Hey everybody, welcome to our final webinar for 2022 titled program models, wait, follow-up programs. Thank you for being here today and we'd like to welcome Kimberly Hurst and Tara Henry as our presenters today. The webinar series was created with funds from awarded by the Office of Victims of Programs for the same program TTA project and at this time I'd like to offer the following disclaimer that the opinions findings and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. Chat function can be used for questions posed during the presentation as well as questions that may arise we will unmute you if you raise your hand. Feel free to post questions and we will bring them up to we'll be monitoring the chat and bringing it up to the presenters as we see as they come through. The evaluations for this webinar will be sent out by Amy Valentine by the end of the week and also Sarah's going to have you all introduce yourselves so I'd like to welcome again Tara and Kimberly as your presenters today and I will turn it over to Sarah and then to our presenters. Thank you. Hi everyone, I'm going to go ahead and allow you to unmute so that you can go ahead and introduce yourself. Carolyn, if you'd like to start. Yes, thank you. For some reason I don't see myself at all but so I wasn't sure if I was muted or if you guys knew I was on the call. I'm Carolyn Dolan. I'm from the University of South Alabama which is down in Mobile, Alabama on the beautiful Gulf Coast and we have a campus-based program there that is partially OVC funded and this has just been very rewarding to participate. I'm also on the sub-award. I don't know if everyone knows this or not but I'm also on the sub-award assisting with the TA for this grant and so I'm what my role is is coordinating ECHOs and you may be familiar with the ECHO concept of education. It's continuing education. It's not that particular ECHO. It's not recorded and it's devoted to interesting case studies that help the same to just ensure quality and that they're up to date with current guidelines so it's going really well. We've had a couple of those already and we have six scheduled for 2023. Thank you. Thank you, Carolyn. Karen, hi Karen, would you like to introduce yourself? Oh yeah, hi. I didn't know I was even visible at all but I'm Karen. Hi, Tara. Long time no see. I'm the Forensic Nursing Specialist for IAFN and the TA provider for Spartanburg Program. Thanks, Karen. Nancy? Hi, I'm Nancy Harris. I'm out of New York and am one of the TAs for the TELUSA. Thank you. Paula? Hello, can you all hear me? We can. Hey, my name is Paula Marks. I'm the Forensic Nursing Manager at the SAFE Alliance in Austin, Texas. Thank you. Thank you. Tammy? Hi, I'm Tammy Scarlett. I'm one of the Forensic Nursing Specialists on the grant as well. Thank you. That's everybody on the call so far. Okay, well then I think you guys can get started with your presentation and if people come on later they can introduce themselves in the chat. Great. Well, hello everyone. I'm Tara Henry and I'm going to go ahead and just start sharing the screen here and then we'll get started. If you guys that are on are able to maybe put in the chat just whether or not you are with a hospital-based program or a community-based program to give Kim and I just an idea of your general forensic nursing or sexual assault nurse examiner program model. Just shoot it in the comment section and chat so that we can see that. That would be great. And if you're not currently with a program, actively practicing, maybe just drop a note in there as to what your background, what kind of a program model you're used to working with so that we have that idea. So we're going to talk about forensic nursing follow-up program models. Shay already gave you the disclosure, but Kim and I will just tell you again that this is a presentation produced under a grant that's awarded from the Office for Victims of Crime and these are our opinions, findings, and conclusions, not that of the Department of Justice. So just a little bit about us. Let me introduce myself. So I'm Tara Henry. I'm the current manager of the Forensic Nursing Services of Providence in Anchorage, Alaska. I've been a forensic nurse in Alaska for a little over 25 years and I also am a nurse practitioner and for about 13 years and I worked in two different emergency departments in Alaska, rural Alaska. I worked as a nurse practitioner in their ER and fast track and then I currently work also at a separate from my forensic nursing job at a level two trauma center in their fast track of the emergency department. So that's my background there. For forensic nursing, I have done a variety of positions from manager roles to consultant roles to, you know, throughout our state as well as nationally. So that's a little bit about me. Kim? Hello. So my name is Kimberly Hurst. I am a PA and very grateful to have an opportunity. The work that I've loved doing for the last 20 plus years, I've gotten an opportunity to work so much closer with nursing and NPs as a PA. I recognize that the field is definitely more nursing focused and so I always really appreciate the opportunity to be amongst all of you and be in this space. So I am the founder and executive director for Avalon Healing Center. We're actually a comprehensive sexual assault center, community based, which we'll talk about. I'm here in Detroit, Michigan. So I'm very far away from Tara and in a very different type of environment. I've been a PA for 22 years and have always been in emergency and trauma medicine as well as pretty much that was the same time I was introduced to the sexual assault population and really fell in love with the forensic examiner aspect of care. So I've been doing that. Avalon has been around in the city of Detroit since we opened in like 2006. And so the work that I've done has been kind of both still working clinically in emergency medicine this whole time, as well as running the center starting with some small services and then growing, growing, growing. And I really enjoy opportunities like this to talk about the model of care, which we'll address, but then really excited to share with you guys the follow-up clinic models, because I think that this is something that we're going to see hopefully grow a lot more in the future because we've been able to really see so many benefits from it. So appreciate you guys. With you guys being a smaller group, we were kind of talking beforehand. Please feel free. They are going to use the chat. And then if there's other questions and you feel like you want to ask that are like too much for the chat or like nuanced for the chat, we can unmute you as well and have some dialogue as we go. So thanks so much for taking time out of your days to be here. All right. Okay. So our objectives for today, we want to just go over a lot of programs in forensic nursing and sexual assault nurse examiner programs. They are more acute-based and they don't necessarily have a follow-up program as part of their department where the forensic nurses are doing the follow-ups. A lot of times they're just followed up by somebody else or not done at all. So Kim and I wanted to give you a couple of different types of forensic nursing follow-up exam models as examples of what this could look like for you to consider and the benefits of having a forensic nurse do that follow-up post-medical forensic exam things that need to be done for that patient care so that you can have an idea of what may work for your community and to establish a follow-up program model for you. And then time permitting, we can talk about some case examples of what follow-up post-exam looks like in our different programs and give you some examples and certainly time for questions throughout and also at the end. If you have a specific objective or a goal that you were looking for in attending this presentation, pop it into the chat section so that we can see that and make sure that we are trying to also meet the goals that you had when you were planning on attending this training. So to start off, I think it's a good idea, we'll just go over our different program models from our baseline and then we'll move into what our follow-up program model is so that way you have an idea of if your program is anything comparable to one of ours as a starting point. So an overview of Forensic Nursing Services of Providence, we are a hospital-based or hospital-operated outpatient clinic. So essentially, our clinic is off-site. It's not at the hospital. It's a couple of miles away from the hospital in a standalone clinic. It's actually part of what we call a multidisciplinary center. So we are co-located in our building. We have the Forensic Nursing Services of Providence also located in our same building is the Child Advocacy Center. And then we have a section of our building that has our Office of Children's Services or Child Protective Services, whatever state you're in and what you call your OCS folks. They have some case managers or some caseworkers that are assigned that are housed within our department that respond to their Child Advocacy Center. And then we have the Anchorage Police Department is co-located in our building. The detectives that work the Special Victims Unit that investigate the sex crimes for adolescents and adults over the age of 16. And then the Crimes Against Children Unit of the Anchorage Police Department where you have the detectives that work the child crimes. They are also