I'm Eric Tade. I was the chief of the Denver Fire Department from 2010 to 2020. I'm currently in my 32nd year with the fire department and I oversee all wellness programs now with Denver Fire Department as well as run one of our operational districts. Today we'll also be hearing from our doctor of physical therapy Casey Stoneberger, doctor of physical therapy Laura Stewart, and our newest physician, our in-house physician that oversees the medical direction of our wellness programs plus about a million other things, Dr. Elisa Coble. So we're going to run you guys kind of through about a little over a decade of work. We're going to try to run it through. We're going to try to run through our slides pretty quick and leave a good 15 to 20 minutes at the end for questions and answers. I think you'll see as we get further on to what we're doing today, we're doing some stuff a little bit different. I think a little bit unique in the world of occupational medicine and integration with not only risk management, injury prevention, but true wellness activities within a department and partnering with our primary health care providers to make some of those things come to fruition and overcome some of the cost burdens. So we'll go through here. First of all, we have to put up our disclosure. I'm not going to say it. You guys can see it. We don't have any financial interest in anything that's being presented here today. We're going to go over the IAFC and the IAFF wellness fitness initiative and our MPA relative standards that kind of guide our principles of what we're trying to do as far as achieving employee wellness and possibly some nationally recognized standards. We'll talk about our stakeholders that kind of brought this whole process together. We'll give you the timeline. Like I told you, it's a little over a decade of work. And then towards the end, we really want to be able to have a discussion with everybody and make it more of an interactive session so that we're not just all staring at PowerPoints for an hour. So we call it pillar by pillar because if we take a look at the wellness fitness initiative that was put in place with the IAFF. I think I just lost my mic. So I'll move over here. That was put in place by the IAFF and IAFC, which basically tells us it's a labor management agreement. We have our union and we have our managers or our fire chiefs of our departments. You'll see that the pillars include a medical component, which usually comes into our screening pieces. Let's see if that works. Can you guys hear me now? All right. So we have our medical pieces. We have our fitness, which is usually where a lot of people leave off. But for us, I'm going to actually walk down here. I don't like standing up there. So we have our risk management for us or it's always considered the injury prevention, rehabilitation, or kind of traditional OcMed. Somebody gets hurt, they get cut, they go see OcMed, they get patched back up. We have our behavioral health component, which is growing by leaps and bounds every single day. It's probably our number one area of growth, probably our number one area of opportunity as well. And then, of course, data collection. So NFPA 1582, I'm sure a lot of you are familiar with it, but in the fire service, it's our guiding principle. It's the physical that we want to do on all of our employees, both pre- and post-hire. So we've tried to incorporate that in to everything that we're doing, but still maintaining an actual reasonable budget to be able to put, you know, for us it's over a thousand people every year through this, plus all new incoming people. We'll talk about that in depth when we get towards our screenings that we're currently doing today. So the biggest thing was identifying all of our stakeholders early. Anybody can come up with this great program and on paper it functions smooth, get the greatest managers in the world, but if you don't have buy-in from all your stakeholders, it's doomed. Keeping the sustainability is almost impossible. And so what we did is before we put any of our programs together, we went and said, okay, who are our stakeholders? For us, it's a little different than if it's more of a corporate setting, because we start off with citizens. So when you're in government service, citizens are your ultimate stakeholder, right? They fund everything without them. It doesn't matter what you're doing, whether it's military, fire service, police service, you have nothing. So we started with our citizens and then we said, well, how do they even come into the how do they come into the service to begin with? For us, it's civil service, which is the independent hiring body. Knowing that anything that we want to do, we want to start off day one, but this is kind of the expectations. So we brought our civil service hiring partner in and really worked with them to make sure that we're hiring the right candidates and we're doing the right levels of screening. For Denver's Department of Safety, basically everything, police, fire, all falls under the Department of Safety. You got to have support of upper management, right? Then we have once they're in, you have the department itself, which you'll see in the bottom left corner there, it says DFD, so that's the Denver Fire Department. But really a department is only made up of its employees, right? And so for us, that's local 858, which is the union. Another thing that's kind of unique to public safety is that typically, especially in large cities, they're unionized and they're usually very well organized and have quite a bit of plow. And so forcing things upon members in those agencies is very rarely successful. And the word mandate, don't even want to use that word anymore now in public safety, it'll get you killed. So then we look and say, okay, those are kind of the obvious partners, but then we look to philanthropy. So we have our foundation and there's actually quite a few organizations out there that are willing to support public safety, especially in areas of wellness and behavioral health. So we look to them for some money. And then risk management. I can tell you in most municipalities, they're kind of seen as the enemy, right? They're the ones overseeing it because typically the risk management model is claim management, right? It's all about approving or denying claims and quite often it's about denying claims, right? Start off to deny everything, make people prove that it's actually a workplace injury. We were actually very successful in bringing them to the table. It took about eight years to actually get them to switch their model of claim management to risk management and actually start working to prevent injuries, truly prevent injuries, and be an integral part of wellness within our agency. And right now they're probably, I want to say they're our number one partner. I think they probably are our number one partner, maybe not from a dollar standpoint, but definitely from an advocacy standpoint. And then the one that I think is a little bit unique, and we'll talk about that a little bit further, is health insurance. We actually incorporated our primary health insurance provider, which for us is Kaiser, into our model and made them a participant in our wellness models. And we'll get into that in quite a bit of depth here when we get towards the end of our slides to what we're doing today. So here's our timeline. You see we started back in 2008 and we said, hey, we got to do something different. And where do you start? You start with how you bring people in, creating that culture. So we adopted the CPAP test. For those of you who don't know, it's a standardized candidate physical ability test that was also backed by the IFF and IAFC. It's used in various departments around the nation. I can't say that it's the standard for fire service, but it's about as close as there is to a standard for candidate physical ability tests coming in. Then we said, well, let's start building a culture of fitness and wellness within the agency. So we committed to, we're going to get a bunch of people trained up because anybody who wants to as peer fitness trainers can embed them all throughout the agency and all the, you know, whether it's operations, prevention, arson, try to put peer fitness