I'm Dr. David Cochran, I'm the Medical Director of Occupational Environmental Medicine at Dartmouth-Hitchcock up in Lebanon, New Hampshire. And today, myself and my team are going to talk about a high-performing team in occupational environmental medicine. The presentation is going to really focus primarily on the APPs, or APRN and PA, in the clinic and how they make this team function so well that doesn't lack any credit towards the rest of the team. We have an amazing group of nurses, MAs, admin staff, as well as our workers' comp center that I'll talk about in a few minutes. But these two are really kind of the core of keeping our mission going. The other thing I'll say, and I'll say it again later, I'm not taking credit for this team. I inherited this team a year ago when I got to Dartmouth, and I'm going to talk a little bit about our history and how we got to where we are and how I was lucky enough to be able to start working with a team like this. None of us have anything to disclose. So our objectives, as you can see there, we're going to talk about a high-performing team, what that means, and how it would apply to a group of providers in occupational environmental medicine. So what is a high-performing team? In the Harvard Business Review in August of 2023, David Berkus discusses a high-performing team with points of, he talks about common understanding that includes individual expertise, the assigned roles and responsibilities, that everybody knows what those are, and how each team member fits into the team, as well as the communication styles and preferences of that team. He also discusses psychological safety, wherein the team members feel safe asking questions, disagreeing, expressing themselves, and even making mistakes. And he mentions a pro-social purpose, a term that I had not heard before, and this is simply the understanding that every team member understands they're making a valuable contribution to the outcomes, the intended outcomes of the organization. In Forbes in 2021, Ishida Prosak talks about five characteristics of high-performing teams. And you see those up there, trust, communication, which was already mentioned in the previous discussion of it, the different roles and responsibilities again, engaged leadership, as well as the collective goals, everybody understanding what we're trying to do. So with that kind of baseline, let me talk a little bit about Dartmouth Health, a little bit of brag about who we are. This Dartmouth Health is a system network of hospitals, clinics, and other services spread across New Hampshire and Vermont. It's anchored by Dartmouth-Hitchcock Medical Center, DHMC, which is a 500-bed academic hospital that's associated with the Geisel School of Medicine at Dartmouth. There are about 9,000 employees at the medical center, with a little over 1,000 of those employees actually full-time remote, which was an outgrowth of the pandemic. I think we probably all experienced something like that, but we found that it works well to keep a number of the admin-type people full-time remote. Across the entire system is actually 13,000, a little over 13,000 employees across the entire Dartmouth Health system. The medical center is the largest employer in the state of New Hampshire. This is kind of an interesting point there. I do want to note, this is the academic center. Like every academic center, we tend to have our fair share plus of blood-borne pathogen exposure and similar kinds of events. So we do have a lot of students and residents with those injuries, although like most medical centers, our nurses remain the highest risk category for those kinds of injuries. The system is continuing to grow. We're adding Valley Regional Hospital in Claremont later this year to the system. And actually, a couple other hospitals in New Hampshire are starting discussions for a future relationship with us. The OEM clinic, myself as medical director and Paul Boyle as our operations director, have direct oversight of the team at Lebanon, at the medical center, as well as what we call the CGP, clinical group practice. Those are located at Nashua and Manchester, our outpatient centers, and the employee health clinic at Keene, New Hampshire, which is associated with the Cheshire Medical Center. The other facilities and participants in the Dartmouth Health system we have collaborative relationships with, with recurring meetings where we talk about our processes and any issues that come up. What's really unique about Dartmouth Health is that it is a really rural population. As you can see, the medical center, a large academic medical center, sits in a town of only 15,000 people. The largest city across both states of Vermont and New Hampshire is Manchester, New Hampshire, with a population just over 100,000. So you get the sense that it's a pretty rural kind of atmosphere. Total population across the two states is somewhere in the range of two million. The kind of upper northwest of Vermont is UVM, University of Vermont Medical Center, that captures a lot of the care up there. So most of Dartmouth Health's focus is through that central area there. The other key factor that makes Dartmouth kind of a challenging place is New Hampshire has the second oldest average age across all 50 states, and that table shows evidence that it's continuing to get older based on a projected population growth. So as I've mentioned, I came into this team, I did not build it, I inherited it. I want to talk a little bit about a background of how they got where they were. I'm going to start in about 1997 when Dr. Carolyn Murray came on board at Dartmouth. Many of us know her. She is back home seeing patients for us, helping with our exams. When Dr. Murray arrived, it was actually called MHMH, Mary Hitchcock Memorial Hospital back then. Prior to her arrival, the employee health was just a small footprint in the emergency department, just kind of a small little subclinic. Under her guidance, OEM actually became established as a section in the department of medicine, raising the profile of OEM as an actual academic discipline. They then began providing injured worker care to the employees of the medical center, which showed a very demonstrable reduction in work comp costs with the active care of the employees, and they began expanding to clients outside of Dartmouth Health, which continued to grow through about 2020. In about 2005, Dr. Bob McClellan, who I think we're all pretty familiar with, he's actually sitting down here front, came on board. He made his big mark by establishing the Total Worker Health Program, and actually Dartmouth Health was one of the very earliest groundbreaking sites for the NIOSH Total Worker Health Program. He established a collaborative team known as Live Well, Work Well, with the overarching goal to create a sustainable culture of health. The team included EAP, safety, health promotion, the work comp center, primary care, and the OEM clinic. He also served as a medical director of the Dartmouth Health