Thank you. Great. Good afternoon. Sound check. Can you hear me? Yes, we can hear you. Great. Thank you, Dr. Piacentino. So, good afternoon, all, from Connecticut. Both myself and Dr. Hassan are virtually presenting, as you know, and I have the privilege of introducing Dr. Raj Hassan. He's my colleague and friend, and he is an occupational medicine physician, a graduate of the Yale OEM Fellowship Program, and is also an internist. He currently serves as our medical director for occupational medicine for the Yale New Haven Hospital, which is our flagship hospital in New Haven, and he oversees the surrounding region. And since the beginning of the COVID-19 pandemic response back in March of 2020, Dr. Hassan has served as the operational and clinical leader for our employee resource center, our call center, for COVID-19 diagnoses, treatment, return to work, and evolving into vaccines, et cetera, for the over 32,000 employees throughout the Yale New Haven health system. Dr. Hassan is highly skilled, collaborative, thoughtful, and an engaged leader who has strategically applied lessons learned throughout these past two challenging years to pivot forward, finding opportunities to move our department forward in a very transformative manner, and to hybridize traditional clinical offerings with virtual telehealth options. Next slide, please. Today, we will discuss the development. There are no disclosures. Yes, next slide. Today, we will discuss the development of a telehealth nurse service in the health system. We will describe telehealth benefits and existing models in place for workers' compensation injury triage, and how they shape the Yale New Haven health system model. We will discuss nurse telehealth service staffing model, the standing orders that are in place, and the role of the occupational medicine physician overseeing and consulting in those services. And we will describe measures, early measures of success for both employees, supervisors, and the health system. Before I hand over to Dr. Hassan, I just want to read you this quote on the next slide. And this is from Tom Preston, who's the co-founder of MTV several decades ago. And Tom said, innovation is taking two things that exist and putting them together in a new way. And I think we're going to be enlightened by Dr. Hassan's presentation, and how his forward thinking and use of technology has put telehealth into the realm of an occupational medicine practice at Yale New Haven health system. So over to Dr. Hassan. Thank you, Craig. Good afternoon, everyone. Thank you for joining us for this presentation. As much as I would love to take the credit for the entire telehealth service development, Craig has been pretty important in its development and really tying and bringing together a lot of individuals' expertise to kind of develop this as we go along. Thank you, Craig, for that introduction. The intention of today's talk is primarily to have more of a dialogue between other leaders of health systems, individuals who already have telehealth nursing programs in place. And essentially, if you're in the works of developing a program or thinking about developing a program, or never even thought about introducing telehealth nurses services into your health system, this is more of a dialogue for all of us to have to see what has worked, what hasn't worked, what can we learn from you, what can you all learn from us? So going forward, we'll start, every good story usually has a beginning. And I'd like to, you know, this is my inner fantasy sci-fi geek nut, but essentially, if you look at Star Wars or the Lord of the Rings, we're kind of like more in the thick of it as we move forward. And the COVID-19 pandemic would be more of the prequel. So the start of our story really starts with COVID-19, as most of us have all experienced across the country and around the world. The Yale New Haven Health System transformation, what is this? So obviously, during COVID-19, every one of us experienced an increased burden on the health system. The employees needed guidance related to symptoms, exposures at work, at home, in the community, what to do about travel, and what are the recommendations for returning to work and that ever changing guidance that was coming out. In our health system, we serviced around 32,000 internal hospital employees and medical staff. And amongst them, over 17,000 of our employees did undergo some sort of COVID testing through occupational health, mainly from the Employer Resource Center and the Call Center. And amongst them, we definitely had over 4,000 of our employees test positive at least once since 2020. Fortunately, our rates of transmission and our positivities have actually gone down. We're less than 5%. But during the Omicron phase, we were definitely over 25%. So during this time, leadership with IT and the lab department had to meet a lot of different needs. And we were really tied with them in the development of that Call Center, that Employee Resource Center program. We also had to direct a lot of individuals away from our onsite clinics. So as the infection rates lowered and as vaccinations rates increased, our health system emerged with a vision, quote unquote, for transformation across a lot of different departments. So individuals in departments, department heads have to start thinking innovatively about better patient experience, better models of care or faster access to care. And so a lot of virtual visits, a lot of virtual care was already introduced through primary care, through internal medicine. And us in occupational medicine, we joined the vision focusing on innovative strategies. And this specific topic will be the telehealth nurse service. But on top of that, we also had to look at our own internal processes and we wanted to improve them. And we needed to reduce a lot of the waste that was already occurring within our clinics. As time progressed in July, 2021, we pivoted from the Successful Call Center or the Employee Research Center that was focused primarily on COVID-19. And we started expanding other services to our internal hospital employees. So this topic is going to be more focused on the sequel to COVID to the other services that we're now venturing into. So Aurok Health Services, this is before COVID-19. We have occupational medical clinic sites at