exams and

735
00:54:02,600 --> 00:54:08,640
all the tools that we utilize to work through a differential diagnosis to say, oh, this

736
00:54:08,640 --> 00:54:10,000
is actually GERD.

737
00:54:10,000 --> 00:54:12,920
This is not a STEMI because it could be a STEMI.

738
00:54:12,920 --> 00:54:17,120
I don't know until I have an EKG or perhaps troponin test.

739
00:54:17,120 --> 00:54:21,000
How many times do we roll our eyes and say, oh, they called us because they're having

740
00:54:21,000 --> 00:54:24,520
a little acid reflux and the reality is they're having a STEMI.

741
00:54:24,520 --> 00:54:25,520
So it happens.

742
00:54:25,520 --> 00:54:30,720
So we do have to protect those type patients and very important to do so.

743
00:54:30,720 --> 00:54:31,720
Yeah.

744
00:54:31,720 --> 00:54:37,640
And just to echo that, add to that, I agree with Dr. Troutman 100%.

745
00:54:37,640 --> 00:54:44,320
I don't look at this as an abuse of the EMS system or the 911 system.

746
00:54:44,320 --> 00:54:50,880
The challenge is that we've always had just a one size fits all model.

747
00:54:50,880 --> 00:54:57,240
But I think if you go back to the first 911 call that was placed over 50 years ago now,

748
00:54:57,240 --> 00:55:03,760
we have done such a great job in this country of educating everybody to call 911.

749
00:55:03,760 --> 00:55:06,920
If you don't know what to do, call 911.

750
00:55:06,920 --> 00:55:12,400
And now we have two year olds that can dial 911 all the way up to 102 year olds.

751
00:55:12,400 --> 00:55:19,360
And to me, that's a big success and that's an important part of our social safety network

752
00:55:19,360 --> 00:55:25,280
across the country and how we care for our neighbors.

753
00:55:25,280 --> 00:55:32,280
I also think that we see communities who have gotten frustrated with how many people are

754
00:55:32,280 --> 00:55:39,400
using 911 and they've tried to introduce alternates and you see the 311 programs or the 211 programs,

755
00:55:39,400 --> 00:55:45,880
some other three digit number and saying, hey, if it's not a quote unquote real emergency,

756
00:55:45,880 --> 00:55:48,640
then don't call us.

757
00:55:48,640 --> 00:55:54,920
And in my mind and I think the data will show that just doesn't work.

758
00:55:54,920 --> 00:55:59,480
We want people to know that 911 is there for them.

759
00:55:59,480 --> 00:56:01,340
And I think that's really important.

760
00:56:01,340 --> 00:56:05,840
We need people to be able to rely on 911.

761
00:56:05,840 --> 00:56:12,560
We don't need people to be able to make a decision on what type of resource 911 is going

762
00:56:12,560 --> 00:56:13,560
to send.

763
00:56:13,560 --> 00:56:17,780
I think that's where the dispatcher and the nurse come into play.

764
00:56:17,780 --> 00:56:19,520
But we're not asking them to do that.

765
00:56:19,520 --> 00:56:26,080
So if there's a question, call 911 and let us help you figure out what the appropriate

766
00:56:26,080 --> 00:56:28,000
resource is going to be.

767
00:56:28,000 --> 00:56:30,280
Let us provide healthcare.

768
00:56:30,280 --> 00:56:32,420
Exactly.

769
00:56:32,420 --> 00:56:36,640
So the most important person at this point then we're realizing is the dispatcher.

770
00:56:36,640 --> 00:56:42,280
That is kind of the gatekeeper of whether it's nurse navigation, whether it's Josh and

771
00:56:42,280 --> 00:56:47,600
I go on a medic unit or whether it's even a helicopter, like you said.

772
00:56:47,600 --> 00:56:52,180
What I've seen again nationally is that there's a real crisis within that profession.

773
00:56:52,180 --> 00:56:56,640
So before we go to the actual, what someone would experience once they go through nurse

774
00:56:56,640 --> 00:57:02,840
navigation, what are some of the solutions or some of the issues that need to be addressed

775
00:57:02,840 --> 00:57:06,980
so that we can make sure this first line of defense is actually well staffed and rested

776
00:57:06,980 --> 00:57:09,980
as well?

777
00:57:09,980 --> 00:57:10,980
That's a great question.

778
00:57:10,980 --> 00:57:13,880
And I'm a huge fan of dispatchers.

779
00:57:13,880 --> 00:57:16,240
I've spent a little bit of time in dispatch.

780
00:57:16,240 --> 00:57:18,920
It is not something I could ever do successfully myself.

781
00:57:18,920 --> 00:57:24,240
And I'm in awe of the ability of call takers and dispatchers to manage that process.

782
00:57:24,240 --> 00:57:30,840
I think it's, as you said, it's really an under recognized portion of this and it is

783
00:57:30,840 --> 00:57:39,040
the tip of the spear for the delivery of healthcare, of this out of hospital emergent healthcare.

784
00:57:39,040 --> 00:57:46,680
And I think we have today, we have some really strong, really dedicated dispatchers and fortunately

785
00:57:46,680 --> 00:57:52,160
there are some good systems supporting them, whether it's the Pro QA and PDS system or

786
00:57:52,160 --> 00:57:57,440
a complaint based determinant system that can help them work through a series of questions

787
00:57:57,440 --> 00:58:04,560
and identify based on the answers to those questions, what an appropriate tier of resources

788
00:58:04,560 --> 00:58:08,560
our nurse navigation program plugs in pretty seamlessly with that.

789
00:58:08,560 --> 00:58:13,880
So that if it's determined to be, as you said, James and Alpha and Omega, and actually there's

790
00:58:13,880 --> 00:58:21,000
even some Bravo and a few Charlie level determinants that are appropriate for nurse navigation,

791
00:58:21,000 --> 00:58:28,960
then we can certainly help push them into that nurse process based on the dispatcher

792
00:58:28,960 --> 00:58:30,680
asking those questions.

793
00:58:30,680 --> 00:58:37,160
We're also doing some pretty innovative things now using machine learning, large language

794
00:58:37,160 --> 00:58:47,960
model decision support tools to identify and basically sit over the dispatcher shoulder,

795
00:58:47,960 --> 00:58:56,040
listen to that call in real time and say based on the feedback that the caller is providing,

796
00:58:56,040 --> 00:59:00,960
provide some decision support to the dispatcher to proactively prompt them and recognize that,

797
00:59:00,960 --> 00:59:05,600
hey, this is something that was probably appropriate for nurse navigation.

798
00:59:05,600 --> 00:59:11,320
Or on the other end, hey, this appears to be a STEMI or a cardiac arrest or some other

799
00:59:11,320 --> 00:59:14,760
type of high acuity challenge.

800
00:59:14,760 --> 00:59:20,960
Just get those resources out right away and I think those are really cutting edge in terms

801
00:59:20,960 --> 00:59:26,160
of being able to leverage some of this advanced emerging technology in the dispatch center.

802
00:59:26,160 --> 00:59:29,760
Dr. Troutman, you've got a lot of experience with that.

803
00:59:29,760 --> 00:59:31,280
Yeah, absolutely.

804
00:59:31,280 --> 00:59:37,840
I think one of the keys for dispatch is we need standardization and reproducibility.

805
00:59:37,840 --> 00:59:43,240
And Josh mentioned there's certainly a couple of companies or a couple of programs out there

806
00:59:43,240 --> 00:59:45,760
that do accomplish that.

807
00:59:45,760 --> 00:59:50,240
That isn't in every dispatch system across the US by no means.

808
00:59:50,240 --> 00:59:51,720
It isn't a lot of them.

809
00:59:51,720 --> 00:59:57,760
But I think that that also helps with the, if you call it resiliency of the dispatcher

810
00:59:57,760 --> 01:00:04,120
because even if I just take an EMT or paramedic and put them in dispatch and just say, talk

811
01:00:04,120 --> 01:00:10,200
to the patient, that's a lot on them just to have a discussion and make a decision.

812
01:00:10,200 --> 01:00:13,720
And the reality is what's the decision generally going to be?

813
01:00:13,720 --> 01:00:15,440
This sounds like it could be really bad.

814
01:00:15,440 --> 01:00:22,440
I'm just going to send lights and sirens versus having a rather scripted ask questions to

815
01:00:22,440 --> 01:00:26,960
where if that goes to 10 different people, I shouldn't get six different answers.

816
01:00:26,960 --> 01:00:31,660
I should get the same answer with very little variability.

817
01:00:31,660 --> 01:00:35,160
So I think we see positives when we do that.

818
01:00:35,160 --> 01:00:41,600
Josh touched a little bit about on, I'm going to throw out AI because I am, and we'll talk,

819
01:00:41,600 --> 01:00:43,440
we can dissect in that a little bit more.

820
01:00:43,440 --> 01:00:48,520
AI is a little bit of a scary term to healthcare people, right?

821
01:00:48,520 --> 01:00:51,600
Because of course, some people say it's going to come take us over.

822
01:00:51,600 --> 01:00:54,760
We're not even going to need doctors anymore because AI is just going to, you're going

823
01:00:54,760 --> 01:00:58,740
to talk to it and it's going to spit out your medication.

824
01:00:58,740 --> 01:01:02,720
I don't believe that's where we're going to be anytime soon.

825
01:01:02,720 --> 01:01:09,320
But I think we're fooling ourselves if we don't see AI as a clinical decision support

826
01:01:09,320 --> 01:01:17,480
piece, something that can make our lives easier as clinicians out there and not just easier,

827
01:01:17,480 --> 01:01:21,960
but more accurate and ultimately better for the patient.

828
01:01:21,960 --> 01:01:26,920
And just to expand a little bit more on a way that we've been utilizing some clinical

829
01:01:26,920 --> 01:01:32,320
decision support is the technology that can listen into a call.

830
01:01:32,320 --> 01:01:36,960
And when we first heard about this, it would listen to a call and it could pick up things

831
01:01:36,960 --> 01:01:39,440
to say, this sounds really high acuity.

832
01:01:39,440 --> 01:01:44,520
This sounds like a stroke, STEMI, cardiac arrest, and it would alert the dispatcher.

833
01:01:44,520 --> 01:01:50,080
And there's a scientific paper out there that showed that alert came up more accurate and

834
01:01:50,080 --> 01:01:54,920
quicker than going through the entire question and answer process.

