All right, it is right at 2.45. We'll go ahead and get started. I will start with reading some housekeeping items, and then we will move into this afternoon's lecture. So welcome to high margin, high yield, on-site occupational health events. Make sure to silence your cell phones or any other devices. You can evaluate and claim credit in the Swapcard app, either on your phone or on your laptop or device. You'll look for the neon green link towards the bottom at the end of the session, and you'll be able to evaluate it, and then at the end, it will take you to a link where you can claim your credits. If you haven't already downloaded the AOHC 2024 event app Swapcard, then please do that. If you need assistance, please visit the registration desk or AECOM membership booth in the pre-functioned West area, or look for any AECOM staff with the Team AECOM logo on their badge. All right. Well, I am Nicolette Davis. I am a physician assistant by training. I've been a PA for 17 years, and I've been doing occupational medicine in some form or fashion for my whole career. Right now, I serve as a liaison between the American Academy of PAs and AECOM, and my term ends at the end of this conference. And I'm also the president of the Association of PAs in Occupational Medicine. My current professional role is I am the regional director of occupational medicine for Southeast in Atrium Health. And in my personal life, I'm a mother of four, and I have two bio boys and then two adopted little girls that are the joy of my life and keep me very busy and very tired. So, this lecture today is talking about high margin, high yield, how to take occupational medicine services into the workplace to do bulk exams. I do not have any disclosures. So the learning objectives today that are in your swap card, we're going to list employment-related exams that work really well for mobile occupational medicine events. We'll talk about how to design, price, and implement these types of services, and then how to design a sufficient or an efficient workflow and build a team. So here's a picture of some of the ladies on my team, and this is a typical event set up for us. So this is actually a hazmat physical set up that we did maybe about a month ago, and we set up various stations. I think this one had four stations and then a provider area that was in a private area in an office. And so this is kind of what a typical set up will look like for us. We've got, you know, screens with our logos on them. We have tablecloths with logos. Our team is all in logoed wear. We all look the same. And so this is just kind of how we would set up an event at an employer's location. We do a lot of this work within manufacturing plants that do mass hiring or have surveillance-related issues, and we bring a team on site to perform these functions. So why would you choose a mobile solution? Now, there are vendors out there that do this work, but I really think this work lives with the occupational medicine providers, people who know the work, who are close to the work. It's just taking it out of a brick and mortar and into an employer's physical location to perform the functions. So we go on site to the employer to do this. It also helps to decrease employee downtime. So employers are not having to search through and schedule physicals in a brick and mortar occupational medicine clinic, for example. They can actually have a team come to them and then do bulk exams. So this prevents the employees having to leave their place of work, go to a brick and mortar, however long that physical might take, and then come back to the place of employment. It's all done there. And if there are any restrictions that need to be had, then us as the providers can communicate that back to HR and safety real time. And they can start to make adjustments at that point. This is where medicine's going. You know, we're trying to meet patients in the rhythm of their life. That's why telemedicine has taken off. This is just another way to meet a patient in the rhythm of their life. They're working one third of their life in their employment space. So why not take the work to them? So not only do the employers win in this model, but we also, as the medical team, we win in this model. So we get to customize the approach based on what the employer needs versus them coming to our clinic and we give them our canned approach. This sometimes leads to maybe a lasting partnership with an employer. So instead of having more of a transactional experience in an occupational medicine clinic, this develops a partnership with our employer clients to where they trust us even in the future outside of this occupational medicine event. It's also more efficient work for us. So I have occupational medicine clinics, but then I also lead this event team. And honestly, it is the most efficient workflow you will ever see. We have stations where spirometry is performed, audiograms performed, titmus vision, physical exams, and the patient, they just go from point A to point B to point C to point D, and they just quickly move through that workflow. They're not having to wait for maybe a clinical staff to get done with somebody else. That station's open. They just move directly into it and the workflow continues. It is a very efficient medical model for us. It's also a very positive financial model. So you are eliminating a brick and mortar facility and the overhead costs that are associated with that. You go to the employer, they have the space for you to set up, and really the cost of it is initially the supply cost, which we'll talk about, but other than that, there's no brick and mortar overhead because you're using the employer space. So meeting the need with the employer. So like I talked about earlier, this is a customized concierge type approach to meeting the employer where they're at and for the needs that they have in particular for their work environment. Now, you work, probably many of you work with many employers or maybe you just work with one, but every employer has their own nuanced needs. Their employees have different job codes. They have different job restraints. They have different work restrictions that they can accommodate over the next employer that you might be seeing. So this takes a customized approach to that work. So when we meet with clients, we want to know what are their goals? What are they trying to accomplish? And what we find often is that employers are very confused as to what they want to accomplish. So they may have wellness goals and not necessarily job ready goals. So maybe they're mixing them up. It's educating the employer on what is the difference between the two. Are we wanting to do wellness? Are we wanting to do job ready? Are you wanting to do both? How do we make that happen? But how do we let the patient know who's engaging in this exactly what that means and what the results of the exam is going to do for their job? Is it going to do anything? Or is it just for their own knowledge? What OSHA standards does this particular employer fall under? So if they fall under hearing conservation, respirator clearance, what chemicals are they exposed to? And at that point, we take a customized approach to determine what surveillance needs to be done. And a lot of clients come to us working with previous vendors. We'll get into that in a little bit. But in the end, we need to be the experts. We need to relay and educate our employer clients on what is medically appropriate and what's not. And in the end, they're the consumer. So if they want you to do something and it's not medically harmful, then we do it. But we need to educate. So what makes medical sense? A lot of employers that have done this kind