different hospitals within our health system. They expand from Greenwich, Connecticut, all the way to New London in Connecticut and crossing the border into Rhode Island. Our primary focus were patient services, DOT exams, pre-employment visits, workers' comp injury evaluations. And so when you look at the actual patient flow, which is going to be important when you want to consider telehealth services, you want to understand that it doesn't just start with the clinician and with the clinician. It usually starts at the beginning where they're just trying to call into a schedule and appointment at one of our clinics. And then there's a process of being registered. There is usually a nurse that brings them in. Eventually it sees one of us as a clinician. And then there's this whole follow-up program and telephone follow-up and even a patient discharge instructions that are all provided. So here we looked at the opportunities for improvement. And one of the things that we faced within our clinics were typical longer than expected wait times. We had a procedure within our health system for employees that need to return to work. They needed to go through a clearance procedure, even if they had a note from their doctor. And as you know, during COVID and current days, we are also experiencing areas and clinics that are undergoing staffing issues. And as a background, video visits, telephone visits were underutilized in our clinics by the nurses and the clinicians. So for the opportunities for improvement, we're really looking at a lot of the low-hanging fruit. This is just the map just to indicate how far in Connecticut we have clinics starting from, if you look all the way to the left, that's the Stanford, Greenwich region. Then we go into Bridgeport right in the middle on the coast is New Haven. Further east, we have New London. And I did not include Rhode Island. I apologize, Rhode Island. But we do have Westerly Hospital out there. And the rest of Connecticut is really, if you go further north into Hartford and into the other towns, and that's where a lot of our employees do travel from. So we need to bear that in mind. So as we transitioned into the early phase of COVID, it really bottlenecked a lot of the clinic services. It overwhelmed and stressed a lot of our staff, along with a lot of the employees throughout the health system. And meeting their needs in the clinic through the phone triage, it was not going to be an efficient and effective method. So with leadership, with IT, with lab, with AHRQ Health leadership, we developed this telehealth program that really evolved over time using customized algorithms and protocols that were used by nurses and clinicians to guide the care and recommendations for a lot of our employees who were either infected or exposed to COVID. And during that time, we started really using a lot more automated features through website developments rather than relying on people to call in all the time. So an example would be a website for self-scheduling your COVID test. And it would go through questions that would direct you to getting your COVID test if you had symptoms, if you had an exposure at work, if you had travel, when we had a lot of the travel guidance coming around. So that was one of our early successes and it really streamlined and made it easier for a lot of our employees to get tested. So now we get into the middle of 2021 as rates started to essentially become more steady and taper down. And during this time of transformation, we wanted to really use the momentum for thinking of innovative strategies, looking at development and improvement. And one of the things that we brainstormed was the idea of using telehealth. Since we're already using telehealth for COVID, why not use telehealth for other needs? And I'm well aware that other organizations throughout the US for AHRQ Health have already engaged in virtual visits and telehealth for like workers' comp visits and whatever other services you have. But for us, we have not really ventured into telehealth as much. So we also had a lot of remote nurses who were available to us, who are working within our department. So what better way to involve them than to engage them in a telehealth nurse program? So when this was first brought up, there was many thoughts, there were many questions, and of course, many concerns for people and staff members and team members who were unaware and uncertain of what that meant. So just to discuss how we went about our brainstorming sessions, it was primarily more of our core occupational health team. It consisted of the various medical directors and leads, some of our clinicians, some of our nurses, and some of our administrators. And so the initial thoughts would be, this is a great idea, but what would it do, right? We really needed to define the purpose and the role for telehealth. And just like any new idea, there's going to be initial pushback. So if you're thinking about engaging telehealth for yourselves or for your organizations or within your own clinics, these are some of the examples that we faced. So an example would be an RN, his or her role was limited without a clinician oversight. There was some uncertainty about the comfort with a nurse handling the phone triage without having a hands-on approach. A lot of what-if scenarios, a lot of quote-unquote liability exposures. Did we have the technology in place within our clinics and for our clinicians and for our nurses to engage? And did we have a health system support to implement these programs? And have we leveraged the right relationships and partnerships that we've had during the COVID-19 initial phases and during Omicron? So these were our first couple of questions. And then another question that comes up is what is telehealth nurse triage essentially? And we didn't want to completely limit our talk to just the nurse triage because this is actually just one component of the nurse services that you can provide with telehealth. So the nurse triage is primarily a system in which our nurses use standing or standardized protocols developed by ourselves as clinicians to evaluate symptoms over the phone and determine a perfect course of action. And clinicians would be available on backup and we can technically guide a lot of our patients to an in-person visit as