those detectives are co-located in our building. And then the Alaska State Troopers has their Alaska Bureau of Investigators. They have a couple of investigators depending on the time anywhere from two to four investigators assigned in an office in our building as well. So our multidisciplinary center is co-located with those agencies. Our advocacy agencies that respond are not in our building, but they do respond to our cases. So our outpatient clinic, we have office space for our staff, and then we have our clinic space in there. If we have a patient that they are not medically stable or their medical acuity is not appropriate for an outpatient setting, then we do have access and privileges to go to all four of the hospitals in Anchorage, including the military base that we have so that we can respond to those different hospitals if we have to go to the operating room or to the intensive care unit or the psychiatric ER or whatever department within the hospital that the patient may be admitted to if they can't come to us and we can go to them. We also will respond to the correctional facility that are in our area. If the inmate is a victim and their security or safety for transport is too much of a concern for the correctional department, then we can go to the Department of Corrections, that facility, and do an exam in their medical unit that they have. Or if we're seeing a suspect at the correctional facility, we don't have suspects come to our clinic, and so we would do off-site. We would go into the hospital setting or the correctional facility to do that suspect exam. And then our forensic nurses, we also respond to the medical examiner's office to do post-mortem examinations when asked by the medical examiner or a law enforcement agency investigating the homicide. So that's kind of our setup for us. So we're outpatient, but we're operated by Providence Alaska Medical Center here in Anchorage. So we fall under the women's and children's services of the hospital. We serve sexual assault and physical assault patients, and both living and deceased victims. We do adolescents and adults. The pediatric patients are seen by the Child Advocacy Center, Alaska Cares, which is also owned by Providence Alaska Medical Center as well. So they operate both the Forensic Nursing Services of Providence and the Alaska Cares. We are staffed, when we're fully staffed, we have 18 nurses. It's a combination of full-time, part-time, and registry RN forensic nurse examiners, and then myself as the manager. And then we have an administrative coordinator that is a part-time position. They do four days a week, five hours a day. And then we have our medical director. Now, our medical director is not actually employed by our hospital, Providence Alaska Medical Center. Our medical director is employed by our Alaska Native Corporation South Central Foundation here in Anchorage. And they partner with Providence Alaska Medical Center for our medical director to provide services in a partnership. Because we see a large number of our patient population are Alaska Native or American Indian. And so our medical director is from our Native Corporation and in a partnership. Kim? All right. So I'll talk a little bit about us. So Avalon, you know, we're community-based, so different. It looks like, I think, Paula, if I saw in the chat correctly, I think you are community-based and everybody else looks to be hospital-based. So we do, as we're our own separate 501c3 entity, the community that we're in here, the county that we're in, which is Wayne County in the city of Detroit, it's the largest county in the state. And we've got several large health systems. In fact, we have four major health systems and then one or two smaller community-based hospitals. And so the intent with us being community-based was that when I first, when I was practicing and first took training and started to do this work, there really, there was not anything here. And because we had such large health systems, obviously competing for patients and whatnot, we decided that really a community-based approach was probably the best way to go so that anybody who went anywhere in the community had access to us versus having to worry about one health system, not wanting to refer to another health system because they didn't have the services. So we do currently all ages. So we do pediatrics, adolescents, and adults. We're a 24-7 based program for all the acute medical forensic exams. And then obviously we'll talk in a minute about our follow-up care for the post-assault medical forensic healthcare pieces, but we also do crisis intervention. So I think, you know, Tara mentioned that they have, you know, advocacy support with a partner agency, which is I think how a lot of hospitals do it. We actually have employees that are trained to do that. So we have crisis first responders as well as advocates. And then we also have a whole counseling arm of services as well with alternative healing therapies. We do a lot around community awareness. Obviously, you know, our medical team, we provide the expert witness testimony. We do do suspect exams as well. Kind of a similar space in that, you know, we don't typically bring them to us. We usually go to them. Usually they're in the custody of law enforcement. In our community, we have 47 different law enforcement jurisdictions, plus our sheriff and then our local state police posts as well. And when we talk about where we do these exams, and I'm, you know, I'll kind of be going by the slide, but really like I'm wanting to just kind of have a discussion around what we do. So I'll make sure that I click all the bullet points, but we as a community-based program, and because we're so large, we actually have several different clinic locations that are strategically placed through within the county so that we're never more than like a 15, 20 minute drive. Several of our clinic locations are actually located in some of our larger hospitals, in particular, our level one trauma centers. And we have three that are located within level one trauma centers, different health systems, which we've been really fortunate to have been able to grow and really nurture those relationships with the different health systems. They donate space to us. And so we have three locations in level one trauma centers. We have another location that we partner with our child advocacy center on. Our child advocacy center's name is Kids Talk. We also are able to work, and their child abuse pediatrician helps with all of our injury cases for peer review, feedback, and education. And then we also partner with the University of Michigan, Matt Hospital, and their pediatrician there, she does all of our non-injury peer review. But so then we have a fourth, excuse me, a third, I can't count today, a fifth clinic location, which is located within a medical office building, but very close to several of the smaller hospital ERs that are not our larger level one, where we get more of the volume. That was really the thought process, is that where most of our cases came from. We didn't want patients going real far. And then we have the capability of doing the acute exams also within our main center here. And that's also where we do the follow-up care. So in addition to all of those services, our advocacy staff also provide a lot of legal and personal advocacy. So a lot of court accompaniment and really kind of helping advocate and navigate the criminal justice system outside of just the testifying piece. We do a lot of community education and awareness. We have a training arm called the Avalon Institute that recently just kind of got up and running. So we do a lot of education to the local universities. We have a couple of different medical schools as well as a lot of residency programs. So the hospitals, basically all of the hospitals tap into us to come in, to talk about the sexual assault population. We do a lot also outside of all that around policy and best practice development, both statewide and nationally. We are also the multidisciplinary team sort of lead agency. We host, you know, I think most of you guys are familiar with the SART, right? So we host our SART coordinator as one of our employees. And so we also lead the community march. And really the model that we've worked to develop is intended to be a one-stop shop. So we're actually just about to move into our own center, our own building, and we will have a lot more services available to patients. And when they, so it's kind of, they can come to one place to get anything they could potentially need. And then another thing that we're doing that I think is something from a community-based model that we're finding already really, really helpful is that we're actually doing an organizational trauma-informed certification. And there's not many organizations that are doing this yet. But we're doing this through creating, excuse me, creating presence is what it's called with Dr. Sandra Bloom. And it's really intended to not only ensure that our medical team is truly trained in what it means to be trauma-informed in your approach, but trauma responsive and resilient in all aspects of care. But it requires that all of our board, because being a community-based nonprofit, we have our own board of directors as well as our non-direct service staff. So our like administrative staff also are required to go through the training, pretty much anybody who's a staff individual. So that's us in a nutshell. I