trainers anywhere. We hired a wellness coordinator, but in order to get that buy-in, we make sure that that wellness coordinator came from within the ranks. So fortunately, we went and exploited some of our people's strengths prior to coming into the fire service. Luckily, we get a lot of people that have exercise physiology and blood trainer, those kind of backgrounds. So we put somebody out there that was passionate about fitness and said, okay, we're going to embed you at training. And now that becomes part of the academy from the day you come on the job. And then we said, what's our number one opportunity for our most bang for our buck? Where a lot of departments that went with a physician or whatever and said, hey, we're going to have a physician, we're going to do physicals. We went a little bit different route and we went and contracted a physical therapist. And we said, we think that we can actually spend more time with our people, rehab injuries, and start treating them kind of like we do professional sports teams, right? If you get hurt and you're playing for, let's say, the Philadelphia Eagles, you're going to get, you know, let's say interior ACL, right? If you're an average Joe accountant, you're going to go to a physical therapy in a strip mall once, twice a week. You're going to spend 20 minutes. If you're on the Philadelphia Eagles, you're going to be doing rehab and you're going to be doing PT every single day. And so we said, we're going to treat our people like tactical athletes. So that's why we went with that route. We've seen amazing results right there. And we'll talk about that a little bit when we get to our physical therapist. By the time 2015 rolls around, our physical therapy is going so good, we can no longer just do it with a contract physical therapy. We actually hired full-time physical therapists and we embed them in the department. We have two of them, put together a wellness committee to say, where do we really want to go with this and empower them to start making some decisions, put some money behind them. And then we say, we need to move beyond just how people are coming in and how we're treating people. So we put our performance evaluation and our rehabs on. So now we're going to say annually, we're going to test people's performance and we're going to put together procedures for every single incident we go on. What does that rehab look like? Making sure we're taking care of people at the scene, making sure that we're properly rehabbing people, making sure that we don't let them go back into dangerous environments when they're already physically exhausted and more likely to be injured. 2018, we started a pilot program with our firehouse physician, that would be Dr. Koval up there. She was actually the head of occupational medicine at Denver Health, which is our occ health provider, our primary occ health provider in the city and county of Denver. She wanted to do more. She was seeing our patients and she says, I think we can do more. And so we put together a pilot where she went out to the firehouse and said, Hey, we're going to do physicals. We're going to do them in the firehouses. We're going to try to get people involved. We're going to have people invest in their own personal healthcare and their own wellness. That went really well, but we didn't really necessarily have a way to expand that and really scale that up. So right about then we found a company called and they were basically an outsource of wellness provider for professional sports teams. So they did some work around the Colorado Rockies, the Colorado Avalanche, and we started working with them and we said, Oh, there's a whole new model here. Now we're testing people for their physical ability. So we're doing fitness testing. We're doing aerobic capacity testing. We're doing strength testing. We're doing lactate threshold testing to see, Hey, what's your prime heart rate? How do we get people really to be able to work out, lose visceral fat, and then just kind of take fitness and health and put them together because they really go together. And then what happens in 2020, but everybody here can guess COVID hits, right? So beacon is a gym, basically a really fancy gym with all kinds of athletic trainers. They run you through programs. They hit, nobody's going to gyms. They close down, they go out of business and we're left, what do we do now? So in 2021, I stepped down as the chief of the department, but kept wellness with me and said, I want to focus on wellness a hundred percent of the time. The new incoming chief who was one of my division chiefs stepped up and had the same level of commitment. We said, we're going to build our own programs and we're going to take everything we've learned for these last 10 years and put together a program. We're going to actually hire a full-time resiliency coordinator. We got very lucky. One of our firefighters happened to be a licensed clinician too. We moved her into that role and we started a wellness screening program that looked something like the beacon program, just a little bit better. And then to guide all of our decisions to make sure that there was solid medical direction behind all those decisions. We hired our first in-house physician that was geared towards just employee wellness. So we said, we adopted this total wellness model. The first one is fitness. You can see we have our stakeholders over there and it's always going to be the department and it's always going to be union members. And then it's going to be also civil service when we're first bringing people in. So under that fitness model, we talked a little bit about it and we said, that's our CPAT, that's our PFTs, our peer fitness trainers. We're going to adopt those. They're going to be in our model. Everything we do is going to include them from the day you get on to you get assigned to a firehouse. Even now in the far districts and supposedly the retirement house, we want PFTs out there. We want people that are willing to help when you come into that station say, hey guys, we're going to do a workout. We're going to do it together and you're struggling a little bit. Let me put together a program for you. So we got a bunch of PFTs trained up and they were able to do that. The CPAT test is our coming on test. However, we still needed to have some way of performing measurements on our incumbent employees. We'll get to that in a second, but the one that really kicked in right away and we saw the biggest gains was actually our physical therapy. And so for that part, I'm going to turn it over to Dr. Stoneberger. There you go. Just the big ones, the forward. Hi, I'm Casey Stoneberger. I'm a physical therapist and a certified strength conditioning specialist. I've been with the Denver Fire Department for eight and a half years. And so what we see here is our physical therapy visits year by year. So the first three years you'll see we're building our program. Now the service is free to the members, so there's no money exchanged. So when I started the program, I was like, you know, what's the value going to be? So it started off slow, but then it started climbing after that first year, second year, third year. And at the third year we reached capacity. And what you see there is you just see us building our reputation and our rapport with the members and building the value of our service. And then next to that, you'll see our work comp caseload. So the first five years of the program, about 40% of our caseload was just our work comp cases. The other 60% of our work comp caseload was what we call direct access, which is members just coming in for their own personal injuries or post-op rehabs, or even just aches and pains. The funny thing is, is when COVID hit and people started staying home, that following year in 2021, we actually saw that flip. So currently in the last few years, the majority of our caseload is now workman's comp, which is about 60%. And the other 35, 40% is now direct access. And to me, that was just a self correction. It told me that we weren't paying enough attention to our work comp cases, and now we're giving our work comp cases more care. When you look at what we treat, it's pretty typical or pretty comparable to a Division I or a professional