needed. So in order to move forward in really developing a telehealth nurse service aside from brainstorming and getting a lot of feedback and questions from our internal team, we also needed to kind of look expansively to what does the medical literature say, right? What have other external partners or vendors who actually have telehealth nurse services, what's their experience all about? And then as we dwell further, we need to really define what is telehealth nursing? What is that service? What's the scope of our nurse? And how many different parties within our organization and our department do we really need to factor in? And we also needed to understand and remove the threat of any perceived sense of job loss or job replacement that's in the works. We wanted to essentially confirm and reassure a lot of our internal clinic staff that the telehealth service is more of a supplement. It's not meant to remove them from the workplace, it's not meant to replace them. And that usually gives a lot more comfort because there's a lot of uncertainty with new procedures and in a lot of the technology and the concern, especially during COVID. So we really wanted to move forward within our organization, moving forward with this service line with a one team approach and alignment. All right, so what does some of our literature say? When you look at a lot of the telehealth and virtual care models, you'll see a lot of it really based upon internal medicine, primary care and urgent care telehealth. And a lot of it is really focused on the clinician, like virtual clinician visits and not so much on nursing triage. But what can we learn from virtual visits and telehealth performed by clinicians? So telehealth or also known as virtual visits include both visits that use either a telephone or the video. As a caveat in Connecticut, video visits can be performed as long as both the patient and our team are on site in Connecticut somewhere. But the rules change once the patient's outside of Connecticut, but we are given allowance to do a telephonic phone call. So one of the things that a lot of the studies pointed out for telehealth is, can we really determine the quality of care and the outcome comparisons because this is relatively new compared to traditional in-person clinic practices. I mean, considering that telehealth had an inception back in 1990s, this is definitely over or around 30 years worth of experience that's across the US. So I'm not quite sure if we should keep labeling telehealth as new, but it's definitely new as far as the implementation in a lot of organizations. I included this bullet point because it's something that we experienced and you may experience or you already have experienced. So with any organizational change, you have a lot of varying reactions. And some of the literature does point out that you may be hit with a lot of heavy resistance to change and in some organizations, or maybe over time, and if you communicate very well, you may be able to get a lot of embrace for this change. So just bear that in mind. Fortunately, as we look through a lot of the literature at this point out that a lot of hospital system organizations have already embraced telehealth services across many departments. And one of the benefits for telehealth, it really opens up a lot more accessibility to the patients. It could be outside of our normal clinic hours. It could be over the weekends, if you have that structure in place. And some of the other caveats for telehealth, it was more associated with increased telehealth use by age groups between 18 to 64 years of age, which is typically a lot of our patient population because they're all employed individuals between the ages of 18 to 64 or more. You will also see a lot more telehealth usage in areas where there's a lot more increased access to technology and in health systems or clinics where you have physical barriers or barriers for in-person visits. An example would be paid parking structures. So that might prompt a lot of our employees or patients to wanna call in for a telehealth visit rather than coming on site. So out by New Haven, our hospitals, a lot of the parking structures are paid for. You have to take the ticket, you know, and that might be a barrier. But in other sites, if there is open free parking, that might not be as much of a barrier. So some of the outcome measures we wanna look at is essentially what we focus on from the literature. This really point out that there's a lot of time savings, which is obvious. And there's also some cost savings as well, primarily for our patients. Or in this case, we've really focused on internal hospital employees. So our own colleagues will be using this. So it's gonna be more of a cost savings for them. It's gonna be a time saver for them. And it might actually improve upon their coming back to work or getting a release back to work sooner, and really helping the organization with staffing situations. So some of the examples of outcome measures include the cost savings where the patient or our employee would have to spend money on their travel costs. That includes fuel, right? The loss of work time, if they have to leave the clinic to travel all the way to our clinic, or if we're in the hospital, they have to leave the unit and then come down. And then of course, if they're still out of work, they have to arrange things for their family. If they have family, they have to bear the costs. The big outcome measure is really time savings. When we look at some of the definitions that were used in some of the literature is turnaround time. So when an individual comes into our clinic, there's the wait time and then the service time, which is essentially being brought in by the nurse, assessed by the clinicians, and then being discharged at the end. And then when you look at another item called total time, it's a combination of this turnaround time, the wait time, the service time, along with the amount of time it took them to travel back and forth, right? And so there's a lot of good evidence for patient satisfaction. Given the right scenarios, and a lot of patients were satisfied with using that kind of service. What about costs? So the cost of a lot of in-office visits, and these numbers are more of an average in some of the ranges from urgent care evaluations