think the only other thing I'll add, and I don't know if Tara wants to share like from a volume standpoint, just to give you an idea of what we see. So in a year, we typically get about 1,100 calls for acute sexual assault. So we end up out of those, we end up completing anywhere from six to 800 acute actual complete exams a year. We obviously have lots of patients who decline or only want portions of it, or maybe they're outside the frame of being able to get one, but we're still able to provide some additional services. So that's kind of where we're at there. I mentioned our referral process and that we've got these major healthcare systems and that pretty much everybody refers to us. So not one ER is doing their own exams, they're calling us. And so patients will either, if they're not medically and mentally stable, we go there. We have MOUs in place and our staff are all, have the ability to be privileged to have, depends on the language. Some hospitals will allow us to say privileges, others are just like authorized to come in. So if we have something that's inpatient up in the ICU or somebody who otherwise is going to be admitted, we'll go there. We also respond to the, I mean, we've gone to group homes, we've gone to extra care facilities, any place we basically need to go in order to help a patient receive services, we try to make that happen. We're actually written into the county-wide law enforcement protocol from our prosecutor's office that mandates that the law enforcement agencies make sure that they're providing our information. It's actually, we have a state legislative mandate that any law enforcement officer who comes upon or responds to a victim of sexual assault is provided with their victim's rights, as well as the contact information for any local sexual assault services in particular around the medical forensic exam. So I did talk about the consults or the volume that we see. And then from a staffing standpoint, so we currently have six full-time SANE-A, they're all SANE-A and SANE-P certified, five are registered nurses, one is our nurse practitioner. We have one part-time and then we have three PRNs. We have a medical director who is employed by us. She works in a couple of the level, well, she's now one of the directors of one of the level one trauma centers, and then she works with us kind of part-time. And as I'm sure a lot of you feel, and I think Tara kind of mentioned this, like when you're fully staffed, obviously the staffing models are all over the place. This is the first time where I think, we've been like this now. We were lucky, we survived COVID without anybody leaving. We have a really strong team right now and going to the full-time model for us, especially with our volume, has really made it a lot easier to keep staff engaged up on their skills, the continuing education piece. So this is kind of what the staffing model we've had for the last probably three, four years, but we were all over the place before with more, maybe one full-time person and then a lot of PRNs or contracted staff. So we went through a lot of different models before we've kind of found one that seems to be not only great for patient care, but also for self-care for our medical team. And then I pick up, I still see patients from time to time. I definitely, I still help out in the clinic and then I usually cover, or if we have multiple cases going on at one time, because unfortunately that happens, then I get pulled in to help there. And that's us in a nutshell. Can we have a question asking how many advocates you have on staff? So we currently have, oh, you're going to make me count because we just actually hired two more and we have two more starting in January. So we're probably at about 12 to 14 advocates, three of which are full-time first responders. Like that's their primary job. Anybody else that does advocacy work or counseling, they're all mandated to also take call, but they do it much less frequently, right? Like maybe I think it's like one weekday every two weeks and one weekend every three months because we've been able to kind of build the bench a little bit. And they always have a backup person as well. We here in Anchorage at Forensic Nursing Services, we see about, I didn't mention that. So Kim, you asked me to ask her about our volume. We see about 250 to 350 sexual assault victims. We haven't tracked our physical assault ones. We just expanded to physical assault, routinely seeing the physical assaults about a year ago or so. And so we haven't, we don't see a lot of those. They're still primarily sexual assault. But we do have what we call a forensic nurse triage line. And that is a 24 seven triage line for medical providers around the state or law enforcement or even advocacy agencies to call us. And they have access to a forensic nurse to get guidance on what do I do with this patient or how do I access your services? And so we get calls 24 seven from a lot of physicians, a lot of nurses and the ERs around the state or primary care clinics. I have a patient here that was sexually assaulted or physically assaulted or strangled. What do I need to do with them? And so we have that forensic nurse triage line. And then some of our rural communities, if they don't have a sexual assault nurse examiner program or the weather's bad and they can't fly them into the nearest program, then they can call our forensic nurse triage line and our forensic nurse will walk them telephonically through the exam. A lot of that is our physician assistants or nurse practitioners that are in rural medical clinics in Alaska and they don't have access or have the ability to send somebody in or the patient doesn't want to leave their village or their community to go to the nearest hospital. And so the forensic nurse triage line nurse will talk the PA or the nurse practitioner through those exams over the phone as well. So, but that they are not a separate, they're part of our regular staffing, those same nurses that manage the forensic nurse triage line. They also do clinic work as well, just not simultaneously. It's a separate shift that they signed up for to be able to do that consultation and triage for them, but they are part of our 18 staff. So- And I'll just kind of add like, so we only just from a service standpoint, we pretty much just do sexual assault. And then obviously we see a lot of non-fatal strangulation in the context of sexual assault. It's kind of part of our strategic plan that we would love to be able to branch out into IPV and then non-fatal strangulation without the sexual assault component, but our volume is of such that it would be a little overwhelming. So we have some capacity things to work through before we can get to that space, because right now there isn't anything. And obviously we see a lot of SA within DV. And so we know there's a huge need. So hopefully at some point there'll be some additional funding and our ability to grow the staff to be able to do more than just primary sexual assault. Yeah. Great. So a little bit about our funding sources. This is always the big question, right? How do you fund your programs? So at Forensic Nursing Service of Providence, to be honest, we have very minimal funding sources. The vast majority of our operating cost is absorbed by the hospital or donated, if you will, of their time. We do get our local municipal law enforcement agency, Anchorage Police Department, and then some of our state trooper funding. We do, between the two of them, we might get 350 to 400,000 of funds a year for our program. The majority of that comes from our local police department, our Department of Public Safety, may or may not have extra funding that year to give us. So some years we have no funds from them, and some years we have $10,000 or $25,000 that we get from them. So that is really year dependent. But our local Anchorage Police Department, the Anchorage Assembly, Municipal Assembly will allocate funding to us for the Anchorage Police Department cases that we see. But otherwise the vast majority of our operating costs are, we don't bill for our services and the hospital is absorbing that cost. So it's certainly a financial loss there. We did get a OVC grant that was, it was actually awarded October of 2021, same that many of you are on. And we started it here in 2022. And that grant funding was to fund a forensic nurse case manager and a part-time night shift nurse. So two of our staff are now funded with using that OVC grant. Otherwise we don't have a lot of funding. Kim? Yeah, so I'm just gonna mention, I see that Paula had put a question in the chat that I'll just answer really quick and then I'll move into this. And she just had asked how many sites do we respond to? And I think we missed that question, but I did mention, so we have technically six different clinic sites. So if we wanna, we can talk more about like what that looks like. We typically always have a primary and a backup on call. So from that standpoint, that's how we're able to manage so many different clinic sites. Just to wanna make sure we don't forget questions, but so for our budget, so very, very different, right? Like, so I went to school to take care of patients. I did not go to school to run a nonprofit or to write grants or to manage grants. But when you love something enough, you just figure out a way to make it work. And so we now have a lot more staff to help me with this, but we have about a $4.5 million budget