sports medicine program. We see a lot of backs, and we see a lot of shoulders, and we see a lot of knees. And that's just reflected there in the chart. So the intrinsic and extrinsic value of the program. When I got this position, our then Division Chief Scott Heiss said, it takes three years to build up enough data to prove the worth of your wellness program or your physical therapy program. So the intrinsic value is the value of the services that we provide in-house. And the extrinsic value is the value of the service that's downstream because of the work that we've done. So when you take the total value of our direct access physical therapy services, which is the number of our visits multiplied by what you'd pay a physical therapist cash per hour, and you combine that with the amount of workman's comp visits that we provide, which is just what the city typically pays for a work comp visit, you'll get a total intrinsic value of about $300,000. Because we're able to get our people back to the streets quicker than an outside provider, that's very important to the fire department because every shift that a firefighter misses, the administration's paying overtime to fill that shift. So if we can get a firefighter back to the streets a month earlier versus an outside provider, we're going to save the department nine shifts of overtime costs. So what you'll see there is the operational cost savings, which is overtime. So when you combine those two values of our program, those two values, it provides about a half million dollars of savings per year. And then obviously you see the return to work 30 days earlier versus an outside provider when you use our internal service. And it's a lot more than physical therapy. We're embedded in the program. It's a closed community. It really is kind of a family environment. And in 2018, I noticed, hey, we are getting a ton of spine cases, what's going on here? So I was able to work with risk management and kind of pull some data about, hey, whose backs are getting injured? How are they getting injured? Where are they getting injured? And when it boiled down to it, it was our first grade firefighters and it's patient transfers. They have to pick up and pull people out of amazing places and get them boarded and on an ambulance, right? So we took that data and we said, okay, let's create a low back workshop that just kind of puts together, you know, kind of presents that data. Hey, here's where we're getting hurt. Here's how it's happening. And then, hey, here's some really easy self-care remedies for that. Let's make sure your hips and your T-spine are mobile. Let's make sure you have good stiff core control and you can control anti-rotation. And here's really simple exercise. So the first piece was an assessment, a self-assessment. And the second piece was just super simple exercises to make sure your thoracic spine, your hips are mobile and your trunk is nice and stiff and you have a good posture. So we took the entire job through that training in 2018. And then anecdotally, the risk management said spine injuries did decrease in 2019. PFT continuing education. So like Chief Tate said, we have peer fitness trainers that are certified with the IAFF. We can provide them continuing education and utilization. They help us with our fitness assessments, our CPAT. They also come through and work with our annual wellness testing and research for the industry. We've published research with CU on the FMS study, which is the functional movement screen. We're working with the University of Kentucky right now on a multi-site study that basically compares small, medium, large departments with and without embedded services. And do those embedded services really have an impact when compared to the non-embedded services? And peer support and resiliency. So we have a week-long peer support team training that I participated in. And it's a big deal because the guys and gals will get hurt. They'll come in. They want to be in the station. They're not in the station. They're not with their people. They tend to get a little down. If we can recognize that and be there for them and then provide the proper resources, just kind of point them in the right direction, it's very helpful. I like to focus on physical therapy. I'm not really a behavior health guy. So I'll let somebody else do that. Chief Tate mentioned the physical rehabilitation SOG and academy programming. So I've been at the academy for eight and a half years. I've seen probably a thousand bodies come through our academy. They're young. They're old. They're tall. They're short. They're big. They're skinny. They're in shape. They're out of shape. We have to put together a program that benefits, a physical training program that benefits them from day one to the end of the academy and is going to increase their strength, their cardiovascular fitness, and is going to prepare them for the job. And we're also going to make them part of that fitness culture that we want to keep our members healthy. So at the end of our academy, we have a very intense high-rise evolution where you'll climb 30 flights of stairs with full gear. You'll get up to that top. You'll get up that 30th floor. You'll deploy a hose, fight a fire. And then after that, you're going to go on air. You're going to go up another 20 flights of stairs and then rescue a downed firefighter. And it's one of the most physically intense, grueling things you'll ever do. So we have to prepare our recruits for that. So over that eight and a half years, I think we've really dialed in a really good physical training program where it's periodized. We used undulating periodization. We use really simple core movements. And it just gets them strong and mobile and prepared for that, so they're durable and also cardiovascular fit, cardiovascularly fit for that 1999 Broadway evolution. We also have an intern and a student PT program. It's been really beneficial. We're, you know, Laura and I, we're front office, back office, we're program development, we're everything and anything in between. So when we can get some extra hands in there it's really helpful and we also love to teach and we're also preparing people for what I hope is service to the firefighting industry. One of my interns who was a master's exercise phys student, he just took a job with, about a year ago, with Seattle Fire Department as their wellness coordinator and we've also sent a couple of our student PTs to the Air Force as well. And then as part of the 1582 physical for new hires, there's a range of motion for the extremities and range of motion for the spine clearing test. We were able to work with Dr. Koval on using that functional movement screen and get that into the physical to provide that information. Hi everyone, I'm Laura Stewart with physical therapy. I'm going to talk some about our wellness initiatives that we currently have. So right now when a firefighter is injured and we're looking to get them back to work, we want to simulate their environment as much as possible. That way they know that they're ready to do any job duty they could be possibly asked for. So we have a fitness test called the rekindle and basically we have a bunch of stations 75 feet apart. They don all their gear, all their bunker gear, plus their SCBA, which is their oxygen tank and mask system and helmet. And they have two minutes to get all that stuff on, which if they've been out of work for more than six months they get pretty slow at it. Normally it would take a firefighter about a minute or so, maybe less. So they do that, then they have to lift, carry, and throw a ladder. They have to do forcible entry where they get a sledgehammer and there's a pressure plate and they literally swing a hammer against it and that plate gets pushed back until a light goes on. It takes a ton of energy. Then they do a high-rise pack evolution, which is just a simulated drill. They pull a fire hose and wrap it around a corner and then pull the hose. They'll carry saws and they'll lift it up from a very awkward height, which is good for your shoulder people. They'll do a ventilation with a Kaiser sled where they stand on a sled and kind of straddle it, sledgehammer, and they hit an object and push it back to simulate opening up