and primary care, but you're looking at for the patient, if they don't have insurance, or if they're gonna pay out of pocket, a range of like 130 to 150 per visit. And the cost of telehealth services would be a lot less, in ranges between 30 to $95, depending on the level. So urgent care virtual visits were averaged around $50. The other added benefit, there's no travel costs for the patient. So again, we're not looking at external client patients, we're here in this case, we're looking at the benefit of implementing this for our own internal hospital employees. And again, you can also use these evidences even to encourage the use of telehealth. If you are having an overrun clinic with a lot of individuals in the waiting room, you can also offer this evidence to even external clients. So let's look at some of the telehealth time savings. So they mentioned there's a lot of time savings, but let's look at some, let's crunch some numbers. So the typical average commute into the workplace in Connecticut, it's roughly around 26.3 minutes. So you're looking at a round trip of 52.6. So that's kind of dependent on the day, if there's snow storms or ice rain in our region, that can add, right? And when we look at the comparison throughout the US, we're looking at 26.6 minutes, that's just one way. When we're looking at clinic wait times, it ranges from 15 to 40 minutes. And urgent care has a very similar range of wait times. How long does the clinic visit take? It can range also between 15 to 45 minutes, depending on the type. So the ranges are very wide here of the total time, travel plus the wait time, plus the clinician and service time in clinic. We're looking at a range for any of our employees or for the patients that we serve between 1.4 to 2.3 hours. Whereas the telehealth nurse visit can range anywhere between 10 to 15. So we're looking at a lot of time savings for our employees. So over one to two hours. We did reach out to some external partners or vendors. In this case, the company ABC, they actually have a telehealth nurse triage program in place. And so we kind of reached out to them and trying to get a sense of what were the benefits of this program? So they did mention that a lot of the telehealth nurse program took a lot of low level medical only claims out of the system. They didn't need to come all the way to the clinic. They could be directed to just over the phone first aid recommendations, or no, this doesn't really warrant a visit. You can actually do X, Y, and Z steps. And if it gets worse, you can always come to the clinic. And sometimes a lot of the questions our employees face or ask are really administrative questions. They come all the way to Ock Health or call in just to ask how to get the ADA paperwork for accommodations requests. Or I have a condition that I need to be out for, who do I reach out to? And sometimes they just come all the way to the clinic. What else did this company explain to us? Oh, I apologize. They provided guidance for those who didn't need treatment. They didn't have to come to clinic. They were actually diverted away from the emergency rooms. And whenever they had serious calls that required some level of evaluation and or treatment, they direct them to the appropriate care. And the added benefit was they were able to start generating claim information so that the claim teams could work earlier and align the employee with the needs for their worker advocacy program. And the conclusion of our conversation with them was at the end of the day, the telehealth nurse program, it's more of a recommendation. It's not a mandate. So there's no adverse outcome. If the employee agrees or disagrees with the care recommendation, they can disagree with some of the first aid recommendations and still come into the clinic. But at least they had that initial conversation. So they know what to expect. All right, so that was a lot of our background data gathering, looking at the evidence, looking at some promising benchmarks and outcomes. So as we start going into how do we build and communicate this program to our larger organization? Well, the first point is we need to get some buy-in from our leadership members, from our VPs to our CEOs. And then another second point is to really establish a point of funding for the positions during the trial period, setting parameters for success and having some sort of outcome that you wanna measure. So you can actually provide some feedback usually after one or two quarters. So we definitely capitalize on a lot of our relationships throughout the health system. After the COVID call center development and during that life, we really engaged a lot of the marketing and communications teams. We developed phone trees for the telehealth nurse line within the current employee resources system. So COVID is not completely gone. We still have the telephone line that goes directly to COVID related care or COVID related questions. And then for all these expanded services, we have a separate phone tree that answers essentially a bunch of other questions and a lot of the other concerns. We maintained our electronic medical record program to be consistent with the one that we use in clinic. Just for everyone's background, the Yale Occupational Health Program does use the program called SysDoc, whereas that our global organization uses Epic for regular patient care. So what are some of our primary goals? Our primary goals for our internal hospital employees as I've repeated back before, based on a lot of the evidence is really reduce a lot of the time away from work for our employees, reduce a lot of the waiting times and hopefully reduce a lot of the inappropriate emergency room utilization because they could not come into the clinic on time or it was over the weekends. As far as marketing, we did reach out to our marketing and communication team to really display the telehealth program via websites, via our internal hospital system, screensavers and pop-ups. But that also has some limitations. A lot of our employees who are at home or don't typically access the intranet or in hospital intranet service, they may not see these screensavers and pop-ups. All right, so what kind of staffing model did we start off with? So we decided that these services will be under some clinical guidelines, some