of work before have worked with a vendor that maybe they did some things that didn't make medical sense or may actually be harmful. It's having that dialogue and education, but also leading with evidence-based medicine, which is what we do really well in occupational medicine. Also what makes legal sense? So employers come to us sometimes, and they don't understand their own state drug screen laws. And they want us to do something that actually is not legal in that state. And oftentimes, it's not on purpose. It's maybe because there's so much turnover. I don't know if you guys have experienced this in your walk of life. But with HR and safety and the employers I deal with, there's so much turnover. So maybe they pulled somebody from the state of Michigan, and now they're in the state of North Carolina, and the laws are different. And they didn't realize that. It's oftentimes not their fault. It's just we have to lead in that space and be able to educate. Not that we're giving them legal advice, but to let them know when maybe they could be misstepping. Lastly, do no harm. So one example of this, we came in, and we were doing an RFP. There was a previous vendor. So we're trying to bid for this, to take over these physicals for a client. And they were telling us, and I know there's a firefighter lecture going on right now. Our rooms got mixed up. But there was a firefighter group where the vendor was actually doing full-body ultrasounds. So if you look at evidence-based medicine for full-body ultrasounds, you're not going to find anything, right? Because it's just not medically appropriate, could be medically harmful. And in the population in which they were doing this, these were young firefighters. So are you looking for work-related findings, or are you looking for something that could be personal injury illness? And now, as the employer, you're putting yourself on the line. So we try to educate in what is medically appropriate, what is not. And really, we're not going to agree, obviously, to do anything that's not medically appropriate or safe. So what services look really good in this model? So I'm sure there's more that we could do. But right now, these are the things that we've been able to operationalize. And they work really, really well, very efficient work. So we've done FIT testing, where we'll bring nurses on-site and myself as a provider. And we'll perform respirator FIT testing and respirator clearance physicals, works really well in that model. Hazmat, like I mentioned earlier in the picture, we did that about a month ago. Police fire EMS work, this obviously fits really nicely into that model. DOT exam, so we'll go on-site and maybe for an electric company, and we'll do line workers. So we split them up, and we'll go out once a quarter, and we'll do them in bulk. So maybe it's 10 or 15, we'll do their DOT. And then that gets a group of 10 or 15 on the same DOT cycle, for the most part. There could be some short-duration cards in there. Also with our police fire EMS, a lot of them have DOT cards as well. So if we're doing their fire physical, we'll also update their DOT card for them at that same time. We do post-offer hiring events. So I know that there's been a lot of talk about turnover in manufacturing. Well, this is one of those things where you can really be an asset to your manufacturing companies. You can go on-site as they're doing a big hiring push, and you can do the medical exam on-site, go ahead and clear them, do their drug screen. And they actually have moved straight from our medical clearance into on-site training at the manufacturing plant and receive an offer. So this is a big deal, because in manufacturing, at least in our area, I'm sure it's in yours, people once they try to hire somebody and extend an offer, they may have already taken an offer somewhere else by the time it takes to get into a brick-and-mortar facility. So if we can come on-site and perform that medical clearance and drug screen, they can immediately give the patient the offer, employee the offer, and then they can start training immediately. So it really helps to cut down on that lead time. This is something new for us, so first responder training. We initially did some first responder training with our nurse on-site clinics, and in those nurse on-site clinics, we let the nurses lead the first responder training. What we found is our manufacturing plants were using other vendors that would come on-site maybe once a year. They do some CPR, some BLS, you know, and call it good. Well, in a plant of 1,400 workers, you know, you can expect that there's going to be some events happening there. Well, our nurse decided to take over training the first responders, and she's over that program now, and she does reinforcement training every four months. They run mock codes every four months. Two months into this program, they had a 60-year-old man code. He was found on the floor. He had already voided himself. They ended up shocking him three times, got him back with no residual effects after that, so really, really incredible work. I think this is where we can lead in this space. We don't need other vendors to do this work for us. Our occupational medicine backgrounds really bring a lot to the table here. We can also do CPR, BLS training for employers, and then we do supervisor drug and alcohol training. So for those supervisors that work, you know, second and third shift when they don't want to send someone to the ER, then we do training for those supervisors to teach them how to perform a urine drug screen or salivas, which is definitely what we prefer over urine, but we do that drug screen training for supervisors as well. And then, of course, hearing conservation. This gets a little bit more difficult. So typically, when we do a hearing conservation for a manufacturing plant, then we'll do it on once a month maybe, and then we'll do it on a higher date. So we'll bulk a higher date, go out once a month, and we'll do the audiograms that way. So that seems to work really well. So of course, there's many other things that you could do in this model, but so far we feel like this has the best yield and really is efficient work. So when you choose what services you want to offer, obviously there's going to be training needs that come with that. So these are kind of the training options that we looked at when we were developing this model, and it gets expensive. You guys, I know, are all experiencing turnover just like we are, and so to pay for someone to do NIOSH spirometry training, and then CAOC training, and then drug and alcohol training, it adds up. So what we've decided, we do NIOSH training. Spirometry is so complex, and it's so subjective, and it really is up to the person delivering the test to do a really nice job. So we do invest in that training. We are not doing CAOC training right now because the devices we use are considered microprocessors, and that's not a requirement to have CAOC. Not ideal, but that's just kind of where we are with the state of turnover and cost. We do train drug and alcohol for those that are doing that, fit testing training, respirator clearance reviews with our nurses to let them go ahead and do those respirator clearances for the providers. So that kind of eliminates some of that provider work. And then medical record training. So if you are part of a system where you use a medical record, we use Epic, so the registration piece can be quite difficult. So we do also put people through medical record training, those that are doing registration. So if you look up how to start this up, so this was our initial investment. So it's anywhere from $30,000 to $40,000 if you start net new with no equipment