a roof. And then they drag a victim and all of this is, they replicate the skills as much as possible. And it's very cardiovascularly taxing, so we try to start them with doing cardio as soon as possible, especially for long patients that are going to be out more than six months because it goes downhill quickly. And any firefighter at any time needs to be able to carry over a hundred pounds up, you know, 50 floors. So cardiovascular fitness is key and we have them do this, see if they can do it, and then they can get back to work. All right, so the PT program has exponentially improved over time since its inception in 2015. So it was so successful early on that a second PT was added after Dr. Stonemerger. Then that program became so successful that our sheriff and police departments also added PTs and now we have two per agency. So two in fire, two in sheriff, two in police, and the hope in 2024 is that we add a seventh PT to act as a director who supervises all six. This increased staffing has allowed us to expand on everything Dr. Stonemerger just talked about, which is being able to implement other programs and not just do PT all day. We want to implement wellness initiatives, preventative medicine, so we can reduce time of injury as much as possible. The healthier people are before injuries, the quicker they'll rehab. In addition, we have the scheduling capability to get our work comp and acute injuries in within a day or two, sometimes even same day, versus if there was just one of us, they'd be waiting a few weeks, then we're no better than external providers. So we have that flexibility that we're able to do that and then people return to line of duty significantly faster. We're also able to increase our oversight of the physical training for our recruits as well because, you know, if there's 36 people in a fire academy and you have our wellness coordinator and one PT, it's like 13 to 1, it's hard to keep, or no wait, that's not right. I don't know what the math is, but it's a lot, versus like, you know, 1 to 10 with, you know, additional staffing so we can look at all their movement patterns, correct form when it's horrible, which happens shockingly often. So we got to make sure that we have eyes on everybody and the increased staffing has allowed us to do that. So for our wellness initiatives for our recruits, what we've been implementing is movement and mobility classes. So week one, we talk them through how to foam roll, how to use mobility balls, how to stretch, how long they should do it, what the parameters should be, and just general guides for each of them on common injuries and how to treat them themselves so that they can get through their academy. We also update the physical training programming based on new evidence, like Dr. Stoenberger talked about, is just being as up-to-date on the best way to get everyone strong and cardiovascularly fit as possible. They also have that evolution Dr. Stoenberger talked about, where they have to go up, you know, 50-plus flights of stairs and rescue a downed firefighter. We have a training progression that leads up to that. That starts from, you know, just doing 10 laps of stairs with no weight at all and progressing all the way up to being able to do the 50 flights plus 100 pounds of weight. So we've been updating that continuously over the years. We're focusing on continuous education, so, you know, if we tell someone or recruit something one week, in four weeks they've forgotten about it. So we're just continuing to remind them what they need to be doing to keep themselves as well as possible. And we're trying to get them to move a certain way and behave a certain way so that when they graduate and they move into the firehouses, that they're able to continue with their wellness and continue with their nutrition and all that sort of thing. And we're trying to identify future barriers to wellness when they graduate. Right now, after they graduate Fire Academy, they go through EMT class for six weeks. So they go from burning thousands of calories a day to sitting most of the day. And then sometimes they lose a lot of their gains in that time. And we want to basically try to set them up for success as much as possible with education. And then data tracking. We measure and record every single body part that is injured every week of Academy. So we can correlate it with our physical training program. And we're like, oh, you know, if we see five people with back pain in a week, and that day they were all, you know, taking a victim out of a window and down a ladder, then we're not going to hammer them with deadlifts that week, or the next week, we can change up what we're doing based off what the data shows. And that's been extremely efficient for us. Now for incumbent wellness initiatives incumbent or our current members, what we're doing is we're focusing a lot more on preventative medicine to try to mitigate how many patients we see in the clinic, which is a pretty long grind for us. We're trying to educate the members on our services. So we provided crossover symmetry units to every single firehouse thanks to Chief Tade. And it's basically like a banded shoulder system, where it works on the rotator cuff and supporting muscles to try to get activation and strength so that they have better form when they're doing their overhead presses, which they do overhead presses like all day for for their normal firefighter activities. So we created videos to show them how to do it with certain cues so that they can do it properly because done improperly feeds into their issues. We also hosted the O2X human performance conference for a week, and we had a lot of firefighters attend that, particularly our peer fitness trainers. And it basically was a 360 view on wellness, including sleep, nutrition, physical fitness, mental health, resilience, etc. And it was really awesome. We're trying to integrate the PFTs more, and we'd already talked about that. I am trying to work on classes for body mechanics with frequently performed exercises. The firefighters are incredibly fit, they're incredibly passionate about fitness, and yet so many of them that come into the clinic still don't know how to squat, even though they've been doing it for their whole lives. It's just because they've never been trained. And you know, squatting, deadlifting, bench, these are skills and techniques that need to be practiced. And if done right, they're extremely important for resilience and long-term health and longevity in the job. Done wrong, and you'll end up being hurt, and we see that a lot. So we want to work on like having a squat class and have people come in and just show them the mechanics and really break the movement down and try to improve that so that they can have that better longevity. We also want to work on improving, you know, another location for our members so that they can have better access to it. We have people that come from hours away for a shift, and a central location would be great for them. And then we want to add in some more functional capacity training to build up the cardiovascular fitness, as I mentioned before. And we're working to hone in on return to duty and performance evaluations as well. All right, as you can see, our PTs are doing a lot of stuff. We could actually probably do an hour-long session on just what our PTs are doing. But our goal really is to kind of get to our last one, which is going to be our wellness screening. So I'm going to run you through our behavioral health and resiliency really quick. That way we can get to Dr. Koval, and I think you guys will have a lot of questions potentially for her. But you can't have a total program without having something in the behavioral health realm, especially as we start seeing our first responders really suffer from quite a few different mental health and behavioral health, depending on which camp you're in, issues that reflect into everyday performance. So like a lot of departments, we have a peer support program, we have a chaplaincy program, we do some member education, and we have our third-party contractor services. One thing that's unique for us is that all of our members have unlimited psychological counseling available to them from one of our local psychological