algorithms and a physician oversight. So they can always reach out to us, whether it be Craig, whether it be myself, whether it be to our other clinicians that are across Connecticut. We definitely wanted nurses who were experienced with patient intake and assessments. So they can better guide these individuals with their phone. We started off with hours of operation at 7 a.m. all the way to 5 p.m. And also expanded it over the weekends from 8 a.m. to 12. And right now we have two full FTE RNs. Well, one is essentially full-time and two of them are part-time. And this launched in July of 2021. The initial program services were going to be focused on workers' comp injury triage. And we do have a service within our health system. It's called the Return to Work Program. Anyone that's been out of work for longer than three or more days or a non-work-related condition, they may get a letter or a clearance from their own personal doctor. But those clearances and those recommendations may not actually match their job functions or their job tasks and related work if they have to lift over a certain amount of weight. And the health system really utilized occupational health to do a double-take, look at individuals, look at their clearances and confirm whether or not they can come back to work. We also have infectious disease work recommendations. So anyone has symptoms like shingles or they're having symptoms of the flu, they can just call over and get some guidance directly from our telehealth nurse team. So we're going to be thinking big. We're going to start smart. And the intention was to expand over time. As right before we launched, we did develop a tool set of reference documents and standing orders for our nurses. So these include a triage protocol for varying injuries for different body groups. Some of them include the abdomen, ankle, back, and I'll show you an example of what that looks like. We also have standing orders of injury first aid treatments, over-the-counter medications, and essentially the list of potential healthcare worker infectious disease ailments and what kind of restrictions they may need before they come back to work or even if they need restrictions. So the first goal was to launch workers' comp triage. So we really wanted to focus on getting them the right care at the right time. We really wanted to unburden our clinics from any end-of-day walk-in visits. We really wanted to reduce the waiting time for unscheduled walk-ins or unscheduled follow-up visits. And we really reduced the waiting time for our scheduled visits because if we have scheduled visits in the waiting room, and then we have all these unexpected walk-in injuries that have a wide variation on intensity and severity, we don't want the clinic to be overwhelmed and slow down the care of the individuals that were scheduled. Okay. We also, within the telehealth program, if individuals call in with a work-related injury, aside from getting triage and guided to the right care, they will also be aided in completing their first report of injury so that workers' comp can start filing as accordingly. So here is an example of one of the body parts injury triage algorithm that the nurses use. And the slides are all available for everyone to view and to see, but you can see that depending on the severity the person calls in with, they'll either be directed to the ER or urgent care. They might be directed to our clinic for the same day, and our clinic will get a head notice that someone's coming in. Someone may have had an injury a few days ago, and it's not as severe, and it's close to the end of day, they could be scheduled for the next day. And then there are scenarios where we have after hours. Here is an example of a sample first aid guidance for some superficial abrasions. Again, we have other recommendations for lacerations, head injury, et cetera. So in this case, this is more for superficial abrasions, whether they use a topical bacitracin or any antibiotic ointments, and any contraindications in which ones would be directed to the clinic. Coming back to this Return to Work program, as I've explained within our organization, anyone that's missed more than three work shifts for a non-work-related injury or a reason, it could be as simple as maternity care to, they required cardiac care for a recent MI, or a stroke, or just completing the recovery period for knee surgery. So all of these individuals, if it's not work-related, they typically would be coming back to our clinics for a clearance. So we really wanted to optimize this. A vast majority of individuals really don't need to come into the clinic for us to have an eyes-on approach or a hands-on approach. It could just be cleared telephonically. And if needed, our nurse can always reach out to one of our clinicians. So at this very moment, we are requiring anyone that has restrictions placed by their provider. So orthopedic surgeon cleared someone to come back to work, but they are on restrictions of no lifting more than 20 pounds. At this very moment, we are still requiring these employees to come back into the clinic, but we are expanding. And I believe in the next month or two, we will be transitioning a lot of these back into the telehealth nurse program. Okay. The other added benefit of the telehealth nurse program for Return to Works is we're clearing individuals back to work over the weekend. So they're not waiting for Mondays and Tuesdays the hospital supervisors are a lot happier to know that their employees are functional and can come back on Mondays and Tuesdays. So this is kind of a breakdown of what the majority of our Return to Work clearances have been. Again, it's pregnancy, natural or cesarean, non-musculoskeletal laparoscopic surgeries and any communicable diseases that did not require hospitalization. Okay. So now an example of an infectious disease work item. So this is an example of if we have someone that has active conjunctivitis and they call in, what should we do? The telehealth nurse team can actually reference our internal document and advise them on staying out of work and how long they need to be out for and always recommending them to reach out to their primary care doctor. And the same goes with varicella. We have shingles, we have flu. Et cetera. Okay. So that was a summary of a