health plan for the employees. Under his leadership, the OEM team established a primary care practice at Hypertherm, which is a local industrial site, and I'll touch on them a little bit more in a few minutes. Dr. McClellan retired somewhere around 2017, I think-ish, 18, okay? And then Phil Adamo came on in the fall of 2019. I don't know if anybody knows Phil. He has extensive experience in medical center management. Unfortunately, the pandemic came, and so he was not able to make any changes in the program. It was really as we all were doing, just keep up with what was going on. So he decided he was done with it as the pandemic wound down, and so that gave me the opportunity to seek employment there. What I think may be unique about our OEM footprint is, as you can see on the right side, as the section chief of OEM, I align under the Department of Medicine up through the clinical leadership. However, all funding, funding for our providers, funding for our care, is actually through HR. So the employee health function reports up to the, what's called total rewards, system vice president for total rewards, which is basically the benefits, who then reports up to the chief human resources officer. So it's a little unusual, but we have a close relationship, as we all know, pre-employment, and a lot of those functions are really outgrowth of that need for HR, so that's the relationship that's been established for our funding and management. So this is our team, and you can see the structure. We have a little bit over 30 FTEs with growth from somewhere in the range of 15 back when Dr. Murray was starting to build out the program. As I mentioned, we're spread across three sites with close collaboration. We have three times weekly huddles across the team, including our remote team down in the CGPs, Nashua and Manchester. Those huddles are full team, everybody, including our APPs, so it's not just the management by themselves doing that. And so we establish a strong sense of communication. Everybody has a chance to say some of those huddles and express what issues they may have going on. What was impressive for me when I came on a year ago is the level of care, the level of OEM function being provided by these two people here, our APRN and PA. I've worked with APPs several times in my career, I've just never seen them working at the level of work that they were doing. I'm not implying that they were exceeding their skill level, but they were certainly working at the top of their range. It was very impressive to see, and that was really kind of the driver in my wanting to do this presentation. So this is kind of a high-level overview of the services that we perform. We do a bit of fitness for duty evaluation of our employees, and Mindy's going to talk a little bit more about that. We have the Workers' Comp Center, which is the direct care in our clinic, as well as case coordination, administrative support for the cases. We have case management with a couple of social workers who support the more complex cases, both our own employees as well as external work comp injury employees. Our work comp center sees about 73 new cases a month, close to 1,000 a year. What's interesting is New Hampshire, like a few other states, is a patient choice state, but despite that, we're able to capture what we think is about 75 percent of our employee injuries because the first report of injury system automatically sends an email notification to our nursing team. Our nursing team reaches out to every employee who has put one of those reports in. We make sure they're seeking care or if they need care. That allows us to kind of get our foot in the door with them and say, we can provide the care in-house, which, as we all know, in-house with your Occ Med team is probably ideal for trying to get people back to work. We offer the usual special exams, FAA and DOT, and I mentioned Hypertherm. Hypertherm is a local company that does plasma, laser, and water jet cutting technology. They actually have a location in New Hampshire, and the other one is Oregon or Washington? On the other side of the country. The other side over there does not have a primary care team, but our team there is one full-time provider split between actually two people, a nurse and an MA. They provide basic primary care to the enrolled employees there as well as a little bit of low-level urgent care to the non-enrolled employees at Hypertherm and a little bit of the employee health function for the company. So I want to introduce now our team. First is Amy and Mindy, as I mentioned, are our APPs. They're going to share a little bit more about the kind of work they do, all the areas they touch on. We're going to start with Amy Cassingham, who is a certified PA. Prior to coming to the DH Occupant team in 2021, Amy worked as a PA for over 20 years in various primary care settings with some intermittent exposure to the occupational health arena. What's amazing about Amy is as well as working full-time, she is incredibly crafty. In fact, she and her husband tapped their own maple trees and sugared their own syrup, and she gave me a bottle of the maple syrup, and that's just one of many artsy things that Amy likes to do. After her, we're going to have Mindy Doobie come in. Mindy is an APRN. About five years of primary care experience prior to coming to the Occ Med team, where she has been working for over six years. Mindy is currently working on her DMP, and even more challenging, she's trying to manage two teenage boys. So I will turn it over to Amy now. Thank you, Dr. Cochran. So I'm just going to kind of go over a brief summary of what our APPs do. That's a picture of Mindy, myself, and our other PA, Gene Strawbridge. We can provide a variety of different services within our clinic, in part because we have a great team within our department, as well as within our organization. We assist in the pre-employment process. We perform examinations. We manage infectious disease concerns. We support surveillance programs, and we perform fitness for duty evaluations. For our pre-employment evaluations, our nurses are screening the employees who come in, and if there's any concerns, they can consult one of the providers. And we can work with our physical therapy department for any post-off or pre-placement screenings that may be needed, or agility testing that may be required by certain departments. If there's a question of an employee's ability to do a specific job task within a department, we can work with the supervisors to perform field tests. And then if there's an employee who can't meet certain job demands, we can work with talent acquisition to find another role in the hospital, so that way they can still find employment with us. And sometimes in the pre-employment process, we find some unexpected findings that we end up managing. So I'll touch on a few cases that I've personally helped facilitate. We had a 40-year-old who came from Haiti who had a positive quantifier on. He was asymptomatic, but