whatsoever. So when you look at starting this, this is the equipment that we use that we take on site. Some of this equipment we were actually able to get from other various clinic locations that maybe weren't using the equipment. We just put out mass emails to try to find equipment that wasn't in use. And we were able to kind of gather a good bit of equipment. Some things not ideal. So the EKG machine we have is not necessarily the most mobile, but you know what? It was free. So we just went around and looked for equipment that we could potentially repurpose. And that's how we started the model. Then as we started to get more and more events and more money coming in, net money coming in, then we started to replace equipment as we could. So that seemed to work really well. So I'm going to talk to you like was talked to me. So I'm a provider, but I'm also in administration. So when I want to do something, my administrative leader says, show me the money. We think as providers, we want access to care. We want to do what's right by the patient. But in the end, you got to show somebody the money. So what I'm walking you through is just how to create a business plan if you were to want to do something like this from ground zero. I'm going to show you how to create the business plan to do this. It's exactly what I did. And I presented to my senior leaders and got approval to move forward with this model. And we've had this model in place now for 18 months and has been one of the most profitable models that we have in our division. So the way I looked at the equipment, I showed you the $30,000 to $40,000 breakdown. So what I did with the equipment is I broke it out into buckets. So what is my low priority, moderate priority, and high priority items? What do I know I have to have that I haven't been able to borrow from another clinic location, for example, to make it to an event? So I broke it out like that. And then initially went in and said, OK, here's the high priority items. I need funding to do this. And so I was able to get funding for that. And then I go into my moderate bucket, into my low priority bucket, one by one, as the money starts to come in for the events that we're delivering on. So when you start to engage with employers, there are a lot of questions to ask whenever you want to start to do an event of this nature. So the way that I found some of these employers, so we have various clinic locations and atrium. I have over 90 in the southeast that perform some version of occupational medicine. So what I did is I looked at, all right, what are our employers that utilize us the most? If I look in a month's time, how many DOT exams did they do? How many fire exams did they do? And if it started to look like it bulked up, then those are the employers I approached first to say, hey, how about we come on site and perform that? Or how about you bring your people in bulk to my clinic on a weekend and let's perform these exams in bulk? And that's going to be the most efficient work that we could perform. So that's how I initially looked at employers to me and to say, hey, can we do this work for you? Also, as I'm brought in to consult with employers, I'm asking these questions. What kind of OSHA surveillance do you fall under? How are you making that work right now? How is that working for you? Do you have a vendor that you're working with? How do you like them? And so I really get into the relationship building and then how can we meet the need for the employer, not force them into a model that we already have, but how do we create a model that fits them, that's customized? So we talk about with the employer that's interested in this type of model, really, it's budget. You know, this is especially with our firehouses. They'll come to us and say, hey, we want to do the Taj Mahal of NFPA exams. Great. What's your budget? Yeah, that's not going to work. So then we start to prioritize what can they do and what can they not do? And we, as the medical providers, are the ones that can give that best guidance on what's going to give them the highest yield to make sure that their workers are the safest. It may not look like what the employer came to you initially because we've got to try to keep it in budget. So what's their timeline? So we have employers like the firehouses that will give us, you know, six, eight months, maybe 12 months lead time on they need this event. We have others that will call, like the other week, and said, hey, I need you to come out and drug test 30 people and give me a week's worth of notice. So it varies, we really try to get employers to give us as much notice as possible, but they really don't. They don't plan as well as we want them to, but it's also because they're like us. They're short-staffed, they're trying to piece it all together and still trying to do what's right. So we want to make sure that they have access to some of the things that we need to create an event. So like the first picture I was showing you, do they have tables? Do they have a private area where the provider could be to perform a physical exam that's not in front of everyone? Do they have places where we could set up like a large conference room, where we could put those screens up and then have private areas where we can draw blood work and lay people down and do spirometry? So we ask these questions up front. Do you have Wi-Fi access to power? We've been to events where there was no outlet in an entire room, and we have laptops and things that we have to plug in. So we ask these questions up front to prevent that kind of surprise when we come to set up. We do always ask to walk the space. So if we can get out there, if we have enough notice, we want to go and walk the space that they've recommended. This is especially important if you're performing spirometry or audiograms. Audiograms, obviously, you want to make sure the area is quiet and there's not gonna be a lot of slamming of doors. We use a portable audiogram device. I'm sure you guys went to, some went to that, the lecture, the theater presentation on that. We use that shoebox audiometry device, but you do need it to be fairly quiet to perform that. So when we get to the space, we take, usually we'll take the equipment on site, the audiogram, and we'll sit in the room for a little bit and just let it run scans on the room to make sure that it's not going to set the device off. For spirometry, we like areas that are obviously bigger and open, and we also will wear PPE, but we don't want to be in a closed, tight space doing spirometry. So we ask for a date to come walk the space. We walk the space, we look for where we're setting up the tables, making sure it's private, making sure our audiogram device will work, and then we set a date from there on when we can come up and set our equipment up. So we like to come on site at least a day or two in advance and troubleshoot all of the technology that could happen and go wrong, because it always does. We also ask for a map of the location. So we like to put in our meeting planners for our teammates a map of, okay, well, here's where you park. You're coming into this giant manufacturing area and you don't know where to park. So we like to have maps that show exactly where our folks are going to park, and then we like to have a map of the inside of the building, if possible, to show where the stations are going to be located and the flow of the patients through those stations. So the next step of that, after we interview the employer and we ask those questions, we start the contractual agreement. So we do use a master service agreement, which is a very kind of light legal agreement. It's more just saying, hey, we're going to come