counseling firms. They have quite a few different clinicians, so if you don't click with one, you can go see another one. And until recently, we actually had unlimited for family members. Budgets and stuff has constrained that, so now all members of a family get six sessions themselves as well. This is one of our most highly utilized programs. And then we added a resiliency technician. We took a firefighter off the street that had the appropriate background, put him in there, and since putting her in there, it's really opened up the avenue for going in. Instead of having a firefighter have to call down to either an EAP program in a civilian position or just call directly to Nicoletti Flater, which is our psychologist, they actually reach out to what they see as just another firefighter, and they're able to really connect them. Same level as like a peer support, but somebody can really be a navigator and guide them to the appropriate resource. Every firefighter gets this. It shows kind of, you know, what our services are. We'll kind of go through that because, whoops, let me go back one. This is one of the things that by putting a firefighter in that resiliency position, that's very unique, and I think it's very unique in Denver, is that she created this program called Recess. And essentially what it is, it allows a firefighter to say, I need help, I'm not doing well, and to take a break. And so what happens, the department matches 50% of the time, the employee then uses 50% of their time, whether it be vacation time or sick leave time, or if they chose to have even non-paid, and we pull them out of the firehouse and pull them out of that emergency environment, and they get that pause. And so they'll go out for three weeks, and they're out there with our wellness division, our training division, and then we put them in to either counseling or doing things like mindfulness exercises, yoga, just kind of hanging out for three weeks, but with our resiliency coordinator. So at the same time, they're helping the resiliency coordinator out with their assigned duties. They're also participating in events that are designed to kind of give them a reset. It has been an incredible program. We've seen people that were kind of maybe spiraling down a very negative path, take that three-week pause, just pulling them out of that first responder environment, letting them work on themselves, but also because they're helping other firefighters and helping put programs together and assisting in there. That's where we've really seen that level of engagement come back. So far, everybody that's went through that program has went back out on the streets and had a successful return to there, and we've seen that pivot from kind of that declining slide to re-engagement and really seeing them excel. So that has been an amazing program. But the one I want to talk to you today about is what we're doing for our wellness screen. We don't call it a physical. We really call it a wellness screen because this is the one where we work with all of our stakeholders, and so now when we bring a firefighter through what would have been just a physical, they actually come out and we start them in, we bring them out to our wellness center, we get a vital signs from them, get basically baselines. We do an in-body scan, which we'll talk about in depth in here in a second. We do 3D vision analysis, we do power assessments, aerobic capacity assessment, we actually do foot scanning, which is actually our most popular program, and then we do the meeting with the department physician, which we'll talk about in depth because very rarely can you find an environment where you're scheduling 20 minutes to an hour is what most of our employees end up spending in there with the doc, and you'd be amazed at what comes out in those sessions. A lot of stuff around mental health. So what does this wellness screening look like that we're so proud of? Well, it starts off with an in-body scan. So I don't know how many of you are familiar with in-body, but it was basically our equivalent of doing a DEXA scan on everybody. When we were actually with BICA, we were doing DEXA scan, but as you know, we get a little bit of radiation there. Probably not something you want to do on a regular basis and makes it very hard for doing follow-up with people if you want to do it, you know, multiple times either a month or we have people that come out weekly, but basically gives you what are you made of. It shows you, here's your weight, here's your muscle mass, here's your fat mass, here's where your visceral fat's at. A few other things like water outside your cells, which you know we look at that for inflammation, edema, leading towards other things, and then on the bottom it gives you kind of a history. So now our firefighters can track their history, and we can bring somebody out and we can say, okay, that's great, you lost a bunch of weight, but it was all muscle. Or, hey look, you're on the right track. You lost weight, you gained, you know, three pounds of muscle, lost five pounds of fat. That's a good thing, right? And so they can track that on the bottom. Then we move them into a 3D movement analysis. Firefighters, they like shiny things. Dangle something in front of them that's shiny, they engage. So we put them through this 3D movement analysis and say, hey, here's your skeleton as you guys can see up there. Here's where you have dysfunction, and it's really looking for range of motion issues. It's looking for instability issues, and so we get the body mops them out. There's certain functional areas, you know, say, okay, it looks like you have stiffness in your right shoulder, you have stiffness in your, you know, your SI joints, which is extremely common because most of our people are right-handed. Everything in the fire service is done with your right side. You're carrying hose packs, ladders, heavy equipment, using those shoulders a lot. It's also one of the number one injuries our PTs treat, and then SI joints. Why would we have super stiff SI joints? Because firefighters wear 50 pounds, 60 pounds of additional weight on their upper torso, right? All that weight compresses down into those SI joints, and so they either get really strong or they fail. Typically, they get really strong, so we get really nice strong SI joints, but strong is stiff, so they're very stiff, so we treat a lot of low back injuries as well. But we go through that whole thing. Once they're done, we actually send a video link to every area that they have a dysfunction identified, and it shows them how to work those joints out. Then we run them through some aerobic capacity testing. We either usually do a Submax using the Gherkin protocol, or we do a Bruce, which is a maximum effort test, which doesn't utilize heart rate, doesn't utilize age, gender, any of that. It's just maximum effort so that we can get a MET equivalent. The MET equivalent for firefighters to be able to perform their jobs efficiently is 12, so once we run them through there, we can tell them, hey, this is where you're at aerobically. You're doing a great job, or you need to increase that. Then we will do some lactate threshold testing with them, too, while we're doing that, or we'll do it separately. It depends on the firefighter, so we can kind of tell me, here's where your prime heart rate is, so this is where you need to kind of, you know, either be in this heart rate for increasing aerobic capacity, or be at this heart rate basically for losing fat. We can get into a long discussion on that, but we won't. Then we do vault force plates. Some of you guys might be familiar with Sparta force plates, very similar, but we do that basically so we can measure people's ability to produce and then transfer that energy, and then we're looking for asymmetry issues. So we have two force plates, and we do a series of counter-movement jumps, and then we can look at their ability to produce energy and transfer that energy, and then it gives them another map, a nice printout that they can see, and shows whether they're right side or left side dominant. And then we also do a foot scan. This one seems a little bit weird, but it's actually been our most popular program. We actually have a scanner from Atrex