annually. That's a, most of that is a combination of federal and state grants and funds. By most of that, I say probably 75, 80%. So a lot of grant writing. And we, you know, I have two development people on staff. I've had only one for a long time, it was just me. About four years ago, we finally got some funding to bring somebody on. And then we literally just hired a second development person to help really expand our private donor base, our foundation grants. And so now, well, in addition to that, I have a grant writing team of two really amazing grant writers that we engage with as well. They've been a huge help and have taken a lot of that off my plate. So I can focus on programming and patient care. But, you know, we're also, and this is something that I will probably hope I never have to really do again, and that's a capital campaign. And that is a very large capital campaign of almost 10 million. We are currently in the silent phase. We're about 4 million in, and we've been working on it for about a year and a half, like not the smartest thing to do to start this and then have the pandemic hit. But, you know, we didn't know that was going to happen when this started. So from our standpoint, you know, it would be great to have the hospital absorb some of those costs. We definitely have great partnerships with the hospitals. They do a lot for us in kind. We are going to be working with them though at this point. The amount of care that we provide for their patients is one of the sort of business models, if you will, to sort of go to them to ask for some additional support. And we are, so we have a state fund that basically takes a percentage of dollars, it's legislatively mandated, that takes a portion of dollars out of, basically it's kind of like a VOCA model where it's like taken out of like different fees and whatnot. There's like a pot that we get a certain percentage every year that helps reimburse for the acute medical forensic care. When it comes to the follow-up care, those criteria for us to be able to submit reimbursement through that fund become a little bit more challenging. And crime victim compensation is an option, but they're always a pair of last resort. So one of the things that we are just doing now, so stay tuned and I'll fill you in later, is we are looking to be set up to be able to accept insurance for those patients who have it. We would never charge for our services if, you know, we would still provide services if the patient didn't have insurance, we would not be collecting co-pays. And if any of like the reimbursements we receive are not like what we billed for the insurance, then we do have the avenue of using the crime victim compensation fund, or we would just write it off as a free care. But we're looking to try to find some different earned revenue models, because that is definitely one of the struggles as a community-based program is where are you gonna get your funding? So while the hospital has its pros and cons, definitely the community-based side of things does as well. And that's what really impacts, I think, a lot of programs in their ability to handle the follow-up clinic, because there are funding sources usually within most states that are willing to help in some way, shape or form around the acute exam. So it's that follow-up piece that is on the newer side, number one, I think, and number two, people don't think about what happens afterwards, right? They're only really thinking of so much about like the evidence collection and documenting the injuries and that kind of a thing. So I think there was a question maybe. There's a question about having the PowerPoint later. Oh, okay, all right. I was trying to ignore it. All right, okay. Any other questions if you have about our baseline program model, just pop it into the chat. Otherwise, we're just gonna start talking a little bit about our forensic nurse follow-up model. So the way this looks for Forensic Nursing Service of the Providence, we do non-genital and anal genital injury reassessments to assess the evolution or resolution of the injury. And that depends on, you know, the timeframe is gonna vary, it's gonna be case dependent. In general, if we are seeing somebody who's been strangled, then we're gonna see them about 48 hours later, and then we'll see them again in one to two weeks after that. If it's not a strangulation, but it's a non-genital injuries that we want to assess them again, it's gonna depend on, are we trying to assess them because we need to look at the evolution of that injury? Then we're gonna see them and anywhere from 48 hours to up to, you know, five to seven days later. If we're there to assess the resolution to make sure that their non-genital injuries are healed, then we're going to give them a couple of weeks before we see them back to assess them for their non-genital injury resolution. Anal genital injury reassessment, again, the timeframe we're gonna look at is, again, depends on the extent of the injury. Occasionally, if there's a really significant trauma, then we're going to do more frequent follow-ups assessing them in a couple of days and then in a week to two weeks later. If we are just looking to be able to assess the resolution of that injury, or if we are looking at, you know, not really sure, is that an injury? You know, this area is a little bit red or it looks kind of swollen, or there's a finding that we're not sure of and we want to reassess that injury or that finding to see, is this something the patient normally owns? Is this normal for them? So we don't over-call an injury or miss-call an injury, something that is, you know, a disease process or normal for them. Then we would see them back anywhere from two to four weeks later. And sometimes we'll see them further out depending on the extent of the injury. If they had to go to the OR to have an anal or genital injuries repaired, then we'll be following them a little bit more often until that injury is resolved and we don't need to see any additional findings for them on that. And then we will do a three-day follow-up phone call to them. So we basically are checking in at three days, a 72-hour phone call. How are you doing? Did you take, you know, were you able to get your prescription? Are you still taking the medicine if we sent them with a prescription? Were you able to get in, if we made a referral someplace, were you able to get in to see that person? You know, where are you at for housing right now? How's the support at home going? Wherever, you know, you're at. So we're checking in with them. Do they remember everything from the exam? Do they have any questions about that? Reminding them they have a follow-up coming, reminding them that we'll be touching base about lab work and just a general check-in with them to see how things are going at that three-day follow-up phone call. And then we also will have phone calls. We give them the option when they come in because we do full labs on them. We do gonorrhea, chlamydia, trichomonas, HIV, hepatitis B, hepatitis C, and syphilis testing on all of our patients. And so we'll give them the option of, do you want to be called when each result comes in, or do you want to be called, you know, when all of them are in and then give you the results? And so depending on what option they've chosen, we'll be giving them calls to let them know what their lab results are. Typically, if it's a positive lab test, then we're going to call them right away to let them know. But if they've opted to be notified all at once and the results are negative, then we'll wait. It maybe takes a week or two to get all of our labs back. Then we would call them, you know, a couple of weeks later. But depending on the situation, we'll make those lab result notification phone calls. And then we also will touch base with them the day or two before their follow-up exam is to remind them of their appointment. Do they need to reschedule their appointment? Is that still a good time? And then we also wanna find out, do they have access to transportation? Do we need to help them with transportation to get them to their appointment and back to wherever they're going so that we could arrange that? If they need assistance with transportation, then we'll give them the plan, an hour before your appointment, we'll call you, we're gonna send you a cab and we'll pay for the cab when it gets to us. And those kinds of arrangements that we will make for them. And then any referrals, if we see something on our exam that we think that they need a primary care follow-up on or they need some mental health, we generally want people to follow up for mental health, but if we have a patient that has a history of suicidal ideation, they may not have been actively suicidal at the time that we saw them, but given their mental health history, their past attempts at suicide, we're gonna wanna get them into somebody to see them because we know that sexual assault can trigger a suicide ideation response as well post-assault. So do we need to get them into some services? And then any specialty providers, do we need to send them to an ENT doc, an infectious disease for HIV follow-up? Who do we ortho if they have a orthopedic injury? So we can make the referrals to those different specialty providers in town for those patients to follow up with them. Now, all of these phone calls, all of our follow-up exams, all of that is occurring, historically has been done by our on-duty forensic nurse