his chest X-ray showed an opacity of uncertain etiology. He had a CAT scan. There was a loculated pleural fluid with surrounding pleural thickening. And of course, the radiologist said, well, this could be acute or chronic. It could be sterile or infected. And there was also an unexpected finding of gynecomastia. He was just new to the country, did not have primary care services. So I called up our primary care team within the hospital, got him established with primary care, and also called our infectious disease department, who also consulted pulmonary. So he ended up having a thoracentesis. His AFB was negative on the initial stain, but 23 days later, it did come back as mycobacterium tuberculosis. So he still followed within those departments. Our nurses will also screen for anxiety depression. They can do GAD and PHQ-9s. And if there's any concerns, they can round back with one of the providers. And we can offer EAP services. And we also have a Cobalt program for community support, behavioral health, well-being, and self-care. And then we also have some cases where, again, people coming to New Hampshire, they haven't established with any primary care provider. I had a woman who moved from Florida to New Hampshire, diabetic, did not have insurance, and could only afford her Metformin at the time that she came up. When she came into the clinic, her sugar ended up being 400. So we got, again, a call to primary care. They got her in right away so they could reestablish her medications. And then we do have cases where some people just need a bridge of their medications. So they're running out of their blood pressure medicine. They're seeing primary care in a month. So we can help bridge their medication to get them to that appointment. And if they don't have insurance at the time, we usually use the GoodRx program to help them afford those medications. We do a variety of different examinations. So typical DOTs, we do external client traveler physicals. And then what's unique for our department is CREL, the Cold Regions Research and Engineering Lab. So these employees go to remote areas. They're in the Arctic for maybe six months with very limited access to care. So we're doing very in-depth physicals for them, may also include a pap smear. And then with our workers' compensation cases, we are a self-insured system with direct collaboration with the insurance carrier. So we, as Dr. Cochran pointed out, we have a workability team. They act as our liaisons between the employee, the supervisor, and the carrier. They can assist in alternative duty if the department cannot accommodate the current restrictions. We meet twice a month with the workability team and with Dr. Cochran. He offers guidance to assist us in some of those claims, as well as to the carrier as our medical expert. We've also trained our nurses to do telehealth visits because we do have a variety of different locations that we work out of, and sometimes we can't travel to all the sites. So our nurses are trained to assist in video visits and helping us with physical exams if a provider is in one location and the worker is in one of our off-sites. And then we also have an express care clinic where we manage usual sprains, strains, colds, rashes. We can also do evaluations for any reactions that an employee may have concerning, is this a glove reaction, is this a mask reaction, is this a cleaning product reaction? And our nurses are also trained in certain protocols for UTIs, conjunctivitis, or tick bites. So if they call and they meet certain inclusion criteria, they can just prep and pend a medication to the provider without having the employee actually need a visit in our office. And then we also have a vaccine exemption program at Dartmouth-Hitchcock. We have Tdap, MMR, varicella, flu, and COVID exemption requests that come in, and we have what we call the MIRB, the Medical Exemption Review Board. They're comprised of physicians from our allergy departments, rheumatology, infectious disease, and Dr. Cockrum is our occupational medicine representative. So an employee will request an exemption, will gather that information. As APPs, we may need some further clarifying information from their treating provider. We submit that to the Medical Exemption Review Board, and then they review it and determine if there's any risk to the department for the employee not being vaccinated, and then they offer mitigation strategies. For example, if a flu exemption is granted, then the mitigation strategy may be that they have to mask during the flu season. In COVID, in early stages of COVID, Mindy and I were receiving the PCR test results, and we would directly notify each employee who was positive. We would triage them, determine if they had exposed any staff or patients within their window of infectiousness, and we would discuss return-to-work protocols. In cases where a patient may have been positive in the hospital and exposing staff, we would work with infection prevention and determine the period of infectiousness. We would then work with the supervisor to find out which staff was exposed, and we would notify the staff members and track them during their window. Now, with the advent of home testing, our nurses are basically the ones managing our COVID-positive employees. So an employee will call in and self-report a positive test, and our nurses are doing all the tracings and notifications. Because we work in a hospital, we do have certain exposures that may come in. There was a case of a 19-year-old who visited two clinics in one day at our facility. At the second clinic, they were diagnosed with varicella. So we were able to get the employees' names. We fortunately confirmed that their titers were positive, and we sent them notifications, and then we tracked them for 21 days. In our electronic medical record system, we were able to put an alert in there, so that way, if they did call with any symptoms during that time, a flag would show up, so our nurses would be aware that they were under the monitoring phase. And then for blood-borne pathogens, our nurses handle the majority of these cases. We get about 20 calls a month. If there's any concerns from the nurses, they will have a provider see the employee, and then if the provider has any concerns, we can call Infectious Disease directly. And then we help with surveillance programs. We do have a program manager who handles all the tracking of these programs. So for hazardous materials, there's a questionnaire that the program manager will send out to the employees annually, and if there's any concerning responses on their questionnaire, a provider will review it, and then we offer the employee an evaluation in the clinic for latent tuberculosis. We, again, offer treatment and follow-up in our clinic with the providers, and if an employee declines treatment, they're given an annual screening form with the statement that they can always seek treatment at any point while they're employed at Dartmouth-Hitchcock. Respirator