on site, perform this service for this dollar amount. We have that master service agreement expire in a year. We learned this during COVID because the cost of labor went up so significantly that we had actually priced ourselves out of some contracts that we had set to expire in two to three years. So now we do annual contracts. So we agree on the services we're going to do. We agree on dates and times. We agree on pricing, and we give the employer ample time to run this by their legal folks. So typically we use our agreement. Rarely do we ever enter into an agreement with a client's own written agreement. Sometimes we will, depending on how big the client is and how big the margin's going to be. But for the most part, we just use our very basic master service agreement. So we also gather up our equipment costs. So like we talked about earlier, equipment can be really expensive. So when you look at how much your equipment's going to cost, you start having conversations with employers and determine how much you can make off of some events. And then where are you going to get your staff from? So in our model, right now we use our salaried staff for the most part for this work. Eventually we want to be able to hire staff to do this, you know, full-time, part-time folks. We use PRN sometimes. But when you're first getting it off the ground, really you just have to use what you have. And that's the model that we did. Now you take your, for your business plan, we're going to walk through, I know Excel spreadsheets make people cringe, but I'm just going to walk you through what should be in your spreadsheet when you're presenting this to your leadership. So this is what our spreadsheet looks like, but I'm going to break it down for you into bite-sized pieces. So this is the direct cost. So when we're looking at direct cost, we're looking at staffing plus benefits. So you would take whoever your staff that you would be using for this work, and really a lot of this work can be done by non-clinical folks that are trained to do it. So if you think about it, drug and alcohol testing does not have to be done by someone clinical. You know, an audiogram, depending on what device you're using, also doesn't have to be someone clinical. Someone who's doing registration, also non-clinical. Fit testing, non-clinical. So you can use non-clinical folks that maybe have bandwidth within your organization to do this work. There is a group at our Wake Forest Baptist team that had a team called the Screen Team. And so they would send out an email to this massless serve within the organization, people who did various levels of work, and they would say, hey, we've got an event on this date. And they would give these folks just easy clinical tasks. So vitals, lab draws, things that would fall normally in their normal day-to-day life. They would let them pick up those shifts and then they would pay them at that rate. So it was a way of just kind of getting everything started before we were able to create a team around it. So it worked really well. So things that you have to remember when you're incorporating time. So we do, we budget this, or we create these models around the amount of time that the staff will be on site, is we remember to include setup and breakdown, which typically is kind of 30 minutes on the front, 30 minutes on the back, depending on how big your event is. And then also, is there going to be any pre-work or post-work? So if you're using the medical record, there's probably not a ton of pre-work because all your questionnaires might be in there. But if you're going to do an event on paper, then there is some pre-work. You've got to print paper, you've got to send questionnaires out in advance. So sometimes there's a significant amount of pre- and post-work. Also, you have to include leadership time. So my dyad partner is Dr. Mary Ruth Hunt. She's boarded in occupational medicine. And so if I'm going to have to use her for consults, so if I need to provide restrictions for a worker, then I'll probably consult her and say, hey, here's what I'm thinking. What do you think I should do? Do you agree with this plan? So then when I go to the employer, I can say, hey, consulted with my supervising physician. We both agree to this plan of restriction. So you have to include that up front. And what I'm finding is it kind of varies based on the work that you're doing. So roughly around 10 to 15% of folks that you're doing these exams on, when you're doing them in bulk, are probably going to have some kind of restriction. Maybe something easy. Maybe you just need to get their blood pressure clarified, diabetes clarified. But some of them, about 10 to 15%, will end up having some kind of restriction or need additional information. So you have to set the stage with the employer for this, because they think you're coming on site, you're going to clear everybody, and then everything's just going to go back to normal, and that's just not the case. So I try to set the expectation that about 10 to 15% of the time we might find something, and we may have to do something about it. So that really does help to get ahead of that a little bit. Supplies also need to be involved in your direct cost. So if you're doing drug screens and you have to take drug screen cups on site that you had to pay for, you have to incorporate that in the cost. Any folders or paper that you're bringing on site, you have to incorporate that in the cost. So these are supplies that you would use up during the event, not necessarily the startup costs that we talked about at the beginning with those pieces of equipment that you would have to buy just to get started. Mileage is also included in your direct cost. So as you're putting together this business plan in the direct cost, these would be all the components that you would want to make sure are included. You definitely want to identify what radius, initially, that you want to be involved in. So we have some events where we're driving a couple hours at a time, but the further you drive, then depending on the event time that the employer wants, you may have to provide lodging, and we really try to avoid that because that really racks up the cost, and that cost does get passed on to the employer. So it's just something to keep in mind. You probably want to identify what your radius looks like, unless you really want to get into lodging cost. Next, you move into the indirect cost. So this is, if you're using a brick and mortar, you would want to incorporate your overhead cost in there. I think that's around 7%. Now, when we do these events and we're going on site to employers, my goal is 50% margin. So that, I guess, is all going to depend on what your financial folks say, but if I'm doing an event where I'm taking a team out of their normal environment and bringing them into a net new environment, I need to make sure it's worth it. So typically, about 50% is what my margin looks like. If it's a long-term relationship that I'm looking to get with an employer, so maybe there's discussions around an on-site clinic. Maybe there's discussions around putting a nurse out there. So if there's bigger discussions going on, then maybe I'll drop the margin down so that I could continue to develop that partnership, but I don't go below 22% because you are really, I mean, it's an inconvenience to take all the equipment on site, break it down, and pull it back. So that's typically how I look at it, but of course, your financial folks may say something different. So lastly, in your business plan, or in your pro forma is what we call them, so it's your startup cost. So in this section, again, it does not include that initial upfront cost for equipment