examiners. So whoever is on duty that day is the one that's tracking this, making those calls, doing those follow-up exams in amongst trying to do all the acute cases as well. Since we implemented a forensic nurse case manager in July of this year, that forensic nurse case manager now is full-time and they do all the phone calls, the monitoring, tracking of the labs, all the referral processes, and can do the non-genital injury examinations as well, depending on the timing and what the on-duty nurse has in place. And then we have, with each patient contact that we have, whether it's a phone call or it's in-person, we do mental health screening to see, are you having any nightmares? How are you eating? Are you having, how are you feeling? Are you suicidal, having suicidal thoughts? Any, all the mental health screening to see, what's that acute trauma response in those first four to six weeks after that assault when we're touching base with them so that we can help assess what we need to do for them or what kind of referrals do we need. A couple of questions here, let me answer this. Do you refer out mental health counseling, HIV testing, and immunizations? So we do refer out for mental health counseling. We have a great relationship with our, with South Central Foundation, which is our Alaska Native corporation in town that I was telling you about. And so they have behavioral health clinicians and we, for Alaska Native patients, we will refer to them and we can call them up and say, hey, we have this patient. It's a customer owner, joint patient of ours. Can we get them in to see you? Our non-Native patients, it's a little bit more difficult, but we will refer them out to counseling. We also make sure we're referring them to our advocacy agencies as well. Our HIV testing, so we do rapid HIV testing onsite and then we send out for the conventional HIV for confirmation. We start them on NPEP and then we have agreements with four infectious disease providers in town to make referrals to them. And they will see our patients within three days of us seeing them to get them started on, for the remainder of their prescription and to follow them for any lab work or any ongoing follow-up that they need for the HIV prevention. And then the immunizations, we will send them back to their primary care provider or help them establish with a primary care provider if they need to have some type of immunization follow-up. And then Paula says, do you do STI labs at time of exam or follow-up or both? Yes, so we do all of those STI labs at the time of the exam. And then if we see them back on, when we see them back for their follow-up exam, if they're symptomatic or they feel like they've been re-exposed since the initial exam and they would like to have testing, we will offer them and do the testing again at their follow-up exam, if it's something that they are asking for or the nurse sees something on, it's like, oh, four weeks later they have a discharge or there's something going on that we feel like a new exposure may have occurred and then we'll retest them then. And does your state provide any funding for NPEP? No, no. So that's certainly a challenge and we can talk about that a little bit later when we talk about some of our challenges, Carol. So we'll park that question and then Kim and I will talk about how we're addressing that when we do our, a little bit later in the presentation. So a lot of ours is fairly similar. There are some minor differences, but so we do non-genital and anogenital injury reassessment for evolution resolution of injury identified at the time. So when we do the follow-up exam, so like I mentioned, we see for the acute medical forensic exams, we see zero and up, but because we have such a close partnership with our Child Advocacy Center and we're really, really lucky to have an amazing child abuse pediatrician, she does most of the follow-up. We refer directly to her. Typically Child Advocacy Centers will take referrals from like CPS and law enforcement, but because we've got such a great relationship, they will take direct referrals from us as well. And so that's that piece, but for the follow-up model for us, we do not do the pediatrics or to the adolescents at this point, we do 18 and up for the follow-up. We're working to probably look at what that looks like volume and capacity wise for adolescents as well. But as of now, because we really only started the follow-up clinic to get that started. And so our NP runs the program and then I come in and help. She was gonna have her kind of co with me to be able to ask questions, but she's really, she's got, what's a good thing. She's got a lot of patients scheduled today. So, but we do, from a timeframe standpoint, sometimes just like what Tara was mentioning, sometimes the timeframes will vary a little bit, but for in addition to, well, so non-fatal strangulation, we'll definitely make sure that there's follow-up between three to seven days. It just sort of depends on the patient's schedule and how we can get them there. We provide transportation in our community as I think I heard Tara mentioned is a challenge there. We also have a huge issue with our public transportation system just is pretty poor. And so we do, we, I think one of the reasons we have a successful follow-up program to be honest is because we can provide transportation typically through shared rides or cab or bus, but our physical location is such where we're really easily accessible to most of the major freeways, all of the bus stops, but we use a ton of Uber and Lyft. And that's one of the, when we talk about challenges and whatnot, but so I digress, but so the non-fatal strangulation we see in follow-up as well as the non-genital and anogenital injury, those are the averages. And depending on the cases, because basically Michelle comes in and every day looks at the, we use an EMR. And so she logs in and she checks out everything that happened the day before and is able to review injury. And so there are definitely times where we wanna bring patients back sooner or the on-call nurse, because this is the big, one of the other differences in our model is that we have an MP that runs the clinic, that's her full-time gig. And so when our on-call staff are on-call, they're on-call, but we have within our EMR system and just like our intercommunication ability to give heads up or they'll connect with a call the next day and kind of do a rundown of cases from the day before and what some concerns are. And then we do do testing. We pretty much follow the CDC guidelines. This is currently the testing that we do at four weeks, three months, four months, and six months. We do the rapid HIV and rapid syphilis now at six months. We just added the rapid syphilis because we have such a high incidence of syphilis in the city of Detroit currently. We also do a post-assault follow-up call and Michelle does all of those. She also handles the lab result notification calls as well. We have that follow-up exam reminder, reschedule phone call. We do have, aside from Michelle as our director of the clinic, we also have an advocacy position who handles the advocacy side because one of the things that you'll see when we talk about the benefits is that we're able to catch so many issues that probably if we weren't seeing them in follow-up, despite the fact that we have a whole counseling advocacy component of care, things would be missed and slipped through the cracks. And so her right-hand person is one of our advocate directors who kind of helps provide a lot of those additional services so that Michelle can really follow and focus on the medical provision of care. So the referrals, obviously, primary care physicians, mental health specialty providers as needed. And we also do the mental health evaluation and screening. It's always ongoing at every follow-up appointment that we have. And we don't really have any timeframe, even though we may have patients who go through kind of like the whole six-month follow-up, but then they sometimes wanna come back for other services that we're looking to try and like meet their needs because we're in an area where there's a lot of, there's a lot of healthcare disparities where we are. And so we really, and really as it stands right now too, from a staffing model, Michelle is the only practitioner that we have in that space. Our other nurses are RNs and have a little bit of an interest, I think, in the follow-up clinic, but for them, really their passion's the acute side. So Michelle gets it all to herself and really has a lot of autonomy to be able to kind of grow what these services look like, also based on what our volume's looking like. Kim, we have a question here. How frequently or are you offering anoscopy during acute and follow-up and what guidelines do you follow? So this has been something like a lot of programs that we've gone back and forth on. And even though we have a pretty significant volume, we do not typically do anoscopy. They're typically, there's a lot of schools of thought on this. And I think our staff and the work that I've done with the IAFN is, if it's taught us anything, it's that if you're not doing it often enough, your proficiency level, what benefit are you providing the patient? And also what challenges is that when you're really not doing it often enough? And so we do not do anoscopy either during the acute or the follow-up. So for Forensic Nursing Services of Providence, we routinely