clearances, usually our nurses will review those, and if there's anything that they feel needs a provider for review, they will hand it off to us. And then we may need to consult whoever their cardiologist is or pulmonologist to get some further information. And then DOT exams, we do have some employees who have to have DOT certification. Our program manager, again, manages that, so she'll keep track of the expiration dates and notify them when they're due to come back in for another physical. And then that is a picture of our helicopter, our DART team, so that's the Dartmouth-Hitchcock advanced response team. We do the examinations for the drivers, the EMTs, the flight nurses, they do get agility testing and frequent routine follow-up exams. And then we also have a hearing conservation program. Our physician, Dr. Ian Porter, reviews all those results. And then we also have our fitness for duty program, which Mindy will speak about. Thank you. Thank you, Amy. So I'm gonna talk a little bit about what we do with fitness for duty evaluations. So the term fitness for duty we use is a broad umbrella term to describe an employee's physical lack of ability to perform their essential job demands that they were hired to do for us. It can go from an outright impairment concern on the job to lack of ability to perform their job, performance concerns, everything in between. All of our APPs are well-versed to assess a situation and determine whether or not an employee is capable to perform their job demands without risk to their personal health or the health and safety of those around them. Fitness for duty evaluations can be often requested for uncharacteristic behavior changes, odor of alcohol, concerns of impairment, sudden inability to perform job demands which they once were able to do, staff reports of safety concerns, report of somebody using substances on or off the clock, workability concerns. During a fitness for duty interaction, all of our APPs, it's a very collaborative process. We interact with employee relations advisors, which is part of our human resources team, supervisors, managers, leadership of multiple departments, medical directors of departments, our own medical director and doctor, nurses, treating providers of staff, New Hampshire PHP program as needed, our employee assistance program, house supervisors, an onsite mobile testing service, safety and security team, and at times even a psychiatry crisis team. What's unique about us is the DH clinics span across Vermont, New Hampshire, as Dr. Cochran mentioned, the central hub being in Lebanon. The distance of the clinics, it spans 73 miles. So at times we may need to travel up to 73 miles to conduct a fitness for duty evaluation depending on where the employee is physically located. We do utilize telemedicine and a mobile testing service which has improved the efficiency of our fitness for duty evaluations. So at times if we have an employee that's down in our CGP clinics, we may utilize telemedicine and the mobile testing service to have the testing completed via mobile van and we'll do the fitness for duty evaluation utilizing telemedicine if we physically can't get to them in time to do an onsite evaluation. When we do this, if there's a concern for impairment, we will dispatch the mobile testing service to go onsite where the employee is. The senior employee relations advisor will sit down with the employee and the leadership team to go over the concerns and gather consent to do the fitness for duty evaluation. Once the employee consents for the fitness for duty evaluation, the mobile testing unit, if it's an impairment concern and testing is warranted, will meet with the employee. They'll gather urine drug testing, breath alcohol testing as applicable and then the fitness for duty evaluation will take place either telemedicine service or next business day the arrangements will be made through our leadership team with us to take place to do the actual fitness for duty evaluation. Sometimes at night, so we're not a 24 hour service, so if it's at night, we have a house supervisor in Lebanon which is a group of nursing. They will also have the ability to dispatch the mobile testing service to come to Lebanon if there's an outright impairment concern and again, employee relations is involved to take care of the proper consent obtainment and they'll dispatch the mobile testing service if there's an outright impairment concern and the fitness for duty evaluation will take place on the next business day. The primary purpose for these is, it's always for us to make a medical assessment. What has happened with this employer staff to cause the sudden change in their ability to perform the essential job demands? So we make a medical assessment that the individuals fit to perform the essential functions of the job they were hired to do without risk for their personal safety or the safety of those around them. That is the essential basis of us doing the fitness for duty evaluations. We're not diagnosing, we're not treating these staff, we're really making a medical assessment of what is going on behind the scenes. So I'll kind of go through the workflow of what happens during these so you can kind of see our collaborative process and our workflow. So when our management team gets a call from the senior employee relations advisor, they're receiving the concerns of who the staff is, what their role is, where they work and they'll discuss with our medical director, Dr. Cockrum, you know, I have this employee, this is where they work, this is what they do, these are the concerns and he'll decide, yep, nope, this is absolutely appropriate for a fitness for duty evaluation. This is, we can do this and this is how we should have it done telemedicine, onsite and this is appropriate for APPs to take on or it'll automatically be scheduled with one of the APPs based on clinic schedule availability. Then the APP who'll be managing the case is updated with all the concerns, we'll get the employee scheduled. The senior employee relations advisor then meets with the employee and the employee's leadership face to face to review the concerns with the employee and the employee then consents to proceed with the fitness for duty evaluation. The employee relations advisor then escorts the employee to us in OEM and we're then briefed with the senior employee relations advisor on their meeting. Was anything else brought up during the meeting? How did it go? We then go into the room with the senior employee relations advisor for what we refer to as the soft handoff. They introduce us, they say this is so and so, that you're in good hands, I'm gonna leave you now and then the senior employee relations advisor leaves. Because they're considered HR, they do not stay for the fitness for duty evaluation. It's at that time that we then sit with the employee and explain the fitness for duty evaluation process and what we're gonna do, how it works. We obtain our written consents to access medical