lot of the services that we started off with. And over time, over a couple of months and more recently, we started expanding some of the services. Some of them really to meet the needs with HR and the needs of the employees with regards to vaccinations. And then some more innovative strategies kind of handle the volume that's coming into clinics and we'll get into those. So some of the examples include vaccine inquiries, especially for the individuals that need medical or religious waivers. If they need help in regards to immunization compliance, COVID related accommodation requests, non COVID related accommodation requests. So we've actually partnered with our HR team and we started doing a lot of the internal ADA accommodations starting since January of this year. And it's still active now. Our RNs from our telehealth program are acting primarily as a liaison between the ADA team and the clinician reviewers. And another, this is the more innovative and I bet we'll get some feedback regarding virtual PPD reads. So a lot of our new hires that are coming in, they get tuberculosis screenings with the skin test, the PPD and some individuals live pretty far away or they just can't come into the clinic to get their PPD checked. So we've kind of developed this virtual tool with a video visit with our telehealth nurse team to kind of go over how to look at forearms or any indurations, erythema, et cetera, and how to direct them to our clinics. So some of the vaccine services, the telehealth service, the telehealth nurse team are performing now. They're scheduling some of the COVID-19 vaccines, some of the flu vaccines when it was still flu season, maybe even now, coordinating and setting up a lot of the appointments for vaccine, COVID vaccine allergic reactions with the Yale allergy, uh, dispelling some of the myths and false information regarding, um, you know, religious exemptions for COVID vaccines. And hopefully, and we, we attempted through the nurse program to educate different departments and staff members about a COVID vaccine and to decrease a lot of the hesitancy related to it. And we saw that a lot more in our food and nutrition departments and our transport services. So the virtual TB test reading, uh, it's performed by our clinical nurses. They're all clinical nurses. They do a virtual video visits with individuals. So the employee who has a PPD, it's been 48 to 72 hours and they're unable to come into the clinic. They need to be in Connecticut for a video visit. They need to have a smartphone with good video capability. And the video evaluation is performed with a full 360 degree view of the forearm. So the, the protocol right now is any signs of erythema, any signs where the employee voices, they feel a bump or some sort of induration, they're usually directed to the clinic for further evaluation. And, uh, anyone that looks like they may have a positive result, or if the assessment itself is questionable or the there's technical issues with the video, uh, the video screen, they're automatically being sent over. All right. So that's what we've developed. That's a lot of the expanded services. There's a lot more expansion, a lot of ideas that we're considering, and we want to move forward with, especially when it comes to workers' comp, uh, triage and a lot more assessments, uh, where, where, what are our numbers so far since July of 2021 to when, when we looked at the data, this was at the end of March. So I don't have April data for you. Um, we essentially did a lot, some workers' comp nurse triage of initial injuries. So during this timeframe, we had over a thousand workers' comp injuries within our health system and 72 of them contacted the telehealth nurse line and they were directed to the clinic at an appropriate time. So it's a good start. 72, it's only around 7%. Uh, now when we look at the return to work clearances, this is a lot larger. So right now, 256 out of the 15, uh, 1,567 return to work visits that come into clinic, you know, 16% of them are being done via telehealth. Our intention is to really increase that percentage by expanding the services of our telehealth nurse team, the virtual PPDs. So that started at mid March. So this is, uh, looking at a two week timeframe, uh, out of 259 PPD reads, 95 of them were assessed and done over video. So around 37%. And ongoing since January, we are doing the ADA accommodation requests. So we've already had 115 and more ADA requests from our internal hospital employees and it's being done via telehealth. So the value to the organization so far, so looking back at the time savings, we can plug in those numbers and kind of identify with the sheer number of return to works that we've done telephonically. We really saved our internal hospital employees about 300 to over 500 hours of travel and clinic visit times. And that's also a reduction in the number of visits that did not really require to come into the clinic. It's kind of unburdened our staff, uh, the virtual TB tests, right? Uh, during this two week interval saved a lot of employees from driving all the way in and waiting in the waiting room just for a, a 10 to a five to 10 second check of their forearm. So we're saving over a hundred hours right there. Uh, the workers' comp injury assessments and triage, uh, there's been a lot better scheduling experience for those individuals that use the triage service. And with the ADA accommodation, um, I'm not quite sure I'll let Craig weigh in on this one, but, uh, if we were using third parties before, or if HR was primarily doing it now, the telehealth team, along with our clinicians are involved. So, uh, how do we measure success aside from looking at the numbers? We really wanted the feedback, uh, from employees that use the service. So after every service, they are receiving a survey link, and this is the message to our coworkers with a link to the confidential satisfaction survey. There's also a QR code. And, you know, so far this is the range of, uh, employee feedback we've got. So 96% of our employees surveyed felt that they had, they were adequately assisted, uh, here, you know, a lot of, a lot of, uh, success, uh, remarks, excellent and proficient service. They loved having this telehealth appointment instead of having coming to come all the way into this, uh, into the office. And