835
01:01:54,920 --> 01:02:00,080
So of course we know that response times don't matter except when they do matter and things

836
01:02:00,080 --> 01:02:04,560
like strokes, STEMI, those response times are very important.

837
01:02:04,560 --> 01:02:10,240
So we heard about this technology and we liked it, but of course we asked the question, that's

838
01:02:10,240 --> 01:02:12,360
fantastic, that's very important.

839
01:02:12,360 --> 01:02:14,360
I want to take it to the other end of the spectrum.

840
01:02:14,360 --> 01:02:19,200
I want to be able to listen in and for the technology to say, this sounds like a good

841
01:02:19,200 --> 01:02:25,040
call for a nurse because this doesn't sound like this patient needs an emergency department

842
01:02:25,040 --> 01:02:28,600
or having any sort of life-threatening illness.

843
01:02:28,600 --> 01:02:32,080
So let's maybe send this to a nurse to do something with.

844
01:02:32,080 --> 01:02:36,680
So we've utilized that technology in a few places and it's one we're expanding and working

845
01:02:36,680 --> 01:02:41,440
actively with, with really positive results.

846
01:02:41,440 --> 01:02:44,920
It's funny when you talk about the AI, because if you think about it, Josh, well, both of

847
01:02:44,920 --> 01:02:49,720
you, the more you progress through your medical career, the more you can walk in, look at

848
01:02:49,720 --> 01:02:55,280
a patient, not immediately go, this is what it is, but right at the beginning you're like,

849
01:02:55,280 --> 01:02:57,440
this is serious, this is not serious.

850
01:02:57,440 --> 01:02:58,720
And that just comes with time.

851
01:02:58,720 --> 01:03:03,520
So I can see how the more learning an AI model does, the more it's basically doing what a

852
01:03:03,520 --> 01:03:08,240
human, a veteran of medicine already does themselves.

853
01:03:08,240 --> 01:03:10,080
Absolutely.

854
01:03:10,080 --> 01:03:15,280
And even, you're seeing now where we can take essentially a device in, have a conversation

855
01:03:15,280 --> 01:03:19,680
with a patient, whether it's a doctor in the hospital or a nurse or a medic in the back

856
01:03:19,680 --> 01:03:20,880
of an ambulance.

857
01:03:20,880 --> 01:03:26,960
And by the time you get on your PCR, there's the entire chart all typed up and you essentially

858
01:03:26,960 --> 01:03:32,760
give it a once or twice over and it sounds pretty darn good and pretty accurate.

859
01:03:32,760 --> 01:03:38,680
And look at what that does when we start talking about, you know, what makes my job happy.

860
01:03:38,680 --> 01:03:43,360
I'll tell you what doesn't make it happy is a lot of paperwork and a lot of patient charting,

861
01:03:43,360 --> 01:03:45,000
although it's extremely important.

862
01:03:45,000 --> 01:03:46,160
It's the right thing to do.

863
01:03:46,160 --> 01:03:47,360
It's all those things.

864
01:03:47,360 --> 01:03:50,720
But if we can make that easier, sign me up every day of the week.

865
01:03:50,720 --> 01:03:53,800
I don't care if it's AI or whatever's doing it.

866
01:03:53,800 --> 01:03:55,280
I'm happy to be on board with that.

867
01:03:55,280 --> 01:03:58,400
And I think most people would agree with that.

868
01:03:58,400 --> 01:04:01,840
On that subject, just to go on a tangent for a second.

869
01:04:01,840 --> 01:04:04,200
I've told this story a few times, very, very briefly.

870
01:04:04,200 --> 01:04:08,800
When I first moved to the States, I remember looking at the yellow pages from the side

871
01:04:08,800 --> 01:04:12,400
and there was this one section, almost like almost an inch.

872
01:04:12,400 --> 01:04:15,400
It was huge and it was different color from the side.

873
01:04:15,400 --> 01:04:16,960
And I was like, oh, that must be physicians.

874
01:04:16,960 --> 01:04:21,040
You know, there's lots of doctors in the world, but it wasn't, it was lawyers.

875
01:04:21,040 --> 01:04:25,440
And again, coming from England, where back in those days, there weren't the frivolous

876
01:04:25,440 --> 01:04:26,440
lawsuits.

877
01:04:26,440 --> 01:04:29,120
Sadly, they're mirroring the American model now, from what I understand.

878
01:04:29,120 --> 01:04:33,160
You know, you just see all this and then you start working as an American firefighter.

879
01:04:33,160 --> 01:04:34,160
Oh, okay.

880
01:04:34,160 --> 01:04:37,400
Because every time I go to a wreck, the guy's already on his phone to the lawyer and there's

881
01:04:37,400 --> 01:04:41,680
these billboards by the road saying, I got you a million dollars and all this stuff.

882
01:04:41,680 --> 01:04:48,680
But then you start to realize how that factors into paperwork, to paralysis by analysis for

883
01:04:48,680 --> 01:04:49,680
the paramedic.

884
01:04:49,680 --> 01:04:56,040
So, what impact is that frivolous lawsuit element having in medicine?

885
01:04:56,040 --> 01:05:00,760
And if you were king for a day and could make that go away, where only obviously the medics

886
01:05:00,760 --> 01:05:06,480
and EMTs that did something wrong would be held accountable, you know, what would change?

887
01:05:06,480 --> 01:05:10,360
Because I almost felt like there was so much paperwork and there was this absolute terror

888
01:05:10,360 --> 01:05:15,440
of litigation that a lot of our medics and EMTs were doing reports that were really kind

889
01:05:15,440 --> 01:05:16,440
of benign in a way.

890
01:05:16,440 --> 01:05:20,920
You know, it was, you know, he sneezed his stomach, you know, he pulled a muscle, he's

891
01:05:20,920 --> 01:05:22,080
fine, he's refusing.

892
01:05:22,080 --> 01:05:27,760
You've got to do a full on three page conversation on it.

893
01:05:27,760 --> 01:05:33,280
So maybe I'm naive, but obviously I respect the law process.

894
01:05:33,280 --> 01:05:41,200
You know, I respect the potential for litigation, et cetera, and the practice of clinical medicine.

895
01:05:41,200 --> 01:05:47,280
But I subscribe by the dogma of always do what's right for the patient, you know, document

896
01:05:47,280 --> 01:05:48,600
it appropriately.

897
01:05:48,600 --> 01:05:53,160
What should be document, document if it doesn't need documented, it's not important to not

898
01:05:53,160 --> 01:05:56,200
germane doesn't need to be documented.

899
01:05:56,200 --> 01:06:00,260
And lastly, treat the patient right and with respect.

900
01:06:00,260 --> 01:06:08,440
And I think if you keep those three aligned, the chance of a lawsuit situation becomes

901
01:06:08,440 --> 01:06:09,440
very low.

902
01:06:09,440 --> 01:06:15,360
You know, yes, we live in a world where a frivolous quote lawsuit can always happen.

903
01:06:15,360 --> 01:06:20,640
But you know, I also believe in a jury of our peers and I hope that they can see through

904
01:06:20,640 --> 01:06:26,320
that is that we were trying to provide appropriate health care for the patient in a meaningful

905
01:06:26,320 --> 01:06:29,120
way with all the things that we had together.

906
01:06:29,120 --> 01:06:34,560
So I know there are people out there that kind of the scare of a lawsuit kind of hangs

907
01:06:34,560 --> 01:06:35,680
over their head.

908
01:06:35,680 --> 01:06:36,680
And I hate that.

909
01:06:36,680 --> 01:06:40,680
I do think that maybe sometimes that comes if you've been subjected to a lawsuit or multiple

910
01:06:40,680 --> 01:06:46,800
lawsuits and I get that perhaps my perspective will change someday if I remember in that

911
01:06:46,800 --> 01:06:47,800
way.

912
01:06:47,800 --> 01:06:52,000
But I still would stand by do what's right for patient document what's right and treat

913
01:06:52,000 --> 01:06:53,780
them like you would want to be treated.

914
01:06:53,780 --> 01:06:58,800
That just goes a long way on just being a good person and a good health care provider.

915
01:06:58,800 --> 01:07:02,660
I went to a great medic school here where I live.

916
01:07:02,660 --> 01:07:03,660
Great great program.

917
01:07:03,660 --> 01:07:05,080
The bar was held incredibly high.

918
01:07:05,080 --> 01:07:12,000
I think we did like 30% more clinicals than was required you know statewide.

919
01:07:12,000 --> 01:07:18,040
But they did bring a guy in who paraded like a peacock, told us how he was an expert witness,

920
01:07:18,040 --> 01:07:22,640
told us how many paramedics he's put behind bars and it was I think it was a very negative

921
01:07:22,640 --> 01:07:27,200
conversation doing the right thing, understanding that if you deviate from that, yes there are

922
01:07:27,200 --> 01:07:33,280
legal consequences but putting the fear of God into young EMT or medic students I think

923
01:07:33,280 --> 01:07:36,720
does you know has a detrimental effect not the other way.

924
01:07:36,720 --> 01:07:37,720
I would agree.

925
01:07:37,720 --> 01:07:39,880
Yes I'm not one to look at fear.

926
01:07:39,880 --> 01:07:44,560
I mean I think you have to again you got to respect it and be cognizant that it is out

927
01:07:44,560 --> 01:07:49,280
there but just focus on the positive.

928
01:07:49,280 --> 01:07:51,880
Absolutely well Josh let's go to you again.

929
01:07:51,880 --> 01:07:55,600
I don't know if you want to if you have an example already or if it's little Sally the

930
01:07:55,600 --> 01:08:00,960
you know the two-year-old with the febrile or just the fever you know and thrown up once

931
01:08:00,960 --> 01:08:06,960
and the worried first-time parents but whatever that nurse navigate or appropriate call would

932
01:08:06,960 --> 01:08:12,840
be walk me through that 911 call and then let's get to all the resources that people

933
01:08:12,840 --> 01:08:16,320
will find if they use this program.

934
01:08:16,320 --> 01:08:22,800
Yeah great and look I think little Sally is a perfect example of this because I remember

935
01:08:22,800 --> 01:08:28,020
when I was a first-time parent and even though I was a paramedic at the time, my wife was

936
01:08:28,020 --> 01:08:35,920
an RN at the time, we still ourselves as medical providers, healthcare providers when our two-year-old

937
01:08:35,920 --> 01:08:42,480
got sick and had a fever and was throwing up we didn't know what to do and it's very

938
01:08:42,480 --> 01:08:47,820
easy for parents in that situation and of course this isn't just for those worried

939
01:08:47,820 --> 01:08:53,100
parents I think there's a lot of patients who call 911 simply because they don't know

940
01:08:53,100 --> 01:08:55,740
what to do.