do anoscopy exams. Our RN forensic nurses will do them. They've done them since 1997 in our program. And our protocol for the acute exam is if there's been anal penetration or if they don't know if there's anal penetration but they have anal injury, then we will do an anoscope exam to evaluate the distal rectum and the anal canal. If we've done an anoscope exam on the initial exam, then that would be part of the follow-up exam as well to reassess the anal canal and the distal rectum. So whatever we've done on our initial exam would be part of our follow-up exam process. We have another question. Do you find that Michelle, the NP, if I got it right, is able to handle the patient volume on their own? Is there an aid or tech for support? And do the forensic nurses on call sometimes step in to help? So as it stands right now, Michelle has been able to handle the volume pretty much on her own. And so everybody who comes through and has an acute exam is provided with referral information and asked during the time of the acute exam permission for Michelle to reach out for follow-up testing and they get like a little information sheet or it's part of our brochure. And so out of, you know, the between is 600 to 800 in a year on average that we see in the last year, because the first year was a little touch and go considering we're coming out of COVID. We saw like 340 in follow-up. And so that averages out to a couple of day. I mean, so right now the way that are her structure, she has it currently set up as she sees patients Mondays, Tuesdays, Thursdays, Fridays, Wednesdays are kind of like follow-up. And typically we have like meetings and like standing meetings and things like that on those days so that she's able to attend. And then she will do some weekends. Rarely she'll do Saturdays if patients really, really need her to do that. And then she'll kind of like flex her time throughout the week. So as of now, she's been able to handle that volume pretty well without needing some assistance. But as we move into our new center and we're also looking to really, you know, especially if we're able to start billing insurance and have some additional capacity to provide additional services, we will be looking to do that. In which case I'm looking forward to probably taking up a little more time in the follow-up clinic as well as our medical director. And then the RNs, we have a couple of our forensic nurses who have an interest in the follow-up. We have others who have other interests. So I think, you know, if we needed them to, they would definitely come in and help. We're just not quite yet to that point. Okay. Thanks for those questions. That was great. Okay. So benefits of having the forensic nurse do the follow-up or having your forensic nurse clinic do a follow-up is, you know, the nurse who did the exam, you know, at our clinic, we try, we give the nurses the option. A lot of times the nurse who actually did the exam is the one that schedules the follow-up so that coincides with their schedule. So they can also do the follow-up with the patient as well for the actual injury. So you have consistency of providers, you have consistency in exam technique, you have, you know, just that consistency and rapport. If they can't make their schedule work, then they will, you know, whoever the on-duty nurses at the time will see them. But it gives you that ability to assess and document, you know, the injury evolution and the resolution. It gives you, you know, another time to be able to figure out, you know, is that a normal or abnormal variant? Is this a disease process? Like I said earlier, that we're not really sure what's going on with them. And then we can have that conversation with them about, you know, this is what we thought we saw. This is still present. You know, it's normal for you. Or, you know what, this is what we saw. We consulted with our medical director or, you know, whoever we needed to talk to. And this is our plan for you to have follow-up. And we can then get them in to somebody that they would need to see as a specialty provider when we reassess those findings. So it gives you good consistency from a medical standpoint. From a forensic standpoint, it also, you know, is helpful to be able to show, you know, when the patient came in, these are the injuries, what they look like two hours or, you know, four hours post the sexual assault. And now here they are a week later or two weeks later, this is how they resolve. This is what they look like now. And you have that evolution or resolution of injury to be able to show in the process for, you know, the forensic aspect of it. But we are going to do those follow-ups regardless of whether they've reported to law enforcement and we're seeing them as medical onlys, or maybe it's an anonymous case where they, you know, they wanted a full evidence collection and a medical exam, but didn't want to talk to the police or the report exam. So we, you know, are going to provide the same service for that assessment and documentation and basically kind of using the patient as their own control in being able to determine a normal or abnormal variance. And then it also is a really great opportunity. You know, so many places focus on just that physical exam on that acute initial exam, but we know that there's that whole litany of psychological trauma that goes along with those assaults. And so we're able then when we do that forensic nurse follow-up to assess those psychological response, what's happening to them, how are they feeling, let them know, you know, like what's normal post exam, post assault, that this is something that is normal for them to feel and that it's okay that they're feeling that way and look at their coping mechanisms, what kind of referrals do you need? And they don't necessarily have to go tell their story to somebody else, right? Because they have that forensic nurse that they've already told all those details to of what happened to them. And so that rapport is there, even if they see a different forensic nurse, they've still been to our clinic, we know everything that happened and they are able to talk to us more about, you know, what's happened to them. And then if they need assistance in following up with a mental health provider, it's easier for us to kind of help them pave that way where they don't necessarily have to say, I was sexually assaulted and this is my story. They can use us to make that referral to that mental health person to say, we saw them for this, this is what happened to them, this is how they're feeling now, this is why I'm sending them to you. So it gives that provider that baseline to start that trauma, you know, mental health response to them without the patient having to tell them everything from the beginning. So we can kind of help bridge that service for them. Kim, do you want to? Sure. And Paula, I see your question. Just real quick, back to the, just from a staffing standpoint, Michelle will help out on holidays, because she's a champ. And if we're in a pinch, like we had somebody come off on an early maternity leave, so she'll step in. She did do on-call services for a while in her previous forensic nursing role, but she is primarily with us and doesn't have to do weekends or call like she used to anyway. Okay, so when we talk about additional benefits, right, we, this one kind of goes into what Tara had mentioned as it relates to like really connecting the medical mental health services for the acute long-term and the subsequent trauma. But the other side of the benefits is really sort of aside from the mental health piece, which is huge, don't get me wrong, but like assisting with reconnecting the patient with law enforcement, like their officer in charge, their detective or community advocacy agency. So they're coming back for the follow-up a lot of times, right, with a couple of sleep cycles, depending on when you're going to be seeing them, they're in a better space to be able to hear things and kind of process things and being able to ask questions about, remember you were given these resources, had you done anything with those yet? Do you need any support or help? do you have any questions? Oftentimes we get like, yeah, I did call and he never called me back or like the prosecutor, she never returned my call, I don't know what's going on. So it allows us to then really reconnect with our comprehensive services, which is one of the benefits from the community-based programs. But even I'm sure from the hospital side, you're at least going to be able to probably connect back with your advocacy organization to say, hey, Jane really wants to participate with this particular system and she's not getting a call back. So that intentional follow-up, whereas they might not seek that follow-up out when it's not related to their physical health, right? But the fact that they're coming back primarily for that physical health, that just gives us that other door, like open up that little door for us to be able to touch in about like, well, what about this? What about this? What about your mental health? And then on the other side of this as well is the advantages to when you have, we do a lot of trafficking, we do a lot of trafficking. We're one of the only trafficking, we're the only trafficking provider that does comprehensive, also medical care follow-up, but that also allows us to really kind of address when we're seeing patients who are having history of multiple assaults, we're