records, release information, information that's released is no medical information is released. We only release information that is pertinent to their ability to perform the essential functions of the job. We keep these exams very confidential. We're very protective of our employees and their health information and we try to make that very clear when we're performing these evaluations. We do work on behalf of the employer and because it's an employer mandated exam, if it's applicable to them performing their job, there are certain information that we do have to release but medical information, unless it pertains to their job, is not released to the employer. So we try to convey that to the employee. So we do a full history and physical exam on the employee. We discuss with the employee our findings, our thoughts, what our recommendations are. If we feel it sounds like you're having a medical concern, you've told me this or your records show this, that you have a chronic medical condition being exacerbated, it looks like it's impacting your job. We think you might benefit from taking a small medical leave. This is how you do it. You call benefits, you take a short term disability leave of absence and we show them the pathway of how they do that. And then we make our fitness for duty determination of not medically cleared to return to work or medically cleared to return to work or unable to make a determination if we do drug testing. So if we end up doing drug testing because it's part of the fitness for duty that we're concerned, it puts them on a paid administrative leave until the drug testing results come back. If we are concerned somebody has a substance use disorder, we send them to a licensed drug and alcohol counselor to make that diagnosis. Again, we don't make that diagnosis, we're screening for concerns. So oftentimes we may send somebody to neurology or a specialist or a licensed drug and alcohol counselor for a screening. They get that diagnosis. If they then need to enter a treatment program for something else, again, they go the HR pathway for a leave of absence to do so. When they're ready to come back to work, they again, they'll come back in through us and say, I've been out, I've taken care of my medical concerns, I'm ready to go back to work. We make that reassessment, we medically clear them to go back to the work. They may need accommodations to reenter the workforce, great, we work with HR to make sure those accommodations are in place. And then our goal is to get everybody back to work and functioning so they're successful. We update our medical director as to the case so that he's aware, because he usually communicates with our employee relations advisor on all cases. I have a case to review, which is a medical case that came through for an example. So I had a 33-year-old female who was an inpatient pharmacy technician. She had reported to her supervisor that she had some active medical issues with the tachycardia that was causing difficulties walking long distances. She was getting short of breath and dizzy. Her PCP had written a request for a temporary accommodation that she not walk as part of her job and just be provided sedentary work. They were able to accommodate it, so they pulled her off of one of her job duties, which was delivering inpatient medications. That was working for a while, but eventually her condition was worsening and that was no longer efficient. She was sitting at work, becoming more symptomatic. They found her slumped over at the desk and they had to activate a code white medical emergency. At that time, her supervisor's like, okay, now I'm really concerned, you're not safe. They asked for a fitness for duty evaluation and she complied saying, yes, please, somebody help me. Something is really wrong. She came to me and we did the fitness for duty. She's like, please, here, access all my medical records, find out what's wrong with me, something's wrong. I'm getting tossed around to all these different doctors, cardiologists, PCP, nobody can figure out what's going on. I can barely shower, I can't function. It takes me three hours to get up and get dressed and get ready for work and I'm losing weight and I can't eat and this isn't me. So we went through everything, went through her record, did a full physical exam. She was this tiny little petite thing, emaciated, pale. We did look through her medical record. She had a history of a malignant neoplasm of the lung that had been resected. She had been doing great. We did look through and noted that she had a history of a thymus hyperplasia that was recommended for close surveillance. However, when she moved from Florida to here, it didn't look like there was any active surveillance that had been occurring. It looked like a ball had been dropped. So she'd been seeing so many specialists that she wasn't getting the proper post-surveillance that was needed. So that was a little bit of a red flag. So we were a little worried that maybe, is this a thymoma, is it a recurrence? What was going on with all of her weight loss and symptoms? So she consented for me to speak to her PCP, called her PCP and said, she's here for Fitness for Duty. We've now found her slumped over at her desk because she's so symptomatic. And we really can't have her slumped over at her desk. She's miserable. She's taking three hours to get ready every day. She can't walk. And can you help? We were looking over her medical records. What do you think about possible thymoma? She hasn't had the thymus hyperplasia follow-up and her PCP's like, oh wow, I can't believe we missed that. Yeah, let me connect with her pulmonologist. Let's get her and scheduled her a follow-up and handed her off to her PCP, helped her get her medical disability paperwork follow-up. And so out she went on a medical leave. They did the active surveillance. They didn't find a thymoma. The thymus hyperplasia was fine. They found a new lung nodule though. So she's now on a medical leave. She's getting the care that she needs. She continues to be out. We're hopeful that she will return once her medical condition stabilizes. But the nice thing was I was able to help get her back to her PCP and her specialist and she's getting the care that she needs. She's really incredibly grateful. She actually had to relocate back down to Florida where her family is and can take care of her so that she's not here trying to do this on her own. So that's just an example of a case where somebody was really struggling. She wasn't performing her job and her boss is like, this is a stellar employee. Something's really wrong with her. Can you help? So it wasn't an active impairment but it was a fitness for duty concern. There are other types of fitness for duty cases or diversion cases. So when we have a controlled substance diversion case, it's when we're unable to account for medication. Medication may be wasted inappropriately, may be due to poor documentation practices. Controlled substances may be diverted for personal