941
01:08:55,740 --> 01:09:04,760
So let's talk about little Sally and get your two-year-old who has a medical concern all

942
01:09:04,760 --> 01:09:09,440
of a sudden they've got a fever maybe they threw up a couple of times the first thing

943
01:09:09,440 --> 01:09:14,360
the parents are going to do is call their pediatrician's office which is great Monday

944
01:09:14,360 --> 01:09:20,320
through Friday 9 a.m. to 4 p.m. but if it's after hours the first thing that they're going

945
01:09:20,320 --> 01:09:27,460
to hear is if this is an emergency hang up and call 911 and every time you call a healthcare

946
01:09:27,460 --> 01:09:31,920
provider or a pharmacist anybody these days that's the very first thing that you hear

947
01:09:31,920 --> 01:09:36,980
and again we want to encourage people to call 911 that's what we're here for let us be the

948
01:09:36,980 --> 01:09:44,800
tip of the spear for being able to enter that side of healthcare.

949
01:09:44,800 --> 01:09:52,940
So we're not looking at that as a wrong use of the 911 system it's absolutely appropriate

950
01:09:52,940 --> 01:09:54,800
use of the 911 system.

951
01:09:54,800 --> 01:10:00,820
The challenge is that today in the systems that are out there that don't have a nurse

952
01:10:00,820 --> 01:10:07,220
navigation program the dispatcher is going to answer the call get the basic information

953
01:10:07,220 --> 01:10:11,680
say we have a sick child and we're going to send an ambulance and potentially first responders

954
01:10:11,680 --> 01:10:19,060
out to that home they're going to get on scene and really what the patient needs from a healthcare

955
01:10:19,060 --> 01:10:24,480
perspective is for somebody to tell the parents the appropriate dose of pediatric Tylenol

956
01:10:24,480 --> 01:10:29,340
and to tell them that you know they should try to drink some Pedialyte and they'll be

957
01:10:29,340 --> 01:10:35,780
okay and they can follow up with their physician and so on but we don't have that option as

958
01:10:35,780 --> 01:10:39,520
paramedics you know getting back to what you were talking about a few minutes ago with

959
01:10:39,520 --> 01:10:49,060
living in this litigious society when a paramedic or an EMT shows up on scene they're obligated

960
01:10:49,060 --> 01:10:55,240
by the healthcare regulations in those communities to offer the patient a transport to the hospital

961
01:10:55,240 --> 01:11:00,620
that's what we're here to do and if the patient says yes that's good great then we put them

962
01:11:00,620 --> 01:11:05,020
in the ambulance and we transport them if the patient says no I just need some help

963
01:11:05,020 --> 01:11:10,900
with this or I need to know the you know the right dose of Tylenol to take or anything

964
01:11:10,900 --> 01:11:17,060
else like that something that's going to deviate from those protocols for the EMT and paramedic

965
01:11:17,060 --> 01:11:21,740
that's where those alarm bells start ringing and that's when we start to go back to thinking

966
01:11:21,740 --> 01:11:26,340
about when we were in paramedic school and the expert witness came in and said yeah I'm

967
01:11:26,340 --> 01:11:32,700
going to put all of you guys out of a job so that's when we say well you know what I'm

968
01:11:32,700 --> 01:11:35,980
really not able to tell you that but let's just put you in the ambulance and bring it

969
01:11:35,980 --> 01:11:40,060
to the hospital and then the doctors can help you.

970
01:11:40,060 --> 01:11:45,540
We recognize that's just not the right thing to do from a healthcare perspective from treating

971
01:11:45,540 --> 01:11:53,980
that patient appropriately and so in the case of little Sally if she lives in a community

972
01:11:53,980 --> 01:12:00,020
that has nurse navigation as part of the 911 system when the parents call the dispatcher

973
01:12:00,020 --> 01:12:05,180
and dispatcher asks the initial questions hey tell us what's going on what are the symptoms

974
01:12:05,180 --> 01:12:14,020
and so on they use whatever EMD process they're using for emergency medical dispatch and based

975
01:12:14,020 --> 01:12:19,580
on the outcome of those initial questions determine hey this is a low priority call

976
01:12:19,580 --> 01:12:25,140
and maybe it would benefit from speaking to a nurse and whether they're using the machine

977
01:12:25,140 --> 01:12:29,380
learning tools to help get them there or they're following the card prompts or whatever the

978
01:12:29,380 --> 01:12:37,220
case may be that call taker dispatcher is going to say to the caller look this could

979
01:12:37,220 --> 01:12:40,660
be something that would benefit from speaking to a nurse would you like to speak to a nurse

980
01:12:40,660 --> 01:12:43,920
before we dispatch any units.

981
01:12:43,920 --> 01:12:50,260
Assuming the caller says yes and today we're not in any community automatically putting

982
01:12:50,260 --> 01:12:55,140
people over to the nurse without their consent this has to be with the consent of the caller

983
01:12:55,140 --> 01:12:59,720
but assuming the caller says yes then the dispatcher will hot transfer that call over

984
01:12:59,720 --> 01:13:02,760
to our nurse navigation center.

985
01:13:02,760 --> 01:13:07,900
We have most of our nurses are based out of our headquarters in Lewisville Texas it's

986
01:13:07,900 --> 01:13:14,780
a 24-7 operation at any point it's staffed with you know up to 10 to 15 different nurses

987
01:13:14,780 --> 01:13:18,820
and of course that number is continuing to grow every day as we add new programs into

988
01:13:18,820 --> 01:13:25,260
this and those nurses all have technology so that when the call comes into their system

989
01:13:25,260 --> 01:13:32,100
they get a little ear whisper that says I'm calling from so-and-so community and so they

990
01:13:32,100 --> 01:13:37,260
get the right set of protocols up on their screen they know how to answer the phone and

991
01:13:37,260 --> 01:13:45,620
the nurse will answer the phone to say hi thank you for calling the Seattle nurse navigation

992
01:13:45,620 --> 01:13:53,180
program my name is Josh I am a nurse how can I help you today and so typically the dispatcher

993
01:13:53,180 --> 01:13:58,520
that connected that call they'll stay on as a hot transfer until the nurse picks up we're

994
01:13:58,520 --> 01:14:05,180
picking up the phone in about 25 seconds or less right now for every call once the dispatcher

995
01:14:05,180 --> 01:14:10,320
hears that the nurse has picked up the call generally speaking that dispatcher will disconnect

996
01:14:10,320 --> 01:14:18,940
and the nurse will take over from that point the nurse runs the caller through an algorithm

997
01:14:18,940 --> 01:14:24,620
and this is just like our ACLS algorithms or any other type of algorithm in health care

998
01:14:24,620 --> 01:14:34,140
it's a closed-ended binary type of a if this then that sort of protocol the same way that

999
01:14:34,140 --> 01:14:40,260
you know if we're running our ACLS protocols for cardiac arrest we're gonna do this then

1000
01:14:40,260 --> 01:14:46,340
that then that then that the nurse asks those series of questions and based on the answers

1001
01:14:46,340 --> 01:14:54,020
to the questions then the protocol will suggest appropriate types of action for that patient

1002
01:14:54,020 --> 01:14:59,760
the first few questions that the nurse is going to ask are based around that severity

1003
01:14:59,760 --> 01:15:04,700
of the illness or injury and it will help them identify if this is something that actually

1004
01:15:04,700 --> 01:15:11,180
is a higher priority call and if it is a higher priority call then the nurse will say hold

1005
01:15:11,180 --> 01:15:14,980
on we're going to connect you right back to the dispatch center and send an ambulance

1006
01:15:14,980 --> 01:15:20,140
for you and that's typically done within the first 30 to 60 seconds of the phone call so

1007
01:15:20,140 --> 01:15:27,740
there's really no delay for those higher priority calls once we get past that series of questions

1008
01:15:27,740 --> 01:15:33,140
and the nurse will ask additional questions to determine what we call an m tara level and

1009
01:15:33,140 --> 01:15:40,300
tara it's nmtara stands for needs matched time appropriate resource allocation and that's

1010
01:15:40,300 --> 01:15:47,020
the name of this proprietary set of protocols that we use for this system as they run through

1011
01:15:47,020 --> 01:15:53,780
the protocol they determine what we call an m tara level somewhere between one to five

1012
01:15:53,780 --> 01:15:59,260
that helps the nurse identify number one how quickly that patient needs to receive some

1013
01:15:59,260 --> 01:16:05,340
type of interventional care and number two what's the best type of care for their needs

1014
01:16:05,340 --> 01:16:11,020
now that care certainly could be an ambulance ride to an emergency department there are

1015
01:16:11,020 --> 01:16:17,260
a lot of reasons why people call 911 for low acuity complaints that clinically would be

1016
01:16:17,260 --> 01:16:23,900
best served in an emergency department and so roughly half the time that the nurses are

1017
01:16:23,900 --> 01:16:29,740
screening the call that patient winds up in an ambulance and gets that emergency transport

1018
01:16:29,740 --> 01:16:37,060
to an ed and that might be because the ed is at that point the very best place for them

1019
01:16:37,060 --> 01:16:43,380
it could be because if it was middle of the day during the week they'd wind up in an urgent

1020
01:16:43,380 --> 01:16:49,260
care but because it's after hours and there's no urgent care open at this point they need

1021
01:16:49,260 --> 01:16:54,020
to go to an emergency department because that's the failsafe for the health care system or

1022
01:16:54,020 --> 01:17:00,380
it could be we go through the full screening process we give options to the patient and

1023
01:17:00,380 --> 01:17:05,220
the patient says you know what all that's great but I still just feel more comfortable

1024
01:17:05,220 --> 01:17:11,460
with any ambulance to the er if that's the case that's what we'll do as well but separate

1025
01:17:11,460 --> 01:17:18,380
from that as the nurse continues that assessment and determines what other options exist then

1026
01:17:18,380 --> 01:17:22,300
the nurse can actually direct that patient over to an urgent care or some other type

1027
01:17:22,300 --> 01:17:29,860
of alternate destination that could be a walk-in dental clinic it could be a behavioral health