that makes a 3D model of your foot. We know that most things start in the feet, right? A lot of knee problems, hip problems, back problems, they start in the feet. Since we've started doing this, we actually went through several hundred pairs, actually about 400 pairs of orthotics of people coming through and actually going with either a semi custom orthotic, or they have the ability right from the scanner to hit order and print, and it prints a 3D insert that's printed exactly to their foot. Really we're looking at arch support, forefoot pressure, and pronation, and we're able to correct most all of those. We see the benefits to the firefighter, but it's also kind of that dangly, you know, got a dangled carrot out there to get people in the door to do their screenings, because this program is 100% voluntary. We have an 87% participation rate though, which is amazing for a voluntary program. So that gets them through the door, they do all this cool stuff, treat them like they're a professional athlete, great benefits there. But after that, the whole thing is we got them in the door, now we got them captured, right? Let's funnel them into the doctor, and that's what's hard to do is get first responders to go meet with doctors. And so with that, I'm going to turn it over to Dr. Koval. Thanks, Chief. So I'm a walker, I'm gonna walk around a little bit. Imagine for a second how luxurious it is to, walk right by a speaker, to have as much time as you need to talk to someone about all of this stuff. I think the thing that I feel most fortunate about is that I'm in this position. I could not be more grateful to have such a wonderful department to work with, who's giving me the opportunity to truly practice preventive medicine. Always have wanted to do it, there's not a whole lot of places where you can actually do it. So what do we do in this visit? You saw all the wonderful fitness data that we're generating, and I've got to tell you, it's so much fun to sit there and try to piece together, you know, kind of a gestalt about where someone is at. What does their visceral fat look like? What can I correlate that with? Okay, so the framework, you know, that I really like to use are these lifestyle vital signs. So every conversation, we are talking through each one of these. And there are patterns that emerge, right? You know, you've got the person who's, you know, doing well with fitness, but is kind of lax on nutrition. One very big theme is sleep problems that seem to underlie mediocrity in every other area. So identifying those patterns is a really fun thing to do. But as far as, you know, sort of data review, we're going to go over all that fitness testing, okay? We're going to go over their annual blood work, and so this is where the partnership with Kaiser really comes in. So I'm able to access Kaiser's electronic medical record, pull up their blood work, and the great thing that Kaiser has done, which we've been asking for for a long time and finally achieved this year, are these firehouse blood draws. So these are happening four times this year to cover all of our different districts. So we're trying to make it as easy as possible for people to show up and get their blood drawn at work. So the rigs rotate through while they're on shift, which is amazing. So since we started doing that, the percentage of people who have blood work to review at their wellness screening has skyrocketed. I mean, we're well over 60% at this point, which is very exciting, because that really makes for a far more robust conversation. You know, when I can talk to someone about their visceral fat measurement and their hemoglobin A1c at the same time, you know, you can really drive home some important behavioral change goals, okay? Then of course, cardiovascular disease is always a huge concern with this population given the exercise demands and the environment in which they work. So for everybody over 40, we're calculating a 10-year risk score. And that kind of starts us off on an algorithm as to whether that person needs additional screening or not. If they're 5% or less, plenty good. If they're between 5 and 10%, we really need to get ahold of your risk factors. If you're 10% or higher, you're getting some sort of additional test, whether it's a stress test or an echo or whatever is appropriate for that person, okay? So like I said, we're paying particular attention to what some firefighters refer to as the three-legged stool, which is the cardiovascular risk factors, okay? Cancer screening and pulling in family history to that discussion because it's just, it's another factor to think about. You've got all this cancer risk and that's obviously a whole other talk which you can see somewhere else in the conference. Incorporating all of that into this discussion. And finally, the behavioral health, which is, like Chief said earlier, just exploding in terms of the evidence for the need, okay? Our utilization of our public safety psychology practice is absolutely enormous and going up almost every year. So that's what that meeting is really all about and we are covering all of those lifestyle vital signs. Okay, so here's again where the magic happens. So in addition to the wellness screen, either coming out of the wellness screen or if someone reaches out to me individually, there's all sorts of kind of random issues that come up, okay, people call to ask questions. People call because they need a referral and they haven't seen their PCP in five years. Some people, Kaiser's pretty good about assigning PCPs but not everybody engages with them. We definitely see the healthy worker effect here. People are like, yeah, I'm good, I'm fit. I'm 45 and I haven't been to the doctor in 10 years. Happens all the time. So with our Kaiser concierge team that we work with, it kind of sets us up to shuttle people to the right place. We can just contact them and say, how do we get this person where we need to be? Example, we recently had a person who was being treated for a work-related shoulder injury who had an MRI of his spine and an incidental finding of a spinal syrinx was discovered. Kind of a big deal, right? So we needed to get that guy into a neurosurgeon but not in the work venue, in the Kaiser venue. So we were able to contact our concierge team and facilitate. So everything from getting colonoscopies scheduled to those additional cardiac screening tests I mentioned to getting people connected with additional medication management for behavioral health issues. That partnership is just, we're sort of discovering new ways to flex that all the time. So again, there's a gap that exists between the way primary care typically works, okay, and the needs of this population. That's the gap we're really trying to fill. We're not trying to replace primary care per se. We're just trying to add to it, okay? So a little bit, you know, what we love about Acmed is our ability to zoom in on the individual and zoom back out on population health, right? So just from our initial couple of years, this is kind of a hint at what our population data is looking like. So BMI, not so reliable in this population. When you have people with a lot of muscle mass, in all honesty, I kind of tend to blow off that 25 to 30 category because there's a lot of people that fall in it. Visceral fat, however, is a huge, huge risk factor, as you all know, for several chronic diseases. Cardiovascular, metabolic, cancer, you know, it plays a role in all of those. So, you know, our 37% of people who are 10 or above on the in-body, we really want to hammer home how to address that. Hemoglobin A1c, you know, we're definitely picking up a fair amount of prediabetes, and if you can catch that and educate someone as to how to reverse it, that can be life-changing, right? Exercise capacity, not so bad. You know, our average METS for our population is over 12, which is exactly where NFPA 1582 wants us to be, is 12 or higher. And then finally, our 10-year risk score. You know, it's a small amount of people who are up in that 5%, but let me tell you, those are scary catches because when you think about the kind of job someone's going to every day and the exercise demand they're being subjected to, it can hide until it doesn't, right? And someone has a terrible