here, this is the case of someone that had maternity leave, right? Um, this was a lot easier than driving and sitting in the office. So, you know, this is a lot of the low hanging fruit, um, when you want to measure outcomes and patient satisfaction. And thinking forward, well, what else do we, what are we thinking about? We'd like to market more of our telehealth nursing services to our hospital employees, the managers and departments, because a lot of managers are still used to sending them down to Ock Health, sending their own, uh, employees, or if an employee calls them about coming back to work, oh, did you get, did you check with Ock Health? Go directly to the office. So we really need to improve upon that marketing and that communication to all of these individuals that they can actually reach out to this nurse line. Uh, we are going to launch more QR codes to enable, uh, some sort of decision tree to what the purpose of telehealth nursing is, and if you will benefit from it with a QR code. So that QR code will be accessible to employees who are not in the hospital and don't have access to the screensavers or pop-up ads. Um, we do want to expand a lot of the video visits for our nurses, and we also want to start developing a lot of the virtual video visits for our own clinicians. And eventually if, if we're doing this well, we would like to start offering this to our external clients. And eventually we will be emerging as long as COVID does not have any more spikes, any more surges, we would like to start merging our telehealth services with our current COVID, uh, program. And here, uh, you know, we would like to end our, our talk with this, uh, quote, welcome the challenges, look for the opportunities in every situation to learn and grow in wisdom. And this is, uh, Brian Tracy, CEO and author and a self-development leader. And with that, here are some of the references. And really we would like to just open, have an open dialogue, questions, comments, suggestions, what has worked for you, uh, what have you been surprised by? Thank you. Great. Thank you very much. Uh, and so we do have an opportunity for some questions and if folks here in the room have questions, um, please come down to the microphone in the front and line up, and we'll be happy to take your questions. I know that we've also had some chat going on. Uh, so I, I, while we wait for folks to come down front, why don't I just read some of this stuff in the chat? Um, one question is either clinical conditions or injuries, um, that do not work well within the nurse triage program. Well, uh, we have to kind of look at severity. Uh, so if we're looking, we have to kind of understand and break it down between telehealth clinician assessments versus nursing care. So a lot of the nurse triage is a question and answer on where to go for care. Uh, the nurses are not primarily giving treatment unless it's a very mild, like first aid care. So individuals call in and ask about, well, you know, I hit my head. I had a, I have a head injury. How soon should I get into the occ health clinic or should I go to the ER? And based on our protocol, they can provide some better guidance. Um, video visits are available if there are rashes, but, uh, it's very difficult to kind of assess those. And a lot of workers comp injuries like a shoulder injury, a neck injury, uh, if you're worried about cervical radiculopathy, uh, abdominal pain, hernia-like pain, um, I can't walk, I have a knee injury. Those are all going to require an in-person visit. But the benefit of our telehealth nurse program is they can look at our, our clinics. They can look at the scheduling blocks. They can see how busy one clinic is versus another and kind of give a heads up to our injured employee on where to go, when to go, and how to get your care in a more efficient, um, efficient way. Great. Thank you for that. To add to that, um, everyone, you know, a lot of the background to preparing these nurse guidelines looked at evidence-based clinical guidelines, including a comms, musculoskeletal guidance, but several orthopedic, um, sources as well. So that for each of the body, uh, parts or systems, uh, Dr. Hassan, um, showcase the knee. Uh, we carefully went through severity, uh, for each of those, uh, body parts or, uh, systems and then developed amongst the physician leaders in occupational medicine within our health system that consensus. So, um, we felt that by going through this careful iterative evidence-based approach, uh, we would certainly, uh, err on the side of, of being conservative in terms of immediate care or advanced care. Uh, but we convinced ourselves that there are many, many conditions that could be, um, scheduled into the clinic later the same day, rather than an urgent care pile up, uh, and, or if it's the end of the day, use first aid treatment and see the individuals, uh, first thing in the morning, rather than, um, punishing them by sending them to, uh, an ED, um, you know, late evening or, uh, or overnight. So I hope that helps as well. Great. Thank you, Dr. Thorne. Uh, we have a question in the room. Hi, first of all, I just want to thank you for this presentation. We're actually, um, I'm part of Atrium Health in the Charlotte market, and we're looking at implementing this exact thing. So actually this is quite timely for me putting together a business plan. So thank you. Um, I was wondering with the nurses, were those resources that you already had in place, or did you have to put together a business plan in order to get those FT resources? Are they working, you know, days and nights, or can you elaborate on that a little bit more? Um, so during the COVID call center, uh, the employee resource center that were responding for COVID related reasons, we had a wealth of per diems and some staff nurses and clinicians working that call center. And as we started dwindling down with COVID, we had the opportunity of developing this program and seeing who would be interested in coming on board. So I believe, uh, Craig can probably speak a little better to this, but our nurses were primarily working with the COVID call center. And, um, as far as the business plan, I'll hand that off to Craig. Yes. Great question. Um, nothing comes easy. So it did come with a business plan. What we did was as, as Dr. Son mentioned, we