because that equipment would be used for multiple events going forward. So this startup cost would be if you have an employer that wants you to come on site monthly to do a particular service, and you're going to purchase equipment to stay at that location. So that would be where the startup cost would be incorporated. So for example, we have employers that we do hearing conservation for. So we keep an audiogram there at that location that the employer contracts with the vendor to have, and we use that equipment to perform the service. So that would be part of the startup cost if I was bidding on that employer, which is where we would run through this spreadsheet together. So does that mean we need laptops and scanners that would stay at that particular employer location because we're coming out monthly? Then that would be incorporated in the startup cost section, but not that upfront equipment cost that we would take from employer to employer to employer. So now that we've done all of that work, all the not fun work, which is spreadsheets, business plans, talking to the Excel spreadsheet folks, now we're ready to get started with our event. So you can use all of that information up front to really build this plan and present it to your leadership as something that you want to try. And then going forward, that would be how you would look at every individual employer client. So it took me about six events to pay off all of the startup costs for our equipment. So that was getting the $40,000 worth of equipment. And it took six events because we had one big event, and then we had a couple of smaller events. We really haven't engaged in an event greater than 250 yet because there's so much logistics that goes into that. So we're kind of staying in that small to moderate range. We definitely want to get into the bigger events, but honestly, if you get into the bigger events, sometimes you lose some of that personal connection. And the whole goal around this is to create partnerships. So getting started, we talked a little bit earlier about the team. So how do you build this if you're starting from the ground up? Well, you've got to use your people. So my role is a director over a region, but I'm the one that goes out and performs all of these services right now. So it's my idea. I better get my hands in there and do the work. So in that way, I can figure out what's working, what's not working. How do we become more efficient? What else do we need to be successful? And how is the team working together? And what additional resources does the team need to be successful? So I definitely recommend the leaders jump in from the beginning. When you do anything new, I prefer to be on the front end because if it's going to fall apart, I want it to fall apart on me, not on my team. So leaders jump in. You can use a PRN team. So if you have a good PRN pool, you could always pull from them. Who are the underutilized clinic staff that you have? So if you're working in an OccMed clinic, I can tell you right now, one of my clinics, I've got a CMA that is underutilized. So she will start doing events here in the next couple of weeks because our volumes decreased throughout the summer. So she's going to be performing those functions. So look around and see who has some bandwidth and you get them experienced in this work. You also leverage non-clinical people. Obviously the cost usually is a bit cheaper and then you wear multiple hats. So I went to a drug screen event the other day and I was the one performing randoms on folks. You wear multiple hats, you get the work done. It doesn't matter what your license is or what your title is. The job to be done is to take care of patients and employers and that does not matter who you are or what your title is. So getting started. So talking about documentation. So you have some options, right? Occupational medicine, for some reason, we just love our paper. We're very attached to it. It's part of our identity. But honestly, and just, it's true. It actually works really well for this model. So taking paper on site, you don't have to worry about Wi-Fi connections and power outlets and things of that nature. Now, if you do paper, you can't see the patient's personal medical record. So sometimes that doesn't matter. So if you don't have access to an epic or sorts, then it probably doesn't matter to you. But we do. So sometimes it's nice to have access to that because a patient will say, hey, I don't have my sleep apnea study. Can you pull it? Or I don't have my cardiology report. Can you pull it? And so in those scenarios, it is kind of nice to have the medical record, but the medical record creates additional complexities. So if you're going to do paper, one thing that we found out is that DocuSign works really well. So you can take your questionnaires, put them into DocuSign, and at the end of the DocuSign, you can have it go to a generic email box that's for your team. So we've created that. And then we take those PDFs and then we can push them into the medical record. So it's just a way of kind of being a little bit more efficient with a little less paper. And you can also print those to be on site at the event. But this is a way that you could push questionnaires out in advance if you don't have that ability in your medical record, which we currently don't. When we use paper, we have folders that look just like this. We put patient labels on the outside as shown. And then on the inside, we have all the patient questionnaires in there. We also have a flow sheet where we can go through and check off the services that they've already had performed. Because inevitably, you'll show up to an event and everybody has a time in which they're supposed to present and they all show up at once, every single time. So you just have to be prepared for that. And so then you just farm them out to whatever station is open, and then you just check off the boxes when they're complete. You do want to make sure that you always have your employer authorization if you're going to be billing them directly. And we have every patient sign a third-party release of information. I was listening to an earlier lecture that was talking about how patients need to sign a release. Well, our release has that they understand that the information from that date of service will be released to their employer. They also understand that we have access to their personal medical record and we'll use it for determination. So that's what our third-party release says. That has to be a signature. So either in DocuSign or actual wet signature. Verbal doesn't, you can't do that. So if you use the medical record, you can create templates in the medical record. You know, Epic's got a ton of stuff. AucMed platforms have a ton of stuff. So you can create templates for this kind of documentation to make it a little bit faster. I'll just tell you from experience when we try to use the medical record on site, we're not attached to the network. Wi-Fi's slow, depending on what you're doing. And you're in a, usually manufacturing, you're in a cinder block building. So good luck. So it just doesn't work for us. So we really just reflex to paper. We do take our computers and Wi-Fi. And if we can do some stuff in the medical record, we do. Especially lab ordering needs to be in the medical record. But for the purpose of documentation, it just, honestly, it just doesn't work to date. You know, we still have some work to do around that and connectivity, but you plan for the worst, but you just gotta hope for the best. Like I talked about checklist, you can have a checklist on paper inside the folder, or you can put the checklist on the outside of the folder with a