1028
01:17:29,860 --> 01:17:36,460
care center it could be a federally qualified health care center some other type of community

1029
01:17:36,460 --> 01:17:42,260
clinic but basically an alternate brick and mortar option to receive health care in their

1030
01:17:42,260 --> 01:17:48,780
community that would not have been available to the ambulance system because remember in

1031
01:17:48,780 --> 01:18:00,460
pretty much every state that we have right now the sorry about that okay maybe we'll

1032
01:18:00,460 --> 01:18:06,580
just edit that clip I'll start over because because remember in pretty much every state

1033
01:18:06,580 --> 01:18:12,940
where we operate ambulances are only permitted in a 911 system to transport a patient to

1034
01:18:12,940 --> 01:18:19,060
an emergency department so even if there are alternate options in communities that would

1035
01:18:19,060 --> 01:18:24,620
be better fits for those patients such as these urgent cares or dental clinics or behavioral

1036
01:18:24,620 --> 01:18:30,380
health care centers if somebody's called 911 and the ambulance shows up we really don't

1037
01:18:30,380 --> 01:18:36,420
have any other option but to bring them to an emergency department without nurse navigation

1038
01:18:36,420 --> 01:18:42,060
so the nurse can recommend those other options and we work with every community where we

1039
01:18:42,060 --> 01:18:47,000
have this set up to build out a network of those resources so that the nurse can look

1040
01:18:47,000 --> 01:18:51,720
and say okay you're calling from 123 Main Street well there's an urgent care two blocks

1041
01:18:51,720 --> 01:18:56,900
from you and in a lot of cases can actually go into the urgent care system and see what

1042
01:18:56,900 --> 01:19:02,820
they have for availability for appointments that afternoon and get that set up we can

1043
01:19:02,820 --> 01:19:09,740
also if the patient doesn't necessarily require an in-person assessment and exam connect that

1044
01:19:09,740 --> 01:19:15,820
patient directly over to a virtual care option and so we work very closely with a couple

1045
01:19:15,820 --> 01:19:20,980
of different telehealth providers now we're not a telemedicine service ourselves and we

1046
01:19:20,980 --> 01:19:26,360
don't have doctors other than Dr. Troutman that that are directly connected into this

1047
01:19:26,360 --> 01:19:34,400
program but we can refer that patient over to a virtual care option and the virtual care

1048
01:19:34,400 --> 01:19:40,860
partners that we use have physicians and advanced practice providers available around the clock

1049
01:19:40,860 --> 01:19:45,700
and so if that's the appropriate option for that patient we'll help navigate them to that

1050
01:19:45,700 --> 01:19:53,500
direction we also find probably 25 percent of the time that the call can be managed just

1051
01:19:53,500 --> 01:20:00,380
through self-care and the the nurse after going through the screening process can provide

1052
01:20:00,380 --> 01:20:05,600
some physician developed guidance for that patient you know maybe it's hey in the case

1053
01:20:05,600 --> 01:20:12,340
of little Sally here's the dose of pediatric Tylenol you know she weighs 40 pounds this

1054
01:20:12,340 --> 01:20:16,200
is how much Tylenol you're going to give her and then you're going to check again in four

1055
01:20:16,200 --> 01:20:21,300
hours and see how she's doing and that could be all that was needed in the case of little

1056
01:20:21,300 --> 01:20:29,040
Sally's fever and then the call ends at that point we do callbacks 24 hours later to make

1057
01:20:29,040 --> 01:20:33,860
sure that everybody got the care that they actually need and then to ask some survey

1058
01:20:33,860 --> 01:20:38,860
questions about what they felt about the program but aside from that that's really how the

1059
01:20:38,860 --> 01:20:45,340
program works it makes so much sense on on so many different levels and what I love when

1060
01:20:45,340 --> 01:20:50,860
I think back now out in the real world I talk about when I work for Disney's fire department

1061
01:20:50,860 --> 01:20:54,260
a bit because that was a unique situation a lot of refusals which really is kind of

1062
01:20:54,260 --> 01:20:58,600
the halfway point between you know what we're talking about now but the number of times

1063
01:20:58,600 --> 01:21:03,660
that I went you know sometimes the person was just lonely so again we'll obviously get

1064
01:21:03,660 --> 01:21:09,300
to that point as well but prescription refills you know the person's slightly hypertensive

1065
01:21:09,300 --> 01:21:13,180
it's not a crisis by any means but they're worried that you know they're they've run

1066
01:21:13,180 --> 01:21:17,860
out of their meds and the ability to refer to a nurse practitioner or a physician that

1067
01:21:17,860 --> 01:21:22,940
can then you know assuming you know if all things align they can write a prescription

1068
01:21:22,940 --> 01:21:26,660
and now you have you know we'll talk about Lyft and Uber you have these abilities now

1069
01:21:26,660 --> 01:21:32,700
to even get those meds brought to you so there is no better time for that person to be at

1070
01:21:32,700 --> 01:21:41,600
home when I was at the the Disney department they there was an abuse of the the 911 simply

1071
01:21:41,600 --> 01:21:45,300
because they told the guests we can call you an alpha they didn't tell them what alpha

1072
01:21:45,300 --> 01:21:50,460
meant alpha meant call you a an ambulance with paramedics on it you know so we would

1073
01:21:50,460 --> 01:21:55,060
get there and it was literally little Sally and so again you would be able to coach the

1074
01:21:55,060 --> 01:21:59,740
parents tell them you know unofficially you know read the directions of the the time law

1075
01:21:59,740 --> 01:22:03,660
I can't tell you exactly what it is but it's on the box you know don't bundle her up you

1076
01:22:03,660 --> 01:22:09,780
know allow her to just be in her underwear and be cool and I think it was probably 90

1077
01:22:09,780 --> 01:22:15,060
95 percent that never called us back so the ability to put someone at ease whether it's

1078
01:22:15,060 --> 01:22:19,340
a parent whether it's someone who's older because as you said we're you know within

1079
01:22:19,340 --> 01:22:24,060
medicine we understand what sounds and symptoms mean a lot of times you know some of these

1080
01:22:24,060 --> 01:22:28,460
are terrifying to people especially if you know they saw on ER once that a person just

1081
01:22:28,460 --> 01:22:32,380
had you know wrist pain and they ended up dying of a massive heart attack you know so

1082
01:22:32,380 --> 01:22:37,740
there's all this kind of misinformation simply being put to a trusted professional I want

1083
01:22:37,740 --> 01:22:44,100
to jump in and make a comment about the telehealth piece please and yes and you know we could

1084
01:22:44,100 --> 01:22:50,260
even go back and assuming everyone recalls kind of the ET3 project and we could get into

1085
01:22:50,260 --> 01:22:56,860
all the nuances with that but the reality is that project ultimately failed and a lot

1086
01:22:56,860 --> 01:23:03,540
of people do seem to be surprised at first why telehealth isn't our primary solution

1087
01:23:03,540 --> 01:23:09,940
and I think the medication refill is a great example there are other agencies out there

1088
01:23:09,940 --> 01:23:16,980
that their plan or the system they're doing is to take that 911 call and connect them

1089
01:23:16,980 --> 01:23:23,940
directly to telehealth we think that's a fail because ultimately what we want to do is establish

1090
01:23:23,940 --> 01:23:31,060
the patient within their community to care providers so that's why after we've cleared

1091
01:23:31,060 --> 01:23:36,860
that this patient doesn't need an emergency department our next goal is to get them plugged

1092
01:23:36,860 --> 01:23:44,020
into a local brick and mortar solution right now because of time of day etc etc there may

1093
01:23:44,020 --> 01:23:48,900
be reasons why that can't happen so before we end up on the ultimate fallback which is

1094
01:23:48,900 --> 01:23:54,860
an ambulance that's when we fit the telehealth providers in and Josh mentioned we have we've

1095
01:23:54,860 --> 01:23:59,740
had virtual er which is a board certified emergency medicine physician but just recently

1096
01:23:59,740 --> 01:24:04,060
actually added a virtual urgent care and I think we're the only ones that are actually

1097
01:24:04,060 --> 01:24:09,960
utilizing both and we decide that based on the acuity level so the higher nemtara acuity

1098
01:24:09,960 --> 01:24:14,540
levels would only be accessible to the board certified emergency department the virtual

1099
01:24:14,540 --> 01:24:19,900
er but the lower acuity ones that just by sake it's 2 a.m. and there's not a brick and

1100
01:24:19,900 --> 01:24:25,160
mortar urgent care we could connect those patients to the virtual urgent care but ultimately

1101
01:24:25,160 --> 01:24:31,300
like in that medication refill absolutely you could connect to a doctor an np and get

1102
01:24:31,300 --> 01:24:35,300
the prescription written and they could get that prescription tomorrow but what happens

1103
01:24:35,300 --> 01:24:39,940
two weeks from now or a month from now when they're out after the patient in florida talked

1104
01:24:39,940 --> 01:24:45,100
to the patient and talked to the doctor in new york all they're going to do is call 911

1105
01:24:45,100 --> 01:24:50,820
again versus our premise is if i can get them plugged into an urgent care maybe that urgent

1106
01:24:50,820 --> 01:24:55,980
care hopefully we'll get them plugged into a primary care and ultimately try to help

1107
01:24:55,980 --> 01:25:01,860
break that cycle or at least massage it does it happen every time no but we've had and

1108
01:25:01,860 --> 01:25:08,140
teased out some data certainly out of dc when we looked at some of the medicaid data we

1109
01:25:08,140 --> 01:25:14,060
did see a decrease in er utilization from those patients that called 911 nurse navigation

1110
01:25:14,060 --> 01:25:19,820
and ended up plugged into a system so i think that's a real important caveat to point out

1111
01:25:19,820 --> 01:25:26,300
that going straight to a telehealth provider it's a bandaid it is not the ultimate robust

1112
01:25:26,300 --> 01:25:33,820
solution of offering all this cod gray of what really fits the patient best yeah and

1113
01:25:33,820 --> 01:25:39,180
if i could expand on that a little bit further from the provider perspective so james i'm

1114
01:25:39,180 --> 01:25:46,060
sure you remember from your time in the field that we see those high utilizor patients right

1115
01:25:46,060 --> 01:25:52,460
there's a whole bunch of nicknames forum frequent flyers etc right but ultimately these represent