use, may be diverted for sale. When this happens, we are notified that a potential diversion case is being investigated. We have a controlled substance diversion committee. They sit down, they meet. We have a drug diversion specialist that heads this team and they actually review data from an internal software program and they conduct a closed loop dose reconciliation and this helps them to ensure that all doses of medication are accounted for. They can actually track medication from when it comes into the pharmacy, when it comes out from the pharmacy, to where it goes, to when it's pulled out from the location. So they track that, find out where the variances are and it can actually be narrowed down to a specific individual that has pulled the medication and they can give individualized data on a person's controlled substance behaviors compared to a similar peer group and detect anomalous patterns and documentation accuracy, dispensing versus corresponding administrations, medication usage and handling, action times, mobility, waste patterns and full package waste habits. It's a pretty fabulous package that they use. So they discuss with local leadership, employee relations. They meet with the staff member if it's an individual staff member concern. They review all this data with the person to say these are your habits. This is how you compare to your peers. This is our concerns. Can you explain this anomalous behavior please? If they like the answer they get or if the answer they give supports the data or they are like what you're telling us doesn't really match the data we have, then they'll ask that the person is brought to occupational medicine for a fitness for duty concern due to the diversion. Same process is followed. We obtain the consents, we review the concerns and say you know, there's missing medication, you have some anomalous behavior in your practices. The answer you gave didn't really match so we're doing this fitness for duty. We screen them for substance use concerns. We ask them the same question, you know, did you take the medication? Did you use the medication? And then we will do drug and alcohol testing. And then they are out until the drug and alcohol testing comes back. And in those cases we, depending on the substance, may do hair and nail sampling. Our nurses do the testing for us. So they'll collect the urine for drug and alcohol. They'll do the breath alcohol testing and collect the nail and hair sampling. Any over admission of diversion is reported to Employee Relations, our medical director and the diversion team. And if anybody does admit to a substance use disorder, we do get them right into a, if they have a license, we get them right in with the New Hampshire PHP program for the proper treatment. If they're non-licensed personnel, we do help them through the COBOL or EAP team so that they can get tied into the appropriate treatment program. And that is what I have. I'll give it back to Dr. Cockrum to finish up. Thank you, Mindy. So as you heard, the two APPs kind of do everything that we know that a medical center occupational OEM clinic does, but they kind of run on their own. I'm there to oversight and support, but they kind of keep things going. In the chart on your left, I kind of broke down the kind of major functions that we have in our clinic. The ones at the top are kind of an any provider function, and we can basically lean on these two professionals to keep all of those things going. That allows the staff physician and myself to focus on the physician-required areas, as well as keeps me freer to do all of the administrative oversight. I spent 20 years in the Air Force before I left and then went in the civilian sector. There's a term we use in the Air Force, or actually all the military, called force multipliers, and this basically refers to any resource that allows an organization to achieve its mission more efficiently, more quickly, more effectively. So that's how I kind of see the APPs as force multipliers. I'm acutely aware of the conversations that have been going on for the last couple of days. I will tell you this session was proposed before that became a discussion issue, so this is not a plant by anybody, but the point is very valid that our APPs are a vital and necessary part of our success at OEM. So I started out by talking about a high-performing team and how we need to round back around and see if I can justify why this team with these two professionals meets those definitions. From the beginning, they both garnered my trust. As I was coming in and learning the local politics, local processes, and the extent of my job, I didn't have to worry about the clinic maintaining because they were getting things done and they would consult with me appropriately. Communication, I've talked about frequent huddles. We have a huddle with just myself and the APPs every two weeks privately so we can discuss cases or any kind of issues. Roles and responsibilities, they're very aware of where they fit into the big picture and what they're supposed to do, and they understand the goals and how they play into those. Leadership, they've been fortunate, these two as well as their predecessors, to work under what I consider to be really amazing leaders with Dr. Murray, Dr. McClellan, and Dr. Adamo that really gave them the support and oversight they needed. So as we go forward, we have some challenges, as all places do. Dartmouth Health is a growing health system. We've got to figure out how to integrate across all of those sites so that our OEM product is consistent, primarily on pre-employments and the fit for duties. We want to make sure that every facility has a consistent approach to that. We're trying to regrow the external client base. That, of course, got shut down at Pandemic, which is where Phil Adamo was not able to do that full expanse of stuff, unfortunately, so we're trying to regrow the external client base. I'm looking at some opportunities to collaborate with PT and OT and possibly PM&R. Dr. McClellan had established a presence in what's called the Pain and Spine Center, where as an injured patient would see the surgeon or the pain doc, there would be an OC doc or OC provider in that clinic as well, so they would address the work issues right there at the same time as they're seeing the other specialists. Again, COVID, that kind of fizzled away, so I'm looking at opportunities where we can try and reestablish some of those close relationships. Still trying to define benchmarks best for our clinic. I've been looking for really good OEM benchmarks for a long time. There's always workload benchmarks, which are fine, but all they tell you is how hard you're working, and if anybody knows any really good quality benchmarks that I can use to show, monitor how we're doing for success over time, I would definitely entertain that. And I'm re-looking at total worker health. That's a concept that I had heard of but do not have a lot of personal experience in, but I have found in our