cardiac event. So just to give you a glimpse at what we're trying to track every year, this is where we're sitting. Then, you know, what do we do with all this information? What are we supposed to do as op docs? We're supposed to make our observations around our individuals, right? And then we're supposed to step back out and say, okay, how can we feed information back to the beginning of this cycle and educate people? So obviously there's lots of individual education going on, but we have this wonderful creation. We started it in the fall of 2020, actually. We call it the Coffee Talk. It's a virtual meeting that all the firehouses are welcome to join. Actually, we do it twice a month, and the first session is primarily cancer prevention topics. The second session every month, we invite the whole Department of Safety, and it's generally a more chronic disease prevention-related topic. But we take everything and we put it into that, and that's how we decide what to talk about, right? We take what the members want to hear about, okay? We take what we're seeing in our risk factors, and we're specifically addressing those things, okay? And we're taking our injury data that the PTs work so hard on, and we're trying to tell people, okay, this is what we're seeing happen to you, so here's how we can get ahead of it, and we have some examples of topics that were there. So that's actually pretty fun, I'll say, because people are generally pretty quiet. They don't say much, but my phone is always blowing up. People tend to text their questions because they don't necessarily want to put them on the Microsoft Teams chat, but it spurs a lot of conversation. And then finally, if we have a weak pillar, it's data collection. We have tons and tons of data, but we are operating in an 80s, 90s time frame. So much of it is still on paper. I actually have a lockbox where I keep HIPAA compliant, but it's a lockbox where I actually keep the history forms that people are filling out, and this is obviously one of the growing pains of being part of a brand new program that never existed before, right? You sort of have to build it from the ground up, but I'm very excited that this year we actually did our first EMR evaluation, and we're trying to pick out what system would serve our needs best. The PTs already have a great one that's very, very customized to physical therapy, and fortunately, at this point in time, there's a lot of wellness-focused EMR options out there, and so we just did a price analysis, and it's basically in our budget for next year. So all of this data that you see, we're gonna be able to just collect and correlate and put in a format that is much easier than doing it by hand with data entry. I'm fortunate I have a steady flow of MPH interns and residents who come through to help us out in our clinic, so they get a lot of good experience with that. But important to mention that the machines that we use, the computers that we use for all of this testing and all of this data storage, they were purchased by the union, and even to this day, we've been functional for about two years now, even to this day, I get questions from individuals. Who do you work for, and where is my information going? Privacy is a huge concern with this population. So I love being able to say, hey, I work for myself. I'm a contractor. I don't work for the city, right? And as far as your information goes, we don't even use the city system. We use a completely separate Outlook account to send everybody the summary of their fitness data. So again, confidentiality, absolutely huge. And again, it goes back to what she said earlier, when you gain the trust of this population, it does not happen quickly. It happens with consistency. It happens with being there for people in their worst moments, and you sort of have to prove yourself. I can't put it any more, I guess, bluntly than that. But, hello. There we go. So back to our stakeholders. So you may have noticed on each of our sections, you know, we had some colored arrows pointing to each section, which means, you know, every single one of these has participated in a unique way. And I'll revisit for a second the health insurance one. You know, that has been a work in progress probably for five years now. And getting these big health insurers to pay attention to the needs of this population, you know, we have some data, some good data to support that, but that's an area that's really exploding. I don't know if any of you saw the National Firefighter Registry just went live this year, which is very exciting. Getting people to participate in it is going to be, you know, another challenge, because again, there's that trust issue. But my hope is that at least enough people will participate that we can, you know, make some data that better demonstrates how the risks of this career translate to chronic disease risk, cardiovascular disease, cancer risk, behavioral health stuff, because just volume-wise, the proof is there. But we really need to, it needs to be in our language, right? It needs to be codified, you know, in our literature a little better than it is now. So, with that, thank you for your attention. And please feel free to pop up with questions. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. So, we have some questions, I think, right? Yeah. You be the leader, Chief. Sure. All right. You can go first. I'm sorry. Great job, fantastic. I have one question that's on the cost of the program, and another on, you know, the bells and whistles. Do you have a data report that can be tested via our basic screening that we do with the conference, the MRI kind of? So, we do have a bunch of that. Well, I'll start with the cost of the program. That's probably what makes it unique. So, all the blood collection, analysis, urine collection and analysis there, plus baseline vitals, Kaiser does completely free. So, they come out to the firehouses, they do 100% of that collection, and that's because it's a win-win. Because we've been, not only do we get that data, now Kaiser has it in their system, right? And now they get that population health data unlike they've ever had before, because about 20% of our population annually we're actually getting physicals and going through that. And so, as another piece of that, so we can talk forever on this, one of their doctors that oversees their primary care physicians, he's actually at every one of our blood draws and meets with each one of those members. He's reviewing their data, and he's consistently making changes to their plan, saying, hey, this medication should be adjusted, this should be done, we need follow-up here. Plus, when the blood work comes back, and let's say your A1C's really high, they have their pre-diabetic care team that immediately contacts the member. Or if we see, you know, lipids are way off the chart, then they have their teams that are dedicated to that. So the way Kaiser breaks out their specialties, once that blood work hits certain levels, they immediately engage with the member there too. So that piece of it's all paid for. The wellness screening part, we bought all the equipment for around $60,000. Where we're really starting to see the efficacy is both in the PT program, is that return to work. Every day a firefighter comes back to work early translates into roughly $1,500 worth of savings. So when you take an ACL and you make it four months instead of six months to come back, two months, 10 shifts, you know, there's 20 shifts right there times $1,500. You start seeing that. And then through these screenings, I think I'll let Dr. Cole talk about the significant cardiac. And then what we're seeing is we're catching a lot of prostate cancer early. So we're seeing those PSA levels go up. And then because of the advocacy of having our in-house doc, and being able to be in the Kaiser system, she gets them in urology right away. Do you want to expand on that? Sure. Particularly with respect to cardiovascular testing, that ASCVD 10-year risk score really is worth its weight in gold, okay? We've had a handful of people, not many, but the ones we have discovered had elevated risk, had no idea, you know. It's the public health conundrum, right? We don't know exactly what we prevented, but if that person had