had nurses in place to help augment our COVID response. And as that sort of waxed and waned and the tide went out, we, um, we had some, uh, surplus help. And then we began to create the program. Um, then of course, as COVID numbers have decreased again, slightly surged again right now in Connecticut, I'm a victim of that. I have COVID currently. That's why I'm not there. But as, uh, cases declined, we did have to put a business plan together to show the value of these services, um, in a way that Dr. Hassan mentioned. So, you know, we didn't, we didn't have to, uh, do a comparison to another capital investment, for example, but we do have to go through a vacancy review process. We have to stand up our, um, FTE requests, uh, showing, uh, in, in some sort of quantitative way, the benefit to the health system of that added FTE. And in, in fact, uh, because of COVID, if we were actually going to replace, um, a vacant FTE with an incumbent, we first have to convince that, uh, same vacancy review committee of the need for replacement. So it's, it's quite an ask, but I will tell you that by averting, uh, the care to the onsite clinics and reducing per diem staffing costs that we've had in our clinics. So freeing up, uh, some of the services that are just simply triage services or reading TB skin tests by our usual nurses in clinics, they can actually, uh, do more care for the other work that we do, particularly because we serve over 200 external clients, uh, and municipalities throughout the state. So it's, it's averting, uh, the onsite visits that could be done, uh, virtually. There's certainly a cost savings, uh, in that, and then using some of the metrics that Dr. Hassan used. And we would certainly, um, welcome, uh, an ongoing dialogue. You've got Dr. Hassan's, uh, email, mine is craig.thorne, T-H-O-R-N-E at YNHH.org. And we would be happy to continue to dialogue with you offline if that can help you. Definitely. Thank you so much. Great. We have a couple of other questions in the chat. Um, how did you land on nurses providing guidance evaluation only to Connecticut state licensure, non-compact state, what would be required to expand the service to the Rhode Island location? I think you've answered the question by saying we don't have an agreement as a compact state agreement. So we would have to have our nurses licensed in Rhode Island or create the same service in Rhode Island. Um, to date, our services in Rhode Island are limited because we serve a small hospital, a westerly hospital. Uh, but we certainly are challenged by that. And, uh, we work strictly around the laws and, uh, are guided by our own internal compliance. So we do not offer that currently. Great. Another question. Is the service available 24 seven or what do employees do after hours if they have an on the job injury or concern? Right. So, uh, currently the, the call, the employee telehealth nurse program is, is from 7 0 AM to 5 PM Monday through Friday and 8 AM to 12 on the weekends. And afterwards they would essentially function the way we historically have been pre COVID, uh, or pre telehealth nurse services. So after hours, they would either go to an urgent care or to the ER if they needed services. Um, and hopefully if it's mild in nature, they would just wait until the next business day and contact us. So we do not have a 24 hour, seven day out of the week operation. Great. Thank you. Um, another question, and I imagine many others may have a similar question. Are you able to share the clinical nursing guidelines or algorithms that you used? I, I think that's a very difficult question because it, uh, it crosses from our organization legally to another organization. And I don't have legal permission to do that. As we all know, uh, health is complicated. Um, but certainly you have a snapshot of a knee injury, uh, that one can use, um, and, and certainly advance it. And we would welcome any question that you might have and some guidance on it, but, but these are not, um, shareable documents for those reasons. I wish, I wish I could, but, um, I cannot. Great. If it helps, uh, as far as developing it, we have, every one of you may have some sort of reference on, uh, injury care or musculoskeletal injuries, right? So you can technically classify them into what is severe, what needs to be seen. Uh, you can break them down into time components, immediate versus an hour to two versus over an eight hour day, or can be technically moved over to the next day visit or after. And then that kind of gives you a sense of, uh, uh, severity of injuries. And you will know how your own clinics can absorb that visit within the clinic. So, and having discussions with the clinicians is also very important. I think that's a very good point where we started is currently not where we're at. And as Dr. Hassan mentioned, a lot of these, uh, sort of conditions for return to work that we thought could not be, um, cleared by a nurse. So just thinking about the return to work, like an open abdominal surgery, uh, depending on the individual's, um, workplace requirements, vis-a-vis their physical demands and also clearance from their treating doctor, why, why would we need to see them and go through the same questioning that the nurse can go through? Um, and obviously we have fitness for duty programs in place and education so that if an individual returns to work and show some inability to perform the work, then we would see them. But I would say my advice would be, as Dr. Hassan said, use some, uh, some sources. ACOMS clinical practice guidelines were always my first go-to, uh, and then mature them up as you get more comfortable with them. And when you start with your document six months later, uh, you'll be amazed how much more the nurses can do in, in their tele-triage and their return to work. Great. So I think we've reached the end of our hour. I want to say thank you very much to Dr. Hassan and Dr. Thorne. Thank you for your tele-presentation. We very much appreciate it. Um, and thank you for sharing your practice with us today. Have a good afternoon, everyone. Thank you. Thank you all.

telehealth nurse service

COVID-19 pandemic

symptoms assessment

reducing waiting times

workers' compensation injury triage

return-to-work clearances

vaccine inquiries

virtual TB test reading

service expansion