able to identify that. Whereas if we didn't have the follow-up clinic, it would just be another case, another case, another case, another case. But if Michelle sees like, I'm seeing this person, I'm coming back, I'm seeing them again, like six months later for a follow-up, I just saw this patient before. So it really does offer a great opportunity to kind of connect the dots and almost provide like a safety net in many ways for us to maybe be identifying needs that we otherwise wouldn't recognize them having if we didn't have the follow-up piece in place. You know, with Kim mentioning the reconnecting with law enforcement and advocacy, that's a really great point. And for us, what we will do is we will have before the patient leaves, we schedule when their follow-ups are, and then our advocate is there. And they know then that there's going to be a follow-up appointment for that patient. And the advocacy agency will then schedule their advocates to come to those follow-up exams. So when we confirm that the patient is going to, you know, didn't need to reschedule it, they're going to be here, we'll notify the advocate agency, hey, the patient is going to be here. We're sending a cab or they're driving on their own or whatever. Or the, you know, law enforcement's flying them in from the rural village, you know, back to see us then. So they can reconnect with the advocate again at their follow-up appointment in addition to having the forensic nurse there. We will also notify their detective because they're in the same building with us. And so we'll say, hey, so-and-so is coming back in for their follow-up. Do you need to see them for anything? Because sometimes our law enforcement have been trying to reach the patient and the patient's not been in a space, you know, psychologically that they have wanted to or been able to talk to law enforcement. And so law enforcement may think that the patient is not cooperating, if you will, with the investigation. And so we can let them know, like, when we're all done, we'll let you know. And they can come in and reconnect with the patient again about some of their investigative stuff that they need, if they wish. And sometimes, you know, they'll say, no, we don't need to talk to them again, but the patient may have questions. Or maybe they've called and the detective hasn't called them back. And so we can be like, well, hold on just a second. Let me step next door and see if they're available to talk to you or their supervisor is so that they have an immediate response to their questions as well in that MDT kind of format too. So. And I'll share just real quick, that's probably one fairly big difference between what a hospital-based program could do and what a community-based program could do, depending on funding. So there's a piece with VAWA where our advocates and our medical team has held to these standards as well, is that we would have to, in that situation, ask the patient or the client first, if we would be able to let law enforcement know that they're coming in for follow-up care and get their permission to allow us to even let law enforcement know that we're providing services. There's kind of this extra piece within VAWA dollars right around the confidentiality piece. And so that's like one thing where I think our law enforcement partners wish we could do something like that. And I know our medical team oftentimes wishes we could, because sometimes patients don't know that they want to really participate yet, but if they were to meet the detective, maybe they would decide they want to move forward. But that's one challenge that, while I think that that's an option, definitely, unfortunately, that's not something that our program could finagle without, again, asking the patient to sign a time-release consent to be able to say, hey, Detective Smith, I got this patient coming back. I know you've been trying to reach her, so she's going to be here if you want to piggyback on to like the exam piece. So there are some challenges there in some of those, what in some places would be benefits. For us, it's probably, it poses a little bit more of a challenge. Ken, that's a good point. You do need to have consent of the patient to let them know. And at their initial exam, they are signing consents that they know that we're going to be communicating with law enforcement for their, if they want us to, if they were to say, we don't want you telling law enforcement anything, then we certainly wouldn't be able to to do that. So all of that collaboration is done with the knowledge and agreement of the patient. Yeah, so they wouldn't be notified without the patient knowing that. Okay, I was looking to see, what were the questions? Okay, so challenges to setting up follow-up. So for forensic nursing services of Providence, staffing has been certainly a challenge over the years. I mean, we've always done follow-up since we implemented a sexual assault nurse examiner program, you know, in 1996. So that was built into our response process. And it certainly is, you have to have the staff to be able to respond, to do that. And, you know, so it depends on what kind of program. When we were an on-call only program, then our nurses had to make sure that they were scheduling the follow-ups at a time that they would be able to come in. And see the patient. And now that we're a mixture of full-time, part-time, and registry staff, it's a little bit easier. But we do still have staffing issues related with follow-up exams, particularly because if that follow-up exam or those phone calls are our responsibility of the on-duty nurse, then if that on-duty nurse gets called into an acute exam, then that's the priority for that on-duty nurse. So they're not going to be able to make those phone calls. So that may mean that the patient doesn't get called until four or five days out, or they don't get notified of their lab results, you know, until a couple of days after we have those results. Or it may be that we have to reschedule their follow-up once or twice. And the more you reschedule their appointments, the more risk you are of losing that patient from coming back in for their follow-up exam. So being able to implement that forensic nurse case manager position with our grant funds has been extremely helpful, at least since we implemented that in July, because if that on-duty nurse gets called into an acute exam, we still have our case manager that's available to do some of those examinations. And then we also give the patient the opportunity as to, you know, do you want it to come in at nights? Because some patients are night people, evening nights, and they want to come in at nine o'clock at night for their follow-up. Well, we're 24-7, so we'll have, you know, we'll have somebody come in and do those exams, you know, in the evenings, or weekends, or, you know, whatever works around that patient's schedule. So it certainly is a challenge, though, if you are trying to have that on-duty nurse do the follow-ups and the acute exams in the same day, so the follow-ups don't have the priority then. Other challenges is patients, the patients, I'm sure everybody has patient populations that they serve more than others. For us, we have a difficult, a lot of transient housing issues, a lot of intermittent communication access with our patients, so that follow-up communication can be really difficult. Maybe the phone numbers they've given us, you know, are to burner phones. Maybe their voicemails haven't been set up, and they don't answer. Maybe the phone number they had was, the phone was lost or stolen by the suspect, so there's, you know, or they just don't have a phone, and so it's hard to be able to reach them then. We do offer them, if they have a secure email, we can, you know, send them an email to say call us. We don't put any information in the email, but it just depends on, you know, that access to that. We also serve patients from all over the state, so if they have returned to their village, it means that we have to coordinate airline tickets, transportation to come back to Anchorage to see us again, or those phone calls into those rural areas where they may or may not have good phone access for us to access them, so they can be difficult to access. We do try to communicate with our shelters with permission of the patient to say, hey, is so-and-so there, you know, staying? If you see them, can you tell them to call us? And at some point, maybe the shelter staff or the, it will say, hey, you know, this place called for you, and give them the message, and they can call us, you know, so that's something that the patients, if they've given us permission, we can do that. We do have, a lot of our patients have limited transportation to and from their appointments, so we arrange cab vouchers where we'll pay for that. Our advocacy agency will also pay for cab vouchers, so between us and the advocate agency trying to arrange transport between the patient's location they're staying at, or they want to be picked up at, to us for their follow-up, and then wherever they're going from there. If it is something that, if they've reported to law enforcement, and they're in a rural community, then we will work with that law enforcement agency for them to transport that patient back in, pay for an airline, housing, you know, hotel, whatever, to come back in to see us for a follow-up exam, if they've reported to law enforcement as well. And sometimes, we will, if the