All right, well, I think we can go ahead and get started. That number is kind of slowing down here on my end. Well, welcome everyone. My name is Sarah Jimenez Valdez. I'm one of the project managers here at the International Association of Forensic Nurses. Today's webinar, as you can see, is titled Making the Business Case for Forensic Nursing Care, which is made possible with grant funds that are awarded by the Office of Victims of Crime for the same program TTA project. I'm gonna ask that you bear with me as I always do so that we can cover a few items before we get started, which includes a couple of disclaimers. Ashley, if you don't mind going to the next slide. So this presentation was produced by the International Association of Forensic Nurses under the grant. Actually, this is not the grant one. Can you go to the next one, Ashley? I think it's a little out of order for me. So it's produced by the grant number that you see here on the screen. The grant was awarded by the Office for Victims of Crime, Office of Justice Programs, and U.S. Department of Justice. 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. And if you can go back to the other slide, Ashley, sorry about that. There is one continuing education unit being offered for today's presentation. So we would like to note that the authors, presenters, and planning committee for this webinar have no relevant financial relationships with ineligible companies to disclose. And upon verifying attendance, attending the course in its entirety, and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The IAFN is an accredited provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. You will be receiving an evaluation within a week of this presentation via email. So all that said, we do encourage you to please use the Q&A. We'll be monitoring it and prompting those questions to Ashley, who is our presenter. And you can also use a chat if there is anything that comes up for you. I will be available for any tech questions and or general questions as well. So with all that said, I would like to welcome our presenter today. Her name is Ashley Bowman. She is a board certified pediatric acute care nurse practitioner who has been practicing in pediatric emergency medicine for eight years. She earned her nurse practitioner degree in pediatric acute care from the University of South Alabama and also completed her DNP at the University of South Alabama. She subsequently became duly certified as an adult adolescent and pediatric sexual assault nurse examiner in 2023. She is currently an assistant professor of maternal child nursing at the University of South Alabama and has a clinical practice in the pediatric emergency department at USA Health Children's and Women's Hospital. She is a board member for the Alabama chapter, of the International Association of Forensic Nurses and member of the National Academies of Science, Engineering and Medicine Committee on improving the health and wellbeing of children and youth through the healthcare system transformation. She has presented at numerous national and international conferences and has authored multiple publications on both clinical practice and professional issues in nursing. Dr. Bowman currently serves on several federally funded grant projects with goals including the establishment of SANE programs as well as training of SANE. Through these projects, she has worked closely alongside nursing administration through the recently formed Forensic Nursing Oversight Council at USA Health. The council has been instrumental in transforming care and practice for victims of sexual assault served by the region's only academic medical center. Dr. Bowman, we welcome you as our presenter for this and we are excited to see what you have to share with us. Thank you so much, Sarah. I'm so happy to be able to do this presentation and appreciate all of you that are taking time out of your busy afternoon to attend. I hope that you'll find a few things that are relevant that you can take home to your own programs as we share a little bit about the basics of a business case and also how that ended up applying to us over the last year or so in the development of our Forensic Nursing Program. So we do have objectives for this presentation. By the end of this presentation, participants will be able to define basic tenets of a business case proposal, differentiate between two different business models, including revenue generation and cost savings, execute an ROI or return on investment and break-even calculation, and demonstrate some effective strategies for communicating with hospital leaders about SANE program sustainability. So I'd like to start out with some more general background on why this is even important in forensic nursing. I think that you all wouldn't be here if you didn't know how challenging sustainability is for every forensic nursing program. Whether you have great institutional support or not, there's just challenges in our field as far as finding specific forensic nurses who even fit the role, being able to, and then sustain that program financially. We know that sometimes it's very difficult in our field to prove that we make money, so to speak. And so we'll talk a little bit about that later in the presentation. We also know that forensic nursing goes far beyond just those initial impacts that we have in the first encounters with the patient, but