1116
01:25:52,460 --> 01:25:59,620
patients that are calling 911 on a regular basis generally because they're not receiving

1117
01:25:59,620 --> 01:26:05,300
any other type of appropriate health care and so we have to bring them to the emergency

1118
01:26:05,300 --> 01:26:09,880
department because there really aren't any other options outside of you know now with

1119
01:26:09,880 --> 01:26:16,040
our nurse navigation program but really what they need and and you mentioned a lot of different

1120
01:26:16,040 --> 01:26:20,580
reasons for this they could be frequent callers because of loneliness they could be frequent

1121
01:26:20,580 --> 01:26:30,580
callers because of um unmanaged chronic conditions diabetes co pd patients etc lots of different

1122
01:26:30,580 --> 01:26:40,580
um reasons for them to fall into that bucket but what we can do is break that cycle of

1123
01:26:40,580 --> 01:26:45,900
bringing them to the emergency department and instead getting them plugged into an appropriate

1124
01:26:45,900 --> 01:26:52,060
as dr trautman said brick and mortar option in their community that's an alternate to

1125
01:26:52,060 --> 01:26:57,140
the emergency department and so whether that's an urgent care we also have great success

1126
01:26:57,140 --> 01:27:02,220
when we work with our with those federally qualified health care centers fqhc's which

1127
01:27:02,220 --> 01:27:07,580
are these community health clinics that receive some additional funding to be able to care

1128
01:27:07,580 --> 01:27:15,580
for um those unfunded patients whether they're uninsured or they're have a limited medicaid

1129
01:27:15,580 --> 01:27:21,660
program or whatever the case may be and not only are we able to get those patients plugged

1130
01:27:21,660 --> 01:27:28,740
in in that case but not but the patient can get that immediate care managed whatever that

1131
01:27:28,740 --> 01:27:33,960
immediate challenge might be but then they can also get enrolled with a primary care

1132
01:27:33,960 --> 01:27:39,980
physician and get enrolled appropriately in a medicaid program and get their case followed

1133
01:27:39,980 --> 01:27:45,660
and then what happens is their medications get refilled on a regular basis their mental

1134
01:27:45,660 --> 01:27:52,020
health needs get met appropriately through this fqhc and so on and they stop calling

1135
01:27:52,020 --> 01:27:56,520
911 so a lot of times when we go into new communities and we start talking about this

1136
01:27:56,520 --> 01:28:00,300
nurse navigation program one of those first questions is well what about the frequent

1137
01:28:00,300 --> 01:28:06,500
flyers and really when we get down to the root of these high utilizer patients and and

1138
01:28:06,500 --> 01:28:12,340
what's causing them to be high utilizers very often it's low acuity challenges that are

1139
01:28:12,340 --> 01:28:17,900
not being met through any other type of health care and when we redirect them when we navigate

1140
01:28:17,900 --> 01:28:23,500
them appropriately then they fall out of the 911 system because they don't have to rely

1141
01:28:23,500 --> 01:28:27,540
on 911 anymore for those health care needs.

1142
01:28:27,540 --> 01:28:32,780
I've heard a lot of people say that the community paramedic program which comes from you know

1143
01:28:32,780 --> 01:28:38,460
a great idea it's not having the results of people expected and it kind of makes sense

1144
01:28:38,460 --> 01:28:42,820
when you take a step back but you're waiting for a call and then you're dispatching a unit

1145
01:28:42,820 --> 01:28:47,540
almost the same way as you would with you know a rescue crew what you've described makes

1146
01:28:47,540 --> 01:28:51,780
so much more sense the one barrier to entry obviously that people would think is that

1147
01:28:51,780 --> 01:28:56,460
yeah but how can a patient get to this facility and you even talked about you know dental

1148
01:28:56,460 --> 01:29:01,460
and optical this is a big misnomer too when you have teeth injuries or an eye injury most

1149
01:29:01,460 --> 01:29:05,580
ERs can't handle that so we take them to the ER and they go we can't help them and then

1150
01:29:05,580 --> 01:29:10,580
they have to leave again so talk to me about the empowering of these patients through nurse

1151
01:29:10,580 --> 01:29:15,460
navigation as far as transportation and your partnership with Lyft.

1152
01:29:15,460 --> 01:29:19,260
Yeah I'm so glad you brought that up so one of the things that we learned really early

1153
01:29:19,260 --> 01:29:26,760
on in this program is that transportation is a big barrier to accessing health care

1154
01:29:26,760 --> 01:29:34,940
and a lot of people will call 911 knowing that if they had a car and could drive themselves

1155
01:29:34,940 --> 01:29:39,880
to an urgent care that's what they would have done but they don't and if they don't have

1156
01:29:39,880 --> 01:29:45,180
that ability for transportation they really don't have any other option but to call 911

1157
01:29:45,180 --> 01:29:52,300
not for the health care services but for the ride and so when we recognize that we built

1158
01:29:52,300 --> 01:29:59,140
into the program this partnership that we have with Lyft now AMR if you're familiar

1159
01:29:59,140 --> 01:30:07,060
with American Medical Response as the organization now GMR for a long time had a subsidiary company

1160
01:30:07,060 --> 01:30:11,780
called Access to Care it's actually no longer part of our organization but we still have

1161
01:30:11,780 --> 01:30:19,140
a lot of those relationships and so on and what Access to Care did was non-emergent medical

1162
01:30:19,140 --> 01:30:24,760
transport they still do it's now again it's not part of our company but through those

1163
01:30:24,760 --> 01:30:31,180
relationships we built strong national relationships with Lyft and with Uber as well though Lyft

1164
01:30:31,180 --> 01:30:40,180
is certainly our primary so that we can offer ride share to patients who the nurse has screened

1165
01:30:40,180 --> 01:30:47,700
has determined are not clinically appropriate for an ambulance but would work in you know

1166
01:30:47,700 --> 01:30:55,300
can safely be transported through some other type of alternate vehicle and so the way that

1167
01:30:55,300 --> 01:31:00,940
that works is once the nurse completes the screening identifies it here's an appropriate

1168
01:31:00,940 --> 01:31:04,940
resource for that patient that could be an urgent care or brick and mortar facility a

1169
01:31:04,940 --> 01:31:10,780
dental clinic eye clinic as you mentioned behavioral health or it could even be an emergency

1170
01:31:10,780 --> 01:31:16,860
department once the nurse determines that hey this is the right location for you then

1171
01:31:16,860 --> 01:31:22,460
the nurse determines what's the appropriate form of transport if it's anything other than

1172
01:31:22,460 --> 01:31:29,020
an emergency department obviously the ambulance is not the right form in the ER case it's

1173
01:31:29,020 --> 01:31:33,180
possible that an ambulance still isn't the right form if the patient is clinically stable

1174
01:31:33,180 --> 01:31:38,320
enough to go by alternate means then let's set that up for them if nothing else it's

1175
01:31:38,320 --> 01:31:44,380
better for the system and better for the patient from a cost perspective and so the nurse will

1176
01:31:44,380 --> 01:31:49,900
then get into our software that's plugged into the lift system and be able to order

1177
01:31:49,900 --> 01:31:55,980
that transport that lift ride for the patient if the patient has a smartphone and the nurse

1178
01:31:55,980 --> 01:32:00,260
will send a link over to the patient with details about the ride so that they can track

1179
01:32:00,260 --> 01:32:04,860
it just like anybody else using ride share would be able to see when their car is coming

1180
01:32:04,860 --> 01:32:10,420
and so on if the patient doesn't have a smartphone then the nurse will provide instructions such

1181
01:32:10,420 --> 01:32:16,820
as okay Mary is your lift driver she's driving a red Kia with this license plate and she

1182
01:32:16,820 --> 01:32:22,940
will be outside of your door in 30 minutes to take you to the urgent care and then provide

1183
01:32:22,940 --> 01:32:29,500
that information as well we also in addition to providing the ride to that alternate destination

1184
01:32:29,500 --> 01:32:36,220
wherever it might be we give the the caller instructions if you need a ride back including

1185
01:32:36,220 --> 01:32:40,860
a stop off at the pharmacy on the way here's our phone number call us back and we'll set

1186
01:32:40,860 --> 01:32:47,140
up a return trip for you and there is no out-of-pocket cost for that caller the cost of the ride

1187
01:32:47,140 --> 01:32:50,980
share program is built into our overall nurse navigation program.

1188
01:32:50,980 --> 01:32:51,980
Beautiful.

1189
01:32:51,980 --> 01:32:57,340
Well Jared I saw on the video when you go to your website nurse navigation the Cobb

1190
01:32:57,340 --> 01:33:03,180
County in Georgia had gone to this model so let's go back even though I care deeply about

1191
01:33:03,180 --> 01:33:08,860
the patients let's talk about you know my men and women in uniform what are you hearing

1192
01:33:08,860 --> 01:33:14,860
as far as the reduction of calls and therefore the impact on the the firefighters and paramedics

1193
01:33:14,860 --> 01:33:17,660
and EMTs themselves?