sticker, either way works fine. And then who's responsible for the record keeping? So are we keeping all the documentation? What does the employer want to receive back? Like what copies do they want back? If they want everything, why do they want everything? And then we try to talk them out of that. You know, you kind of just want a health recommendation certificate just saying, are they clear, are they not clear? You really just don't want to have access to things you shouldn't have access to. So sometimes it's just a point of education with the employer to say, you know, here's what you should have, here's what you shouldn't have. Patient still signs a release, so I can give it to you, but do you want it? So we always set expectations with that and educate. So packing for events. You can do this a number of different ways, and we've tried it a number of different ways. What works for us over the past year and a half is we have rolling plastic bins, and we put the, we break them up by services. So we have a spirometry bin, an audiometry bin, an administrative IT office bin, vision, fit testing. So we put everything in a bin that's clearly labeled. We have PAR levels, basically, in a big sticker on the top of the bin, and it has the PAR level of what should be in that bin. So if you were to, you know, use things out of that, you need to replace them. So this makes it so we can quickly, on a dime, show up, pack up, and leave. If we have stuff that's just thrown all over cabinets, counters, and you're trying to pack up, it's really frustrating for our team. We've tried it that way. But if we have everything kind of bulk into a bin of everything that they need, and the PAR levels are on the outside, and they confirm that before they take the bin, it seems to work really well and be efficient. We learned this during our mass COVID vaccine work, where we were having to do vaccines for, you know, 3,000, 11,000 folks. This is a model that worked well, and we've just kind of replicated that, and it seems to be what the team enjoys. We also have packing list. So this would be something similar to what would be on the outside of the bins, but then it goes even further to say, these are the things that you need to confirm that you have access to when you're packing for a DOT physical event. So these should be the bins that you're picking up, and these should be the supplies that are inside. So they have a packing list that they can go back and just double and triple check, because you could be going to an event that's an hour and a half, two hours away from our facility. And if you show up and you don't have what you need, it's really difficult to kind of figure that out on the fly. So we really want to double and triple check that we have everything we need to perform the service correctly. So here's our Hazmat packing list. I just wanted you guys to have a couple copies of what we do. So this is what we use when we were doing Hazmat physicals, drug screens, and general supplies. So when we do an event setup, similar to the picture that you see here, this was one of our fire events, and I have permission to share these photos. So we set up the privacy screens. We have tables and tablecloths. We have label, we label the stations really clearly. So we have big signs on the outsides of the stations that tell folks where they're going. We have a large area, like I said, for spirometry. We have our audiogram tucked away in a room that's not around, you know, a mass group of people and not affected by slamming of doors. Some of the things that we keep on site that you may not think of, these were some COVID lessons. We keep juice, ice packs, and snacks for those blood draw and spirometry stations because those folks bagel, and they do it a lot. So we try to just come prepared for that. You also need a private area for the provider exams. We use massage tables as our exam room tables. They hold 400 pounds. They seem to work really well, and they're very lightweight and easy to transport. We also need, you also need to have a holding area. So a place where you have multiple chairs set up because in that scenario, like I said, everybody shows up at the same time. They just want to be done. They don't show up at their appointment time. You just want to make sure you have a place where they can sit and hang out. And then a copier. So depending on what the employer wants at the end of the event, you need to make sure that you're able to make copies and get that to them in a timely fashion. And then we develop a run of show. So the run of show we typically discuss before the event starts. So we have a huddle, which is maybe similar to what you do in your clinics, where you huddle before the shift starts. But we talk about the why. That's what we lead with. All right, the employer, this is what's important to them. They're really concerned about X, Y, and Z. So we start with the why, why we're here, and then we move into the run of show. So this person's going to be at this station and that station if this happens. So somebody bagels in the blood draw or the spirometry, your provider's right there, and you can go get them. So we go through the run of show. We make sure everybody knows where everyone is at all times and then we really try to have a flow manager that's just kind of floating around to be able to hit those important moments where maybe somebody bagels, they can go grab the provider versus a clinical teammate having to leave a patient, which obviously we don't want that to happen. The flow manager also helps to troubleshoot any technology issues, which like I said, always happen. So they're able to make sure that folks can print when they need to and access the medical record when they need to. And they can also communicate back and forth with the employer. So like we talked about at the beginning of the event, we really like to bring the employer into the space and we like to say, okay, today, how would you like for us to communicate any restrictions that might be needed? Or if something were to happen to an employee here, how do you want us to communicate or find you? So we try to get two points of contacts, two cell phone numbers, and really try to know where their offices are located so that we can go grab someone fairly quickly. So we did time studies. So we've been doing events, like I said, for about a year and a half. So we're fairly new to the space. And what we were able to figure out is through time, we're able to decrease the amount of time that we spend doing these services, but the patients are actually very, very happy with what was given. They feel like people spent a ton of time with them when in actuality, we spent a lot less time with them doing this than we would in a clinic space. So they're very happy with this. So registration, this is with an experienced team. Registration's about two minutes, blood draw 4.5, vitals 4.5, vision 4.5. Spirometry, about eight minutes. This is almost triple in a clinic space. Audiogram, 15 minutes. And that, in this scenario, like we talked about, we use shoebox. We deliver the audiogram to the patient rather than letting them use the iPad. Seems to shave about two minutes off of our delivery. Fit testing, about 15 minutes, but we'll do three people at a time. You could probably do a little bit more. Sometimes it's hard when there's language barriers, so three seems to be a good number. The provider exam is variable. My provider exam is shorter than my supervising physician's exam. She is great at making personal connection. By the time she's done with the exam, she's gonna know what the name of your kids are, your dog's name, your mom's name, and what you like to do for your hobbies. She is