overall how forensic nursing programs can impact health at the population level. And so being able to speak to that as a forensic nurse can be helpful. Other disciplines have successfully leaned into business models as a way to justify and sustain the care models they provide. I'll provide some resources at the end of this presentation that I found either already had or things I've found in digging to be able to give you a resource list. And I hope that you'll take those as you go back to your own programs and are looking for ways that you could maybe use this strategy at home. You can use some of those examples as ways that other disciplines have done this. Specifically, coming across some publications that centered on the clinical nurse specialist role and wound ostomy continence nursing, because those are specialty roles, I thought they were helpful in delineating how we as specialists can also differentiate our care. One of the things I was honestly a little bit surprised to figure out, as Sarah shared, I've been certified as a forensic nurse since last fall, but I had been practicing as a SANE for several years leading up to that and then not including the time I've spent as an advanced practitioner. And I was really shocked in preparing for this presentation how little literature we have to really say the impact of forensic nursing care on health outcomes. I did include a few references at the end that might be helpful, particularly the Hollander reference reiterates that there's a gap in the literature to document improvement in outcomes due to SANE-related care. They were able to find a statistically significant difference in services offered between SANE and non-SANE providers with regards to certain outcomes such as advocates, whether the patient received medical forensic kit, pregnancy testing and discharge resources, but a much larger proportion of those encounters with a SANE did lead to acceptance of a sexual assault kit and use of an advocate. But overall, I was really surprised at how little recent research we have on the impact of forensic nursing care on health outcomes to the point that I did enlist the help, but we are very fortunate here to have a health systems librarian who specifically only looks at literature related to health services. And I enlisted her help just to make sure that there weren't any goldmine articles I was missing. So just point that out to say that I think we all know that we provide excellent care and that we make a difference in our patients' care, not only at that moment, but at the population level, but very little has been documented at broad scale and published in a way that then we could use that to substantiate our care and also promote sustainability. Another pretty interesting statistic I came across is that there's been a 1,533% increase in adults presenting to EDs for sexual assault care from 2006 to 2019. So just in that short amount of time, there's been a massive increase in patients who are seeking out care. And I think that that is obviously brings a lot of importance to our role and why we need more forensic nurses in more areas providing care. At the end of the presentation, one of the resources additionally I'll share is that OVC had the Office of Victims of Crime had created, I believe in conjunction with the IEFN at the time, they had developed a technical assistance guide specifically on sustainability for SANE programs. So while a lot of the resources I'll share are not forensic nursing specific, that resource in particular I found really helpful. And so again, I just want those to be out there for you guys to use whenever you come across these issues. Ashley, we did have someone that asked if there's a reference for that last statistic that you mentioned. There should be at the end of the presentation and I can do a little bit more digging then if that's okay. Sure, we can follow up with Jennifer. Thank you for that question. Thank you for letting me know. I'll try to do the chat as well, but you guys all know how much that is to manage with PowerPoint. So a little bit about us and our health system. So Sarah mentioned that I work at USA Health Children's and Women's Hospital. It's one of three hospital systems within our larger infrastructure. We are the regional academic medical center for the Gulf Coast. I'm currently living in Mobile, but we serve patients along the Gulf Coast and across the region. These hospitals also encompass the freestanding ER where our adult SANE patients actually present now for exams as well as the ER at Children's Women's Hospital where we can see pediatric patients. And then we also have three outpatient clinic systems. They're very large and numerous other practices that are constantly multiplying throughout the region. A little bit about our current SANE infrastructure and this will be more important later as I talk about our journey through sustainability for ourselves. I mean, it's a journey. I don't think it ends at any one point, but kind of how we got to the point of making an ask of administration. So we've had an adult adolescent call team. I said circa 2000s because, you know, based upon the historian, I'm not sure exactly when the program was started, but it'd been around about two decades, if not a little longer. The transition came in 2023 from a community-based coordinator to a hospital-based coordinator. Our adult adolescent