shared drive documents from many years ago that Dr. McClellan was working on, and so I'm trying to dive back in those, see if I can learn what it is, and is there a way to reestablish those relationships and that kind of atmosphere at Dartmouth Health. So that is our presentation on a high-performing OEM team. We are welcome any questions or comments. They're like, OK, let's take a look at it. OK, thanks. No problem. I'm sorry. OK, so this is the bean counters, the MBAs that are running the program. This is not for physician-led or anything. So they're like, OK, so how can we make more money? I mean, do more with less. So the PA, and we only have PAs right now, maybe they can start doing drug screens. Maybe they can start doing breath alcohol. They're starting to cross-train, and some of them are like, and they're saying maybe a physician could do breath alcohol. I said, I don't know. When I saw the lecture high-performing, is that too high-performing? Do you guys feel comfortable? I call it being milked personally. Is there a cutoff? I don't know if it's an ethical question or a legal question. I'm happy to do whatever it is for the needs of the clinic. Mindy and I took the spirometry and audiometry testing. So we are providers that could provide that service if there was a need. Fortunately, right now, our nurses perform those functions. But we truly are a team. So whatever I can do to help out the needs of our clinic and our employees, I'm happy to do whatever is asked of me. But our nurses work at a high level as well. So we're fortunate to have them who are also willing to do whatever they need to do or whatever is asked of them. I agree with you. I don't mind you guys stepping in, but they're doing more than stepping in. You've got to own it. See the difference? It's like you're another body to do drug screens and alcohol. You're not stepping in as neither. That's where they're going. I don't know if you feel comfortable about owning it versus just stepping in. That sounds like kind of an organizational-specific challenge. I'm not sure I'd respond if they asked me to do that. I think I'd be saying no. Because while they are willing to support, in fact, Mindy does our Nashua and Manchester sites. And they were down a nurse. When you go down there, you may have to give some vaccines to pre-employments. And she's like, that's fine. I was a nurse in the past. I can do that. So they're always willing to do it. But I tend to want to protect their work to the level of provider work, primarily. Was there a question over here? OK. Thank you. So this is really from Mindy and Amy. And it's kind of two parts. I think the first part is, how did the leadership before Dr. Cockrum really engender your sense of commitment, value, understanding the mission? Because I think that's something that some organizations struggle with. And then the other part that probably ties into it is, so for our nurses, we ask them to get certified as certified occupational health nurses. And I actually do feel, once certified, they can expand their scope. But they're uncomfortable with that. So I'm trying to find ways, because I really feel like I want to empower them. Because they can do so much more. But I think they're scared. So I don't know if you have any answers that can help with either one of those questions. Yeah. So I worked under Dr. McClellan before he retired. And he really supported me being independent and working to the top of my licensure and being comfortable with the decisions that I made and standing behind them. He was really supportive. And that meant a lot. So that when he retired, and it was just me for a little bit before Dr. Adamo came, that I was OK. But I also had the support of the team that he trained and left behind, holding me up. So it was a great environment that I was in, that I became comfortable. And then the pandemic hit. And so Dr. Adamo came on and joined. And so I was able to show him, this is the environment where a team, we all work together. So just being supportive of each other and everybody working to the top of their roles and communicating, collaborating, working together for the same mission. We're all here to help employees, to make sure that employees are safe and successful, thriving in their jobs. It's the key. We all work towards the same mission. That's always been the foundation since I came there, is we're here for the employees. We're advocating for the employees. That's our role. As far as the certification goes, I think you're right. A lot of our nurses are not certified. And I don't know what the pause is, why none of them want to go to the certification. But there is a hesitancy there. I've tried to talk to them about going for their certification. They're starting to think about it. But there is a hesitancy. And I don't know if there's a fear of them being asked to do more once they get it. And I don't know how to break past that barrier. I don't know what the correct answer is. I think Amy sees the hesitancy, too. Yeah, a lot of our nurses came from a primary care background. And so them stepping into OEM was a little bit new territory for them. I find that the questions that they bring to us for either pre-employment, or they have a call that comes in, sick visit, don't know how to triage it, it's basically taking the role of a mentor and encouraging them. You're asking the right questions. Or what about this? Did you think about this? And that way, when they have a case that comes up again, they already have a little bit of that background to know, OK, these are the things that we had talked about before. And then when there are unique cases that come up that maybe one nurse in one clinic had concerns about, we take it to a meeting with the other nurses. So that way, we're educating across the board, whether it's a bloodborne pathogen case and a source was hep C positive. We're rounding back with all the nurses to give them that education and help boost their confidence that, yes, you can do the job you're doing. But I think, like anyone in a career, there's always that uneasiness or lack of confidence. And so instilling that in the whole team is important. Dr. McClellan. So yeah, I'm Bob McClellan. I just wanted to respond to that. So I think all of us had the experience of being a medical student, going into our first clinical rotation, and wondering who it was who was going to tell us what to do. And who was it who was going to tell us how it worked? It was the most senior nurse there, who really knew how things operated. Yes, there were doctors, perhaps, with more medical knowledge. But it was the nurses who made the place run. And so I kind of cut my teeth on occupational medicine in a tertiary medical occupational medicine program at Yale. We saw highly complex toxicological problems, et cetera, et cetera, and learned a lot about that aspect of medicine. But that clinic did nothing with respect to actually running employee health. And so when I moved away from New Haven up to New