amazing. So it just varies based on provider, and you just have to plan for that. You have to know the way your provider likes to do things. So then you debrief the team at the end of the event. So what went well and what did not go well? So we try to do that when we're on-site because that's when our best thinking's happening because everything is so fresh. So we really try to see what did they like, what did they not like, what are we going to change for next time as a team? And we also get real-time feedback from the employer. And usually it comes organically. The employer's kind of coming in and out of the event, looking around, talking to people, and the employees just love this. So they're automatically going back and telling the employer how fun this is or how nice the staff is or how professional. So you can survey your patients. So here's a lesson learned. If you give them a scale, it's probably not going to be accurate. We tried this on a bigger event of 150, and on the scale of zero to 10, you know, how did you like the event? And people would score like a seven or an eight, but then all of their comments were, this was the best event I've ever been to. You guys are so much better than the previous vendor. I would change nothing, you know? So the scale was kind of weird. So we dropped the scale and we just asked for written feedback. So we're asking them, you know, do they feel like the event length time was appropriate or do they feel like too long, too short? We ask them what their favorite thing about the event and is there anything that we can change? So we keep it short and simple, and then we share those results back with the employer if they want to see it. So nothing too crazy. So here's some things, some lessons learned, and then kind of pitfalls and then what we've done to course correct. So underestimating the pre and post work time. So we have a company we do hazmat physicals for, and they want everything done on site to include lab draw and the provider physical. Well, the pitfall of that is that as the provider, I'm doing a face-to-face full physical and I don't have any lab results. And out of 70 people, there was one person with normal labs, the rest of them were abnormal. I spent four hours doing lab review and writing lab letters to patients where I could have just done that face-to-face and actually been able to provide face-to-face education. Is that patient gonna go to the portal and read my lovely letter about eating healthy? No, they're not gonna do that. But if I was face-to-face with them, I was able to really make that personal connection, then maybe they would take maybe one piece of the advice that I would provide that day. That's been a lesson learned. I'd rather have a nurse go out even by themselves, draw all the labs, and then a few days later, us go on site and perform the rest of the exam. So then I can have a more meaningful conversation about what the lab work means. Otherwise, I'm not sure I would agree to do it any other way, just because unless I'm gonna charge however much that post-work time was, it took me about three to four hours to do. Not worth it, in my opinion. Other than that, charting in the EMR versus paper. Like we talked about earlier, if you're gonna chart in the EMR, it could take a little bit more time based on what platform you're using. And so you have to do a registration of the patient, you have to chart on them, and then you have to review the labs. So it just depends. It can be faster, but you would need a provider that was experienced. And when you're trying to piece this stuff together and just pull folks from wherever you can when you're getting started, makes it really hard to use a medical record. Paper typically works better. And if you're taking over from a previous vendor that did this work, it makes it a little bit challenging sometimes, and other times, it's really refreshing for the employer. So what we have found is some vendors create fear within our employers. So especially in the fire space, I feel like, they're creating fear over cancer in the fire space and then trying to oversell. I don't appreciate that at all. So it's a matter of just talking to the employer about, okay, well, tell me what your goal is. You want a safer workplace, you want to make sure that we're screening for cancer. We can do that in a medically appropriate evidence-based medicine realm. We don't have to scan full bodies. So it's having those conversations about what's medically appropriate, evidence-based medicine, and then moving away from that fear and moving into this is how we're going to take care of your workforce and decrease your risk. So you want to gather from them what they liked and what they didn't like about the previous vendor, and then you make those changes. And then you need the baselines. So when employers have worked with previous vendors, the vendors can't give me baselines. That has been historically a barrier. I can't get audiograms, I can't get spirometries. When a vendor should be able to produce those things really easily, I just haven't had that experience. So it's been hard to kind of take over. Usually we're having to reset baselines, which is not ideal, but when you don't have it, you can't do anything about that. Also, one of the things that we did, if you're changing from a previous vendor to you taking over this work, is you can present to the employees. So whether that's in their town hall or you record something virtual and you let the employer present it on your behalf, it has been the biggest yield. So if I'm coming on site, I show them in a very brief PowerPoint, here's the equipment that we use to do your audiogram and here's how it's gonna look. Here's what our spirometry equipment looks like and here's quickly how you will see us do a spirometry for you. Here's the providers that you could expect to be on site. So it's a very short PowerPoint and it talks about maybe what the previous vendor did and what changes we're making and why. And when the employees understand the why behind the change, they're on board. And you cut down on so many questions and so much distaste for the change. If you explain up front before you even get there, what the experience will look like for them. So that has been a big lesson learned. Lastly, it's just doing a dry run. So when we've tried to go on site to do something brand new and we didn't do a dry run before, the employer never sees it, we feel it. It creates stress for our team, which I don't want that. I want it to be fun. Events are really fun when you do them. So creating a dry run experience for an unexperienced team helps to increase their efficiency. And I didn't mention earlier, but in that time study, if you use an unexperienced team, you can add 25% to those times. So it really helps to kind of get people a dry run and really understand what the workflow is. And then you get that efficiency. Flow manager, we talked about that. Having somebody that's walking around and troubleshooting everything that could go wrong. And that doesn't have to be anybody clinical. And then not having a provider on site for spirometry. We talked about earlier, these people like to pass out. We have folks that are trained, we use NIOSH trained folks to do our spirometry. So they are delivering a really nice exam. And when they do, people vagal and they pass out. So it's nice to have a provider there because it helps to just eliminate some of that stress. So I know that was a lot, but that is basically my entire playbook on how to start an event from scratch, going on site to an employer location. And I'm happy to take questions. I think we have about 10 minutes before the end of the session. There's no