detective is available, the detective, if the patient is still in contact and gives permission, we can have the detective go pick them up, and bring them in, particularly if the detective has some other things they want to do with them, at the same time as our follow-up appointment, we can coordinate those services as well. With COVID, the detectives tend to defer to having us transport by cab now instead, instead of them doing the pickups, but that has been an option in the past as well. And then, certainly, a trauma response, simply, you know, for the patients, calling them up, you know, sometimes you get a mixed response, even though you tell them at their initial exam that you're going to do a follow-up phone call, sometimes when you call them, they don't want to talk to you, and, you know, they'll hang up, or they just want to talk very little about it. And then, sometimes, you know, asking them questions, and how they're feeling, you end up on the phone for, you know, 30, 40, you know, minutes to an hour, if they're having a lot of trauma response, and they, you know, you're the first person that's called them in three days to talk about this, and you're safe, and they just will unload on you about everything that's going on. And so, it can be really heavy for the nurses, sometimes, when they're doing that, those phone calls. And then, certainly, the funding, again, comes back to, do you have positions funded to be able to see them, for them to come back in? Do you have funding available to get them transportation back to the clinic? You know, those kind of services, you know, what's your funding, and is that a challenge or not? Paula is asking, how much time do the follow-up exams take? We schedule two hours, so they come in, they have time to talk to us about, you know, what's going on, how they're feeling now, and what has happened between the time we initially saw them and now, and then to do the non-genital and the genital exam. So, we usually schedule about two hours time frame. If the advocate, if they want time with the advocate, then, you know, one-on-one time will allow that too. So, we try to, that's not counting our charting time, but that's our patient contact time, we usually schedule for two-hour appointments. So, we mimic most everything, or like ditto, most everything in the challenges department that Tara and her team see. We definitely have, I think, these are a couple of like our biggest, if we had to sort of highlight two of our biggest challenges, it's the difficulty to contact. I mean, we are in a large urban area where there's a lot of people who are in their 20s and 30s, where there's a lot of poverty, and there's a lot of, you know, minute phones, no phones, no access to email or internet. So, that can definitely be challenging, which I think is probably one of the benefits to if you're able to schedule something right, like right when you're there with the patient during an acute exam. However, that's also something that on our advocacy side, when we're with the patients during the acute exam, we do have phones that we can provide to patients who don't, who maybe don't have them, or we can give them gift cards for minutes for their phones. You know, obviously, they're going to use it for whatever they need, and they'll determine what their priorities are. But, you know, our hope is, is that they're able to save a few of those minutes so that we're able to contact them for follow-up. And then, again, in the follow-up clinic, reconnecting them to services, a lot of times then, kind of, we can help provide them with additional resources just around those basic things that some patients just don't have access to. And then, the other side being the HIV medication, the non-compliance, secondary to, you know, cost, and the pharmacy, the pharmacy supply chain issues. I know, I think we were going to kind of talk a little bit about some of the HIV pieces, and I want to be mindful of time because we're already at 423. We weren't sure if we were going to have enough content to take up an hour and a half, but those are some of our biggest programmatic challenges in addition to the things that Tara mentioned. Yeah, the HIV med non-compliance with our Alaska Native population is really good because they have such a comprehensive services that they can provide through the Alaska, um, the South Central Foundation and the Alaska Native Tribal Healthcare Network, that they are able to see those patients, get them in, and financially is not an issue for getting those patients, you know, there's not a financial burden to the patient. For our non-Native patients, it is certainly very difficult for our providers, our infectious disease docs. So, if they don't have insurance, then our infectious disease docs can, will donate their time to see them, and then we'll work with pharmacies, the pharmaceutical companies about getting a decreased cost. We are having a lot of trouble with that in recent time because um, the pharmacy that would basically do that service is no longer doing it. So, we're having to look for alternative options for our patients who are not Alaska Native or American Indian to be able to get that, the rest of the prescription for their NPEP because of the cost. So, we still start them on it and refer them to infectious disease, and they have to work with the infectious disease provider to figure that out. Yeah, so we provide them with their, um, with that as well, and then we have a whole bunch of other, we've got, um, being that it's the city of Detroit with a pretty high incidence of HIV and AIDS, we have a lot of clinics that we work with, several pharmacies that we've worked out agreements with, and then we also work with the insurance companies to try and figure things out. So, Kim, you want to go? Yeah, sure. So, for when, you know, as we're talking about, um, all these different considerations, right, we've touched on the clinic structure and the location, we've touched on staffing, we've touched on the funding and the budget and which services will be provided. So, um, you know, now that we've kind of shared what the two different models look like, um, Tara, if you don't have anything to add, do we want to ask some additional questions or have them, I'm sorry, if they have any additional questions? Sure, yeah, I just, you know, I think, you know, for here is just something to, um, those are probably the core things to look at for you if you're looking at establishing a forensic nurse follow-up program. So, what is your structure, you know, what kind of staffing do you have, what's your budget, and, you know, what are your services? Because you don't have to start with all of these services, right? Maybe your follow-up service is, you're going to start with a three-day follow-up phone call and, and that would be it to touch them with services. Or if you do STI testing, it's those lab phone calls or, you know, maybe you are going to bring them back in for a follow-up exam. So, you know, if you're, if you're looking at establishing a nurse, a forensic nurse follow-up, you know, program, don't get discouraged and think you have to offer all of it at once. So, start small and, and move up and figure out what is within your budget, what is within your staffing, and what is within your structure to be able to do that. You know, um, for us, we've been doing follow-ups in some fashion and it has grown, you know, over the last, uh, 25 years, uh, right? And so, it didn't start out this way. And so, we are now at a point, though, that because of our volume and the amount of follow-up that we are doing, uh, being able to put that forensic nurse case manager into place has been really helpful. And it really is, uh, quite surprising how rewarding it is for the forensic nurse to be able to do that follow-up, you know, because it also helps, uh, give some closure, I think, to the nurse to know, like, this, how this patient's doing, I'm able to still get them into services, I can help them after I see them, and it's not like I just do your exam, document your injuries, your evidence, and I don't see you again. So, it gives some reward, um, if you will, uh, for that nursing care and being able to help, continue to help that patient in those first few weeks after their assault, um, for the, the nurse, um, as well. So, you know, your staff, um, oftentimes, once they start doing it, are, um, happy to do those follow-ups. Um, I think we don't have questions there, just some comments. Uh, thank you guys for all your, um, your attention. Um, Paula, would either of you be available for questions? Um, you know, I, absolutely, I am. Kim, I'll let you, um, answer that afterwards, available for consultations or, or technical support for those who wanted to set up a program. Yeah, absolutely. Yeah, I'll type my, I think, is our info in the last slide? Is our, yeah, okay. Yeah, we're right. I'll type myself in the chat too, real quick, just so if people, you know, prefer that, that's fine too. So, thank you both again for the work that you put into this, um, this really great presentation, and thank you all for taking time today to be with us, and we will see you in 2023.

Forensic Nursing Services of Providence

Anchorage, Alaska

Avalon Healing Center

Detroit, Michigan

outpatient clinic

sexual assault patients

forensic nurse examiners

follow-up care

specialty providers

comprehensive sexual assault services

crisis intervention

medical forensic exams