continued to work for another two years, three years, five years, and these were not older people. These were people in their late 40s, early 50s, right? What's the value of preventing a cardiac event? I'd say we've had at least four of those so far. Now, there's data in literature to put a value on that, and it's kind of different for each situation, but that alone has been worth all of this. Hopefully that answers your question. We can follow up afterwards in more depth if you have a question. I'm curious, in terms of some of the data that you've collected, have you seen, for example, how you've been in the process of developing, like, as you've done the data, in terms of seeing whether, you know, how efficacious it is? That's one question. The other one is, have you received any feedback from any of your colleagues about how efficient the data is? What's the, have you received any feedback on, like, you have the data, the quality data, and feedback from the actual point of view and your guidance? Because that's a huge buy-in as well. So, maybe you've seen 80% participation with the program, but I would love to see if there's been more visible feedback there. Like, there's been a lot of questionnaires done, so I'm curious. So, the answer to both of those is yes and no. So, on the data, we have so much data now, that was one of those drawing pages we talked about, was that we really need that EMR system to kind of go through and parse through the data. But, as far as the employee, you know, what is the employee feedback piece on it? The biggest feedback you get in a voluntary program is who's coming out. So when we first started, everybody came out tentative. They asked, who's doing this, who's that? Now, that 87% participation rate is solely driven by the members' word of mouth going to tell them, hey, you can trust this program now. When you go out there, go ahead and do the program. And we also have a committee, a wellness committee. The union actually has a representative on there that kind of runs that committee. The union buy-in. And so, when we talk about the computers are paid for by the union, we're about ready to probably start replacing equipment. The union's setting up and writing checks. And so, when the union writes the check, we think of the union as this big monster or whatever. The union is the members. So the members themselves are authorizing their executive board leaders to go ahead and fund the program. And a lot of times we say, hey, you want to see where people's priority are? Look and see where the money is? The members are investing their own membership dues back into a program for the department. And so, that's the biggest we know there's employee buy-in. The one last little piece that we have to try to get that buy-in is some of the ones that we know are probably our worst candidates. They know they're that bad, but they don't want everybody else to know that they're in that bad of shape. And so, that's the one hurdle that we still have not been able to overcome is when you have a voluntary program, how do you get the person that intentionally hides from the program in there? We have seen some of them come in, but obviously, you know, we have a handful of people that aren't participating. The other thing, limits are only down to 87%, is because the blood work and all that stuff is through Kaiser. Most of our membership has Kaiser, but we do have some people that have Tricare and some of those. And so, because it's more burdensome for them to actually go to their doctor, get the blood work, and come in, a lot of them just won't go through the whole process. I'll add to that, that when we have been vetting EMR systems that are wellness focused, we're looking, we had looked specifically, we picked out three that have feedback mechanisms built into the registration process. So, no, we don't have the Likert scale data yet, but that's exactly what we're looking to implement with our new EMR when it comes. Yeah, congratulations on implementing all the elements of the wellness initiative. Not necessarily, I'm going to ask about cardiovascular fitness. So, not necessarily before a member gets to the physician, but maybe in the steps prior to that. The test reveals that they have, that the member has an increased risk of sudden ascitation related to cardiovascular potential, cardiovascular illness. Who identifies that individual and if you let that individual continue to work? That's the first one. And then the second one, on the data that you presented about the treatment of your members with low back injury, you alluded to the fact that they're introducing their backs at medical calls, not at their appointments. So, that's the first one. And then the second one, at medical calls, not at the senior choir or not necessarily at the top down overall process. So, what percentage of your calls are medical only? And, if you have data on those individuals who injure themselves, what was their pre-injury cardiovascular fitness, what was their pre-injury physical fitness? Sure. I'll answer the first part of that then I'll let these guys jump in for the low back part of it. So, every time someone comes in for a wellness screen, we have a physical activity readiness questionnaire that we have them fill out, which is pretty standard for this environment. So, that's one screening mechanism. We're also checking blood pressures on both arms before we let anyone participate in anything. We have identified a handful of people who come in with an extremely elevated blood pressure, but they're not. So, we immediately say you're not participating in the fitness piece of this today. And, we don't, we can't take them off of work. Again, we're still maintaining that this is a voluntary program, but what we do say, and I have said this to people, I strongly recommend that you leave work today, go to an urgent care, get checked out because, particularly if they're showing signs of, you know, end organ symptoms. Do you have any headache symptoms? Do you have any cognitive difficulties? Is your vision okay? You know, I'm doing all of that sort of ED level screening on blood pressure before anybody gets started as well. So, there's those two pieces. And then, if someone does get on the treadmill and they're not feeling well, our threshold to stop it is pretty low. You know, there have been a couple of people who, once they get started, you know, their blood pressure is pretty low and they're not in a hurry. So, you know, we have some safeguards in place, you know, to get that done. You guys want to talk about the low back piece? Yeah, yeah. So, you identified individuals who have elevated blood pressure who naturally are talking about people who have a low back. But, you're saying that this we have to account for the fact that some people who have elevated blood pressure, they live at a higher blood pressure, okay? If someone is completely asymptomatic and they're adapted to that to some degree, am I going to disrupt for that reason? If I took everybody out of work who was over 140, over 90, they wouldn't have any people left, they wouldn't have any people while they're at work. So, I'm going to talk to them very, very carefully about their symptoms that day or any other day. But, no, I'm not going to take them out of work if they're asymptomatic. I'm going to say, look, you need to take people out of work because taking people out of work is definitely not our goal. Sorry, did you guys want to mention the low back? Yeah, in regards to the low back question, when we published that study with the FMS, the functional movement that they would miss from being injured, and that also, so they'd get to MMI quicker, and also their case would cost less. So, there was a correlation there. The other thing the low back workshop did is it created a lot of discussion about culture change, so that we're not having to lift them off the ground anymore. So, those have been two big changes from that. Alright, we'll keep answering questions. We're about 10 minutes over, but we're happy to answer questions, so.

wellness programs

Denver Fire Department

employee wellness

risk management

collaboration

healthcare providers

wellness screenings

early detection

high participation rate

data analysis