1194
01:33:17,660 --> 01:33:24,180
Right so I love this topic like I said every rock we seem to turn over is positive and

1195
01:33:24,180 --> 01:33:29,420
I like to say and actually give a talk at various conferences called putting the E back

1196
01:33:29,420 --> 01:33:37,040
and EMS and we know that at the end of the day most people in emergency care we came

1197
01:33:37,040 --> 01:33:43,420
to this or had a calling to this specialty why because of that emergency piece we like

1198
01:33:43,420 --> 01:33:48,020
those sick patients we'd like to be able to think and work through some of those difficult

1199
01:33:48,020 --> 01:33:55,060
situations and the low acuity stuff becomes a dissatisfier and as those dissatisfiers

1200
01:33:55,060 --> 01:34:00,300
build up I don't like my job as much I don't like going to work I don't look forward to

1201
01:34:00,300 --> 01:34:06,300
it and so we've always felt anecdotally like look we're taking these low acuity patients

1202
01:34:06,300 --> 01:34:12,100
out of the system doing what's better for the patient it's helping operations how is

1203
01:34:12,100 --> 01:34:19,540
it is it really positively impacting our providers out there so we have what's called a GMR cares

1204
01:34:19,540 --> 01:34:25,780
program so several years ago we realized you know whenever we look at clinical stuff how

1205
01:34:25,780 --> 01:34:30,420
do we improve it the number one thing we have to do is do what we have to measure it if

1206
01:34:30,420 --> 01:34:34,660
we don't know what our IV start rate or our first pass success rate is if I don't have

1207
01:34:34,660 --> 01:34:40,620
that number I can't put plans into place to correct it so we started surveying all of

1208
01:34:40,620 --> 01:34:46,820
our clinicians and providers and asking them questions and one of the as far as I know

1209
01:34:46,820 --> 01:34:53,140
one of the first EMS agencies to really do that do you like your job do you enjoy showing

1210
01:34:53,140 --> 01:34:58,940
up to work do you you know all these questions about the day-to-day activities and so then

1211
01:34:58,940 --> 01:35:04,260
we can learn from that and put things in place to work that through positive well what we

1212
01:35:04,260 --> 01:35:10,620
found kind of as a sidebar we were just looking at some of the data and we noticed a few particular

1213
01:35:10,620 --> 01:35:16,100
spikes that were higher on a few questions that I'm going to turn to Josh in a second

1214
01:35:16,100 --> 01:35:21,580
because I think he knows those particular points but there was statistically significant

1215
01:35:21,580 --> 01:35:27,420
higher positive ratings over essentially the clinicians like their jobs better they liked

1216
01:35:27,420 --> 01:35:32,140
showing up to work and caring for patients in places where we do nurse navigation now

1217
01:35:32,140 --> 01:35:35,980
obviously there can be lots of confounders in that but of course as part of the nurse

1218
01:35:35,980 --> 01:35:40,300
navigation team I like to think it's all because of the nurse navigation but I think we do

1219
01:35:40,300 --> 01:35:45,460
know that this is certainly a large part of that because we do pull those dissatisfiers

1220
01:35:45,460 --> 01:35:53,940
out of the system yeah James you talked earlier about recruiting and retention in EMS and

1221
01:35:53,940 --> 01:36:01,980
what a challenge that is and as Dr. Troutman mentioned one of the initiatives for GMR is

1222
01:36:01,980 --> 01:36:06,340
trying to figure out what can we do to take better care of our own people and so as you

1223
01:36:06,340 --> 01:36:11,060
said to that point we actually commissioned Gallup the survey company to conduct these

1224
01:36:11,060 --> 01:36:17,540
surveys and we do them every six months or so across the organization every provider

1225
01:36:17,540 --> 01:36:23,700
gets asked a series of questions and what we found is when we looked at the nurse navigation

1226
01:36:23,700 --> 01:36:29,300
markets compared to the non nurse navigation markets and tried to match up everything else

1227
01:36:29,300 --> 01:36:35,260
around call volume how busy the system is things like that to try to get an apples to

1228
01:36:35,260 --> 01:36:42,220
apples comparison what we found is almost a 5% increase with field providers who said

1229
01:36:42,220 --> 01:36:48,300
that they felt like their job is important 6% increase in field providers who said that

1230
01:36:48,300 --> 01:36:52,940
they feel like their training and skills were well utilized and most importantly almost

1231
01:36:52,940 --> 01:36:58,300
a 12% increase in the field providers who said that they have high job satisfaction

1232
01:36:58,300 --> 01:37:04,300
and so when we look at those three metrics you know certainly we're not able to ask the

1233
01:37:04,300 --> 01:37:08,420
question hey do you think nurse navigation has stopped you from going out on that call

1234
01:37:08,420 --> 01:37:14,460
at 2 in the morning for little Sally who's two years old and has a fever but I think

1235
01:37:14,460 --> 01:37:19,500
when we look at these questions about how satisfied somebody is with the job that they're

1236
01:37:19,500 --> 01:37:26,740
doing and we recognize that we can make some systemic changes to the delivery of EMS then

1237
01:37:26,740 --> 01:37:31,620
ultimately these are going to benefit those field providers and we're really proud of

1238
01:37:31,620 --> 01:37:37,980
this impact again not just for our patients and our communities but for the men and women

1239
01:37:37,980 --> 01:37:42,980
who are working on our ambulances or as you've been telling this story and I'm thinking again

1240
01:37:42,980 --> 01:37:47,980
what another beautiful string to the bow for department and their community I mean this

1241
01:37:47,980 --> 01:37:56,060
this affects everyone but as a bragging element to say hey young recruits if you're looking

1242
01:37:56,060 --> 01:38:00,800
for someone to work we have nurse navigation here so this is really positively affecting

1243
01:38:00,800 --> 01:38:06,100
you know the the way that we do medicine and improving the chance of responding to you

1244
01:38:06,100 --> 01:38:10,500
know the emergency calls that I know you guys trained to do when I think of the dispatcher

1245
01:38:10,500 --> 01:38:16,380
side the ability to pass off a call that may take 10-15 minutes of their time you know

1246
01:38:16,380 --> 01:38:20,180
now it goes immediately nurse navigation you know now you freed up some more time there

1247
01:38:20,180 --> 01:38:24,940
and again you know we have those pending pending pending and I would argue even on the law

1248
01:38:24,940 --> 01:38:28,660
enforcement side we didn't really touch on it much but you know the the mental health

1249
01:38:28,660 --> 01:38:32,660
side of this again you know high acuity of course of course it's got to go one certain

1250
01:38:32,660 --> 01:38:38,220
way but the lower acuity the you know the the depression the anxiety the loneliness

1251
01:38:38,220 --> 01:38:42,900
a lot of the calls that we are sent to the ability for the law enforcement to pass that

1252
01:38:42,900 --> 01:38:48,260
on to you know a culturally competent provider who would be able to interact even better

1253
01:38:48,260 --> 01:38:52,540
with that person because that's what they're trained to do so from a recruitment point

1254
01:38:52,540 --> 01:38:58,620
of view this seems like such a powerful element to provide and to talk about as far as recruiting

1255
01:38:58,620 --> 01:39:03,500
I'm sure people listening though are wondering yeah but what's this going to cost my department

1256
01:39:03,500 --> 01:39:09,900
so let's break down that that side I mean we all know that if someone calls 911 and

1257
01:39:09,900 --> 01:39:14,260
they take an ambulance ride and they go to an ER and they are given you know two hundred

1258
01:39:14,260 --> 01:39:20,260
dollar aspirin pills you know that patient's getting a large bill so what is the cost or

1259
01:39:20,260 --> 01:39:26,220
what are the different kind of models that you have for a cost or not a cost to a fire

1260
01:39:26,220 --> 01:39:31,420
department and then also what is the reduction in costs to that patient what is the selling

1261
01:39:31,420 --> 01:39:39,900
point to the individual themselves yeah that's that's a great question and so we're going

1262
01:39:39,900 --> 01:39:45,420
to take it from a couple of different standpoints from the patient in the community when we

1263
01:39:45,420 --> 01:39:53,220
look at calls that would have resulted in an ambulance transport to an emergency department

1264
01:39:53,220 --> 01:40:01,780
we can assign a specific cost to that because we know BLS ambulance ride is you know certainly

1265
01:40:01,780 --> 01:40:06,180
it's going to get charged out at different rates but by the time it all washes out between

1266
01:40:06,180 --> 01:40:12,140
different payers and different rate schedules and so on there's a cost of that that you

1267
01:40:12,140 --> 01:40:18,660
know we can find an average cost in every community call it say 450 to 500 dollars we

1268
01:40:18,660 --> 01:40:23,380
also know when that patient goes into an emergency department there's a cost associated with

1269
01:40:23,380 --> 01:40:29,140
that care now again it's going to be different for every individual patient between what

1270
01:40:29,140 --> 01:40:33,300
the payer is responsible for depending on what type of insurance they have how much

1271
01:40:33,300 --> 01:40:41,380
that patient has to pay out of pocket and so on but we know that just the physician

1272
01:40:41,380 --> 01:40:49,060
engagement alone can be north of two thousand dollars and then whatever the cost is going

1273
01:40:49,060 --> 01:40:55,940
to be associated with a different additional ed fees and again if there's x-rays associated

1274
01:40:55,940 --> 01:41:02,980
or lab studies and so on then all of that adds to additional cost but we can say hypothetically

1275
01:41:02,980 --> 01:41:09,740
that the cost the bare minimum cost of the patient going to an emergency department is

1276
01:41:09,740 --> 01:41:17,820
about three thousand dollars between the ambulance the physician the ed costs and so on and again

1277
01:41:17,820 --> 01:41:22,540
how much of that is the responsibility of the patient compared to their payer that's

1278
01:41:22,540 --> 01:41:26,460
going to be different in every circumstance but but we know what that total number is

1279
01:41:26,460 --> 01:41:34,140
going to be when we look at that and then we compare it to the cost of alternate care

1280
01:41:34,140 --> 01:41:43,660
whether that's an urgent care visit or virtual care ed or virtual care urgent care or some

1281
01:41:43,660 --> 01:41:51,900
other type of alternate option for that patient that cost is a fraction right it's maybe two

1282
01:41:51,900 --> 01:41:57,700
hundred dollars compared to that three thousand dollar bill so there's a significant delta

1283
01:41:57,700 --> 01:42:06,660
there's 2800 2500 dollars easily in every case when we take a look at the hundred and

1284
01:42:06,660 --> 01:42:12,620
seventy five thousand patients that we've now navigated through nurse navigation since

1285
01:42:12,620 --> 01:42:18,460
the inception of this program and we can break it down and we look at okay well how many

1286
01:42:18,460 --> 01:42:23,020
of those patients still wound up in an emergency department compared to alternate care what

1287
01:42:23,020 --> 01:42:28,860
the alternate care option was and then how many wound up with self care and so on we

1288
01:42:28,860 --> 01:42:35,700
can come up with a number pretty accurate as to what that savings has been and i don't

1289
01:42:35,700 --> 01:42:39,300
have it off the top of my head but i want to say last year when we looked at this for

1290
01:42:39,300 --> 01:42:45,140
twenty twenty three is about thirty five million dollars in savings for the health care system

1291
01:42:45,140 --> 01:42:51,580
just in twenty twenty three alone and that is hard fast concrete that we can point to

1292
01:42:51,580 --> 01:42:56,060
say hey these are patients who would have wound up in an emergency department but we

1293
01:42:56,060 --> 01:43:04,260
were able to navigate them to an alternate care option instead and that's even including

1294
01:43:04,260 --> 01:43:09,660
a discount for the folks that we think probably just would have refused care so they wouldn't

1295
01:43:09,660 --> 01:43:14,820
have incurred any type of cost we factor that into that thirty five million calculation