Hampshire, who taught me, really, about occupational medicine and how to run a program? It was actually a nurse practitioner who taught me, who had been in that program for a long time, understood client relations, understood all of those aspects of employee health and an occupational medicine clinic that I didn't learn in my experience at Yale. And when I moved up to DHMC, same was true. There had been a nurse practitioner there for a long time. Yes, Dr. Murray was there. And she, again, kind of knew a lot of the medical stuff that maybe the nurse practitioner didn't know. But the nurse practitioner knew how to run the program. I think what you're talking about here is a program takes many different skill sets. And one of those skill sets is someone who really understands the basic operations of an OCMED program. Hi, my name is Peter Lo. I'm the medical director of UNC Pardee and pretty new in my role. Thank you for the great presentation of your high-performing team. It was tremendous. So I'm learning the idiosyncrasies of my job. And one of the pressing questions I have is regarding fitness for duty. So when you're doing fitness for duty, do you have decent job descriptions or job analyses? I'll tell you, I found out historically our physical restrictions got removed from our job descriptions a decade ago. And so they don't exist. And we have no HR director. And I was told I can't give any input into the job descriptions until we have an HR director. We have really bad job descriptions. They need to be rewritten. But being that we do all the pre-placements and everything, we have a really good working knowledge of pretty much the essential job demands of most positions. But yeah, they're really bad job descriptions that we have. So how do you handle that, then, in regard to doing a fitness for duty? I mean, how do you? So if we encounter a role that's unfamiliar to us, we really do go back to the leadership and say, what are the expectations of this person's job demands that you're expecting us to assess? We just go right back to the leadership before we even start the evaluation and say, you have these objective concerns. What are the actual baseline essential functions that you're expecting us to assess? And so the leadership, is it HR? Is it director of the? No, it's their local leadership. It's the manager. It's the HR manager? No, it's actually the unit manager for where they're coming from. Yeah. OK. That really helps. Yeah. Thank you for that. First of all, thanks, y'all. I appreciate it. I'm so happy to hear it's not just my organization that has these things. I came in as the, we're 52 clinics, 140 providers, about 100 or so, 120 mid-levels. And I was brought in to kind of, as an Achmed doc, to kind of put it all together. So thank you. This is excellent. Then I was made regional medical director. And I found it's nice to be RMD and be Achmed, because your bonus depends on if you do the job right. So I get to review that. And that gave me a little bit of leverage. But my question is, for the back office staff, because there's so many different labs to run and tests to run, how do you maintain, what program, what protocols do you use to maintain their proficiency? Do you have in-services that you run weekly? Or how do you kind of maintain that proficiency in the back office staff? So as I said, we have full team huddles three times a week. The other two days a week, the sub teams, nursing and admin, have their own huddles. And so their managers, our clinic manager with the admin team, nurse manager with the nurses, will review any issues, do any proficiency training or discussion of processes. And so that's how they address it. So twice a week, very compressed, 10 to 15 minutes, instead of a big block of training. But it seems to have worked so far. Anything else? Oh, yes, ma'am. Sorry. Yeah. Hi, my name's Lynn Carroll from Kentucky. And I walked into a system to where the emergency department is so overwhelmed, and they can't refuse anything. So when it comes to blood borne pathogen exposures or other exposures like a meningitis outbreak after hours, currently we've been using a doctor on call system, but our doctors are retiring. And so now we've got some advanced practitioners taking call for blood borne pathogen calls, and it's one person on call at a time. But we just had a meningitis outbreak of 30 people exposed. Good luck with that on call person. So anyway, we created a collaborative care agreement with pharmacy. So we've got our 24-hour pharmacy at the hospital, and our pharmacist is always present there. And for them, it's amongst their proficiency and their literature for the management of blood borne pathogens. So they stepped up and said, hey, well, what if we're part of your first line for taking care of blood borne pathogens? And that way, the ER is not so overloaded. And then our backup is you. We're part of University Health Services, and I'm an OCDoc. There's a few OCDocs that are part of the on-call team. And then we kind of teach the other OCDocs the current updates for blood borne pathogen management. And then we're the backup. And we work with infectious disease to put together protocols in order to determine what constitutes an exposure, how close you were to their airway, and what was on your face. Was it an aerosol generating procedure? And that way, the pharmacists are trained, have algorithms for reference. And they're the ones that can immediately give that ciprofloxacin for meningitis and determine whether it's indicated, and have us as a back reference to try to expand our reach out. So pharmacy is something that we are now reaching on bringing into that group of expanded areas of practice. And I was just wondering if that's something that you've incorporated in working with pharmacists. And what you feel on that, if there's any OSHA standards that we might be aware of? I'm not aware of any OSHA standards. Other dots and cross-Ts. I think it fits, because it's licensed health care professional acting within their scope of practice. That's the key. As long as the pharmacist is within their scope of practice, I think it's actually a great idea. OK. Thank you. We don't have our pharmacists involved in the bloodborne pathogen. That's a great idea. What we do have are pharmacists embedded in primary care. So they're actually working with, in particular, diabetics. And so they're actually using protocols to manage some of the diabetes care, assisting the primary care providers in insulin management and whatnot. That is a great idea with adding them to the bloodbornes. Thank you. So that's something I have to bring back, if you want. It was so good. So thank you. Thank you. Thank you all for your attention. We very much appreciate it. Thank you.

Dr. David Cochran

Occupational Environmental Medicine

Advanced Practice Providers

High-Performing Team

Dartmouth-Hitchcock

Collaboration

Communication

Fitness for Duty Evaluations

Total Worker Health Programs

Bloodborne Pathogen Exposures