mic, so I'll just project. Yeah. How do you price the initial startup cost on the visits? Great, how do I price the initial startup cost? So when I was showing you that spreadsheet of the direct, indirect and supply cost, I'll plug all that information in. So when an employer says I have, my last event was 68 hazmat exams. They want it broken out, four day events, 16 people per day. So then I look at how long is that gonna take me? So if I break it down into four stations and I can move people through those stations and I have the time study right to say how long it's gonna take per station, then I can time it out. Then I determine how much time and how many staff am I bringing on site. And that's how you decide how much you're gonna charge. And so you do it based on time, not on service. So how much time am I gonna be on site? What licenses am I taking on site? And like I said, this could be non-clinical. If you have non-clinical bodies, if you have one clinical person out there, you're fine. So that's how you could price it. So we have registration people that are underutilized. I can take them out and they can do drug and alcohol testing if I train them. Doesn't take a nurse, RN license. You see what I'm saying? So you can drive that cost down. I really like taking nurses on site. Personally, I love them. They educate, that's what they love to do. So I love taking nurses. But if I can't or if the budget doesn't allow, then I have to look at ways to be creative. But you charge based on time, that time study that I showed you, the amount of time you're gonna be on site, mileage, like those indirect cost mileage supplies that you need to take on site. And then you come back to the employer with, this is what it's gonna cost to run that event. And I add 50% margin to that. Yes. That's the presentation. How do you have the mechanic value to have that blood sugar of 300? Ooh, good question. Yeah, great question. Great, thank you. That's a great question. So in those scenarios, we typically try to connect. So we're part of a big healthcare system. So that's where I'm really lucky. I can phone a friend and say, hey, I've got this patient with this lab value. Can I get them into their PCP today, tomorrow? Sometimes I have to escalate to the emergency room, but rarely. Most of the time I'm able to make a phone call, call in a favor, and then somebody takes them right then. But most of the time, it's not the blood sugars, it's been the blood pressures, for goodness sake. They're through the roof. I mean, out of control. So that's typically where I'm having to escalate care. But because I'm just lucky that I'm part of a healthcare system. So it's phoning a friend or trying to find an appointment for that person. If not, I escalate to the ED. Not ideal. But yeah, great question. Thank you for bringing that up. Yes. I was gonna ask a question. When you do these onsites, it's the previous vendor's. Yeah. Are you finding that with your market, the client is happy to spend less money? So he's asking. Great question. Yeah, so his question's around how do employers feel about when you bulk everything together, you can typically come back with a lesser cost than maybe they would do if they had a previous vendor. Or maybe than they would receive in a clinic location. So normally, I'm more expensive than the previous vendor. So that's typically where I come in at. But where we win is the partnership, the access to a healthcare system, the delivery. So when we talk about and we show them what our model looks like and show pictures of what an event looks like, they're just blown away as to the professionalism of what the team looks like. But I don't always come in underneath the previous vendor. Usually, we're a little bit more than the previous vendor. But we're less than if they were to go to a clinic. When you look at the cost of the clinic exam plus the downtime of that particular employee to go to the clinic, maybe it's a couple days before they can get an appointment, they have services rendered, they go back to the place of employment. When you add that in, typically, we are less. Yeah, great question. Yes. Really nice presentation. Thank you, sir. And I'm not sure if I heard this correctly. Sure. Did you say that you would have them sign a release to give their personal medical information? Oh, good question. So a point of clarification. So we have them sign a release of information that says that the information gathered from their health clearance today can be given to their employer, and we have access to their personal medical record, and we'll use it for the purpose of clearance. Yes. And I have a question on it. Yes, please. Under the GINA, the Genetic Information Non-Discrimination Act, you're not allowed to ask for any information that may have family history. I just want to make sure you're- Correct. Legal standards. Yes. And GINA is not currently part of, in the Southeast, part of our release document. It is part of my Midwest partners release document because of some state laws that follow that. Now, that will be changing coming up soon. So we will include the GINA language on there, and we've worked with our EMR partners to help sequester that information so that it's not face up to our providers. But that's a really great question and call out. GINA's a federal one, not a state one. Correct. So I just wondered- There's some work in the Midwest. Yeah. You're starting to rifle through personal information to not hide something. Right. And we've incorporated not only our internal legal counsel, but outside legal counsel around that very topic. And I have pushed back in similar ways. Some ideas around that would be through using the medical record to prevent seeing those pieces of information. It can be done. And it's really easy. UC San Diego has done a lot of that work. They wrote the white paper on it. So that's the route that we're going. That's a great, great question. Yeah, great comment. Anything else? Great. Oh, yeah. So, very interesting. The question is very practical. Exam. Sure. A medical exam, you have to complete exam. How do you handle hand washing and all that kind of stuff? Great question. So typically we have access to some kind of bathroom for hand washing. So most of the places that we've been have a sink inside the room that we typically utilize for the provider. So that's one of the big reasons why we try to go on site first. We try not to take people's word for it that, oh, we've got a perfect space for you, because most of the time they don't. So we'll go in, we'll look, and we'll say, oh, well, who's using that room? Can we have that one? Because it has a sink in it. So we look for things like that, or we'll get an office space that's right adjacent to the bathroom so that we have a place to do hand washing. Great question. Yeah, that's definitely a logistics thing. Yes. Yes. That's a great idea. I've not thought about that. But we have access to that in our healthcare system. That's a great idea. And we really try to let the equipment be ours. So I'll have to look at how much that costs, because we try not to rely on Midline or somebody to deliver our equipment, because what we found during COVID is they don't show, and they don't meet your timeline. And then that makes you look bad. We don't like to look bad. That's a great point. I'll take a look at that. Anything else? Awesome. Well, thank you so much. I'll hang out here. And then you guys make sure to do your survey at the end so you get your CME. Thank you.

occupational health services

on-site

physician assistant

occupational medicine

bulk exams

employer locations

health information privacy laws

hand hygiene practices

workflow optimization