1296
01:43:14,820 --> 01:43:20,240
as well so that's the overall savings to the health care community and again some of that's

1297
01:43:20,240 --> 01:43:26,380
payers individual patient out of pocket etc different every place where we go but let's

1298
01:43:26,380 --> 01:43:34,900
talk about the cost and savings for the ems system now it is different every different

1299
01:43:34,900 --> 01:43:42,060
place where we do this if it's a market where we are already the ground nine one one provider

1300
01:43:42,060 --> 01:43:46,180
then we're going to take a look at that market and see if it makes sense and it's something

1301
01:43:46,180 --> 01:43:51,780
sustainable for our organization to cover the cost of nurse navigation and in a lot

1302
01:43:51,780 --> 01:43:58,340
of cases it is because when we take a look at the calls that we're not having to respond

1303
01:43:58,340 --> 01:44:04,540
to we see a corresponding decrease in the dry run rate which means that we can be a

1304
01:44:04,540 --> 01:44:09,820
lot more efficient with our paramedics and emt's and our ambulance resources that are

1305
01:44:09,820 --> 01:44:17,700
out on the road and so in turn we don't have to necessarily staff as many ambulances out

1306
01:44:17,700 --> 01:44:22,820
there on a regular basis because we know that a certain portion of calls are going to go

1307
01:44:22,820 --> 01:44:30,020
to nurse navigation and not require response we also look at communities where today we

1308
01:44:30,020 --> 01:44:35,540
might not be able to fulfill the response time requirements for that contract and again

1309
01:44:35,540 --> 01:44:40,660
this is because of all the challenges that are facing ems nationwide between recruiting

1310
01:44:40,660 --> 01:44:46,900
and staffing and supply chain of vehicles and everything else out there and we can look

1311
01:44:46,900 --> 01:44:51,060
at this as a way hey if we put this program in place we're going to be more efficient

1312
01:44:51,060 --> 01:44:56,980
with our resources and we don't have to you know respond to as many calls which means

1313
01:44:56,980 --> 01:45:03,100
we can be more effective in meeting our response time compliance and that in turn helps to

1314
01:45:03,100 --> 01:45:06,540
support the overall contract and the overall program.

1315
01:45:06,540 --> 01:45:11,880
Now there are other markets where we look at it and maybe we're not the 911 provider

1316
01:45:11,880 --> 01:45:16,780
today in that community then we're going to look at saying okay does it make sense for

1317
01:45:16,780 --> 01:45:23,140
us to partner with that fire agency you know particularly these big urban markets because

1318
01:45:23,140 --> 01:45:31,180
we know urban fire the big metropolitan cities out there like Washington DC like Seattle

1319
01:45:31,180 --> 01:45:39,140
Washington like that metro Atlanta area in DeKalb County these places that are high volume

1320
01:45:39,140 --> 01:45:44,700
high performance ems systems that are on constant demand and maybe they're running their own

1321
01:45:44,700 --> 01:45:50,340
ALS units today but they just don't have enough units on the road well let's figure out the

1322
01:45:50,340 --> 01:45:55,500
right way to partner with them so that we can use nurse navigation as a point of entry

1323
01:45:55,500 --> 01:46:00,900
and then for those calls that the nurse determines hey this is still clinically appropriate for

1324
01:46:00,900 --> 01:46:08,500
an ambulance but not for that immediate high priority ALS response well let's bring some

1325
01:46:08,500 --> 01:46:14,300
ambulances into that market too through American Medical Response AMR and have some additional

1326
01:46:14,300 --> 01:46:20,740
ambulances out on the road to handle those lower priority calls that get identified as

1327
01:46:20,740 --> 01:46:25,220
part of nurse navigation we can do that for these communities and then we can work with

1328
01:46:25,220 --> 01:46:32,020
them in a least unit hour model or something similar so that while certainly there's a

1329
01:46:32,020 --> 01:46:37,060
cost associated with putting our ambulances out on the road there's a benefit on the back

1330
01:46:37,060 --> 01:46:42,460
end for that urban fire department because they're able to bill and collect for the trips

1331
01:46:42,460 --> 01:46:47,980
that we're running on their behalf and so there's a cost offset there so it becomes

1332
01:46:47,980 --> 01:46:54,180
cost neutral for that fire department and not a big impact on their budget and then

1333
01:46:54,180 --> 01:47:01,140
finally there are some other markets out there you know take a look at Washington State for

1334
01:47:01,140 --> 01:47:06,420
example so we started nurse navigation in the city of Seattle a couple of years ago

1335
01:47:06,420 --> 01:47:12,780
the Seattle Medic One program nationally known for high performance CMS really a very high

1336
01:47:12,780 --> 01:47:21,900
level program that works very well run through Seattle Fire Department we brought nurse navigation

1337
01:47:21,900 --> 01:47:28,660
to that as part of our BLS support for that system a couple of years ago since that point

1338
01:47:28,660 --> 01:47:36,380
and we've shown how well it works up in that community then the rest of King County Washington

1339
01:47:36,380 --> 01:47:44,140
which is where Seattle is located just recently hired us to put nurse navigation in place

1340
01:47:44,140 --> 01:47:49,540
in the rest of that county so that now the entire county is covered with the nurse navigation

1341
01:47:49,540 --> 01:47:55,160
program that will be going live here in the next couple of months I think we're very close

1342
01:47:55,160 --> 01:48:02,260
to launch on that that's a scenario where the county public health department has said

1343
01:48:02,260 --> 01:48:09,220
look we want nurse navigation we recognize all these benefits for our EMS system AMR

1344
01:48:09,220 --> 01:48:16,140
is not part of the 911 system outside of the city of Seattle and so because of that we're

1345
01:48:16,140 --> 01:48:21,700
going to pay the cost or you know King County is paying the cost associated with that nurse

1346
01:48:21,700 --> 01:48:29,540
navigation program it's not something that we can do ourselves as AMR we need to have

1347
01:48:29,540 --> 01:48:34,860
appropriate funding in order to make it sustainable I think that's an important differentiator

1348
01:48:34,860 --> 01:48:40,420
though because we know Dr. Troutman mentioned this a little earlier that there are some

1349
01:48:40,420 --> 01:48:47,140
911 systems out there that have looked at adding just a virtual care telehealth program

1350
01:48:47,140 --> 01:48:54,860
so the dispatcher will just connect those patients over to a telehealth doc the challenge

1351
01:48:54,860 --> 01:49:03,420
with that is that that telehealth doc is going to charge that 911 caller no matter what and

1352
01:49:03,420 --> 01:49:09,360
it generates an out-of-pocket cost immediately as soon as that 911 provider or caller gets

1353
01:49:09,360 --> 01:49:15,100
connected to that telehealth program you know we recognize that just shifting that cost

1354
01:49:15,100 --> 01:49:19,740
for somebody who called 911 perhaps just didn't know what to do and wasn't quite sure what

1355
01:49:19,740 --> 01:49:26,740
the right outcome would be that's not necessarily the right way to approach this we want people

1356
01:49:26,740 --> 01:49:32,340
to continue to rely on 911 as a free service because that's what it is it's set up in our

1357
01:49:32,340 --> 01:49:39,100
communities not like you have to pay a toll to call 911 today we want to continue that

1358
01:49:39,100 --> 01:49:47,100
and so with nurse navigation when you call 911 there's no cost passed from us to that

1359
01:49:47,100 --> 01:49:53,140
911 caller now certainly if there's services that result from that such as an ambulance

1360
01:49:53,140 --> 01:49:57,660
transport then there's going to be an ambulance bill or if we connect them to an urgent care

1361
01:49:57,660 --> 01:50:01,180
the urgent care is going to charge them for their service the same way as they would have

1362
01:50:01,180 --> 01:50:07,740
to pay if they went to an emergency department but for the nurse advice the self-care options

1363
01:50:07,740 --> 01:50:16,780
any of the other things that we do even that lift ride there's no cost to the patient for

1364
01:50:16,780 --> 01:50:21,820
the nurse navigation service itself i think when i spoke to rob there like you said there's

1365
01:50:21,820 --> 01:50:28,300
different models was there is there a cost to the fire department or are there some models

1366
01:50:28,300 --> 01:50:32,760
where you're billing the patient and that's where you're getting your your your financial

1367
01:50:32,760 --> 01:50:42,140
side from so so as i was saying we don't bill the patient for for any of this for the nurse

1368
01:50:42,140 --> 01:50:48,020
navigation piece if the patient is referred to an urgent care then the urgent care is

1369
01:50:48,020 --> 01:50:51,860
going to bill them if the patient's referred to virtual care then that virtual care service

1370
01:50:51,860 --> 01:50:58,140
is going to bill them but there's no bill coming from nurse navigation to the patient

1371
01:50:58,140 --> 01:51:05,620
in some models we are billing the fire department to provide this service for their community

1372
01:51:05,620 --> 01:51:13,260
because again just like amr benefits in the systems where we're the the 911 provider and

1373
01:51:13,260 --> 01:51:17,620
we're able to make that fully self-sustainable there's other systems like in vancouver where

1374
01:51:17,620 --> 01:51:24,660
rob is the chief where there is a cost associated with nurse navigation some of that cost gets

1375
01:51:24,660 --> 01:51:31,220
offset by the benefits that amr receives but then there are other costs that aren't offset

1376
01:51:31,220 --> 01:51:36,980
just through the benefits that amr gets which means that we have to go charge the system

1377
01:51:36,980 --> 01:51:43,700
for for the rest of that that uptick now from the system perspective if you take a look

1378
01:51:43,700 --> 01:51:48,260
at a system like vancouver i can't remember the specific numbers off the top of my head

1379
01:51:48,260 --> 01:51:57,540
but out of the you know let's say 100 calls get sent from the 911 system over to nurse

1380
01:51:57,540 --> 01:52:04,900
navigation i can tell you just based on our historic performance across the country 97

1381
01:52:04,900 --> 01:52:10,700
out of those 100 calls do not require first responders be in and the nurse is going to

1382
01:52:10,700 --> 01:52:16,000
assess them determine this is not something that's a high priority emergency that requires

1383
01:52:16,000 --> 01:52:22,020
the lights and sirens immediate response from first responders so if you think about that

1384
01:52:22,020 --> 01:52:27,980
from a fire department perspective for every 100 calls that i send over to the nurse 97

1385
01:52:27,980 --> 01:52:33,060
of them i don't have to send a fire engine on there's real costs associated with that

1386
01:52:33,060 --> 01:52:38,180
you know there's less wear and tear on the vehicles less fuel costs less supplies that

1387
01:52:38,180 --> 01:52:42,820
are getting utilized and let's face it gloves aren't cheap and every time you show up on

1388
01:52:42,820 --> 01:52:47,220
scene with your fire engine with three or four guys on it and they're going through

1389
01:52:47,220 --> 01:52:53,180
a set of gloves each there's a cost associated with that and we can avoid that cost through

1390
01:52:53,180 --> 01:52:59,140
nurse navigation the other thing that's important is even in the departments where the department

1391
01:52:59,140 --> 01:53:06,460
does transport and build that fee for service revenue associated where emergency transports

1392
01:53:06,460 --> 01:53:14,180
to the hospital very often that the utilizers of nurse navigation are typically unfunded

1393
01:53:14,180 --> 01:53:19,700
or underfunded people because those are the folks who generally call 911 for lower priority

1394
01:53:19,700 --> 01:53:25,500
complaints and so while you may have a payer mix in your community that has a certain amount

1395
01:53:25,500 --> 01:53:31,100
of medicare and medicaid and private insurance and so on when we look at the payer mix of

1396
01:53:31,100 --> 01:53:38,020
the utilizers of nurse navigation specifically it's heavily skewed towards uninsured and

1397
01:53:38,020 --> 01:53:45,140
medicaid because those are those callers with low priority complaints what that means is

1398
01:53:45,140 --> 01:53:49,580
that even in the cases where we're taking somebody who would have gone by ambulance

1399
01:53:49,580 --> 01:53:56,780
to an emergency department and of course that represents revenue for that department the

1400
01:53:56,780 --> 01:54:02,500
reality is the likelihood of collecting on that revenue at the same rates that you would

1401
01:54:02,500 --> 01:54:10,020
collect from a private insured or even a medicare patient is very slim and so the calls that

1402
01:54:10,020 --> 01:54:14,820
we're not transporting not only is it the right thing to do for the patient but frankly

1403
01:54:14,820 --> 01:54:19,500
it's the right thing to do for for the bottom line because more likely than not that department

1404
01:54:19,500 --> 01:54:24,540
was losing money on that transport in the first place when i think about the 100 or

1405
01:54:24,540 --> 01:54:30,700
97 calls that you know that didn't require a rescue in that particular situation and

1406
01:54:30,700 --> 01:54:36,100
we're talking really this is more utilized after hours that means that the people operating

1407
01:54:36,100 --> 01:54:39,980
these vehicles are probably going to be sleep deprived and it's going to be dark and in

1408
01:54:39,980 --> 01:54:44,100
florida here it's probably going to raining as well there's also the risk management element

1409
01:54:44,100 --> 01:54:48,300
every time we leave there at the station there's a high high chance especially the more tired

1410
01:54:48,300 --> 01:54:52,220
we are that we're going to get into something and now you're talking about you know potentially

1411
01:54:52,220 --> 01:54:56,460
hundreds of thousands if not millions if we hurt someone so i think that's an important

1412
01:54:56,460 --> 01:55:01,900
part of this too there's simply us not leaving is safer for the entire workforce and and

1413
01:55:01,900 --> 01:55:04,900
the people that are you know the risk management you know i'm sure they would love the fact

1414
01:55:04,900 --> 01:55:10,060
that we do a hundred less runs um jared i want to bring you in is there anything you

1415
01:55:10,060 --> 01:55:16,060
want to add because i know we've been josh for a while now before we close this up we

1416
01:55:16,060 --> 01:55:20,060
kind of step through like all the different options that generally are out there on where

1417
01:55:20,060 --> 01:55:25,500
we connect the patient to but one of the things that i really love is that the options are

1418
01:55:25,500 --> 01:55:30,580
endless it's what are the options that you have in your community and there are options

1419
01:55:30,580 --> 01:55:36,140
in the future that we haven't even thought of but the reality is the nurse and the system

1420
01:55:36,140 --> 01:55:41,460
can tap into any option that's out there that exists i know community paramedicine was brought

1421
01:55:41,460 --> 01:55:47,860
up briefly but you know we do uh tag into mobile health crisis type stuff if we talk

1422
01:55:47,860 --> 01:55:53,660
about psychiatric illness or in special uh special groups that can work closely with

1423
01:55:53,660 --> 01:56:00,420
say the unhoused uh we work with uh uh like a mobile urgent care system that can go out

1424
01:56:00,420 --> 01:56:06,100
and see the patient um we've never connected with but we've had discussion on what about

1425
01:56:06,100 --> 01:56:11,100
an oncology clinic or maybe an orthopedic clinic is there a time and place when the

1426
01:56:11,100 --> 01:56:18,460
right kind of patient should be connected directly to that so i i just love how the

1427
01:56:18,460 --> 01:56:24,460
it's an endless cadre of options as to how we can best solve that patient's 911 problem

1428
01:56:24,460 --> 01:56:30,580
that they called for so for people listening where are the best places to go online to

1429
01:56:30,580 --> 01:56:37,660
learn more to maybe start this conversation for their own department

1430
01:56:37,660 --> 01:56:43,020
so first thing i would do is direct people to global medical response dot net uh which

1431
01:56:43,020 --> 01:56:49,460
is the home page of gmr global medical response from there and learn about all of our solutions

1432
01:56:49,460 --> 01:56:55,220
including nurse navigation um it's pretty easy to navigate over to the nurse navigation

1433
01:56:55,220 --> 01:57:01,260
section and be able to fill out uh information form and ask for for more information obviously

1434
01:57:01,260 --> 01:57:06,000
our phone numbers are on there as well uh and yeah we do invite anybody who's looking

1435
01:57:06,000 --> 01:57:10,700
for for more information about this to reach out to us uh we'll be happy to talk to them

1436
01:57:10,700 --> 01:57:17,260
about it in in addition to that um dr troutman especially myself as well we're frequently

1437
01:57:17,260 --> 01:57:25,460
speakers at different ems related events um and uh this is such an emerging topic right

1438
01:57:25,460 --> 01:57:33,320
now in the delivery of 911 systems that uh we wind up uh finding ourselves uh more often

1439
01:57:33,320 --> 01:57:38,860
than not in uh in various conventions and speaking roles and talking about this nurse

1440
01:57:38,860 --> 01:57:44,420
navigation program so i would encourage the listeners if you're attending an event at

1441
01:57:44,420 --> 01:57:47,820
some point in the future we just went through a whole series of them over the spring and

1442
01:57:47,820 --> 01:57:53,500
summer uh please take a look at the agenda see if there's a nurse navigation uh offering

1443
01:57:53,500 --> 01:57:59,020
on the on the agenda and uh and come and meet us and let's talk about seeing whether or

1444
01:57:59,020 --> 01:58:04,340
not this is something that could work in your communities well we have hit on so many areas

1445
01:58:04,340 --> 01:58:08,540
and i think you know what i love about this is is this solution like i said you know there's

1446
01:58:08,540 --> 01:58:14,020
things that we've done and it worked you know maybe 50 years ago and here we are in 2024

1447
01:58:14,020 --> 01:58:19,460
and it's okay to say we need to change things but when you look at each one of these patients

1448
01:58:19,460 --> 01:58:25,060
and the comfort level for little sally as we talked about you know the the much greatly

1449
01:58:25,060 --> 01:58:30,020
reduced medical bill that they will have if there's some sort of interaction um the ability

1450
01:58:30,020 --> 01:58:35,700
to leave another er bed open and therefore less medics lining up and holding the wall

1451
01:58:35,700 --> 01:58:40,460
um and then you know not waking up a crew for every single one of these that gets sent

1452
01:58:40,460 --> 01:58:45,940
through nurse navigation is one less call in a fire station which i think is imperative

1453
01:58:45,940 --> 01:58:50,420
because if we're going to attract young people to be excited about the first responder professions

1454
01:58:50,420 --> 01:58:54,060
we've got to fix the things that are broken they're too smart you know they're looking

1455
01:58:54,060 --> 01:58:59,620
at this and going this does not look good this does not look healthy for us so the 2472

1456
01:58:59,620 --> 01:59:03,540
is something i'm trying to push nationally for the fire service and there's a the dominoes

1457
01:59:03,540 --> 01:59:08,220
are falling florida people are starting to go to it and i think along with that now is

1458
01:59:08,220 --> 01:59:12,340
going to be the conversation of fitness standards is going to be the conversation of telehealth

1459
01:59:12,340 --> 01:59:16,960
or nurse navigation so that we can address all of these things and hopefully the young

1460
01:59:16,960 --> 01:59:21,480
first responders will look around in 10 years and it will look completely different and

1461
01:59:21,480 --> 01:59:25,860
once again there'll be thousands of candidates lining up for a handful of jobs and so we

1462
01:59:25,860 --> 01:59:30,780
can take the best of them so i want to thank both of you so so much for being so generous

1463
01:59:30,780 --> 01:59:34,500
with your time telling this whole story there was elements where i'm listening to you i've

1464
01:59:34,500 --> 01:59:38,780
been saying this wrong because i'm a complete white belt still in this conversation so i've

1465
01:59:38,780 --> 01:59:44,220
learned so much myself but i'm guarantee there's so many people listening going this is the

1466
01:59:44,220 --> 01:59:48,580
thing this is one of the elements that we've been wondering what is the solution and here

1467
01:59:48,580 --> 01:59:53,180
it is now so thank you so much for being so generous and coming on the behind the shield

1468
01:59:53,180 --> 01:59:58,580
podcast today yeah thank you so much if i just got one closing word it's don't forget

1469
01:59:58,580 --> 02:00:03,340
ems provides health care sing that from the top of the mountain that's what we do each

1470
02:00:03,340 --> 02:00:08,740
and every day our patients depend on it thank you yeah thank you james big pleasure for

1471
02:00:08,740 --> 02:00:13,540
us to be here as well we appreciate you all of your listeners and and and what's really

1472
02:00:13,540 --> 02:00:18,940
exciting is how we are on this paradigm shift in the delivery of ems and this transition

1473
02:00:18,940 --> 02:00:24,060
to truly a three-tiered model and all the things that that's going to allow us to do

1474
02:00:24,060 --> 02:00:44,460
in the future so so thank you for letting us talk about it we really appreciate it