SANEs had historically been independent contractors and they were managed by a community coordinator. She was community funded, but she actually was in a full-time primary role that was completely separate from SANE and then managed the SANE program kind of as a part-time job. And so as the program grew, I think there definitely was a visibility of a need to have a full-time coordinator. So the community hired on a full-time person to that role. And then slowly that role, it became more evident that we would be better served as a hospital-based system. And so we've kind of slowly transitioned into that. So that person actually was split at one point between community and hospital. And the point at which we ended up making this business proposal was about the time we were trying to transition her onto the hospital. So she kind of came on kind of halfway and then full way pretty quickly after that because we saw the need and then we were able to justify that need. Our pediatric SANE program's currently in development. So we don't have a stable call team yet, but as our forensic nursing program becomes more formalized, more integrated, everything is kind of coming together for that to happen. And then Sarah mentioned the Forensic Nursing Oversight Council. This is a pretty critical point in our pathway to talking to administrators. In 2023, we were fortunate enough to be introduced to the then CNO or Chief Nursing Officer of our health system and be able to express some of our needs in as the SANE program's growing and needs were growing, training was growing. We were able to have this introduction to our Chief Nursing Officer. And out of that, we formed what's formally called the Forensic Nursing Oversight Council. And essentially what this is, is it's a twice a month, we meet directly with our CNO. So several forensic nursing leaders, such as myself and the SANE coordinator and there are others that serve on that council, they meet twice a month. So we have a regular path to administration for any resource issues, any, how do I say, like tech issues we encounter, like we might have the resources, but we need an introduction to a person. So kind of that technical assistance, if you will, what we are trying to get an email or an introduction, maybe this requires something at a higher level. And so administrator to administrator, they're able to get something rolling for us. So we're very, very lucky that we have that in place, but really the council started at about the same time that we made the ask of administration that we really needed a hospital-based coordinator who was a full-time person. So before we dive into our experience in a business case, I wanted to make sure we're all on the same playing field and hopefully some of this information might be familiar, but if it's not, I'm happy to stop at any point if something's not making sense or you haven't heard these words before. So it is important to understand the terminology. A needs assessment is just like what sounds, it can be formal or it can be informal depending on what you're after, but you really need to know what your organization is valuing, what they think they need. And so this may come in the form of surveys or interviews. Needs assessments take on all kinds of roles and that can help you. You can do a needs assessment internally in your program, see what the staff think they need. It really could take on all kinds of roles. The executive summary we'll talk about in just a second, but it's essentially a high-level overview of everything you are asking for. It is presented first in a formal business proposal, but we would always draft it last because you're gonna need all this information before you could ever draft an executive summary. And there are some really good examples out there in the literature if you need help with getting started. ROI means return on investment. Later on in the presentation, we'll actually show you the calculations. If it's not too cumbersome to look at a lot of math in that late in the afternoon, we will look at ROI and also breakeven. And an ROI just simply means how much money we can return on every dollar spent. So sometimes it's expressed as dollars and sometimes it's expressed as percentages. And then a breakeven would be the quantity of whatever you're trying to breakeven on. So we'll show you a little bit of that at the end, but a breakeven would tell you essentially whether at what point would you get your money back. And then a SWOT analysis details these strengths, weaknesses, opportunities, and threats of any given proposal. SMART goals or SMART objectives are classified as specific, measurable, attainable, realistic, and time-bound. And direct versus indirect costs. Direct costs are anything that is, well, just like it says, directly purchased or directly kind of in front of you, personnel salaries, we'll get into all of that. Indirect would be anything that it's considered an in-kind cost at times or it might be something that comes with a group of things. And we'll go over the budget in a little bit. So I just kind of wanted you guys to see those terms once so they're not coming at you later for the first time. Executive summary is usually a high-level overview presented first but written last. It's no more than two pages, sometimes only one page. And what will be included in there is kind of like your talking points of what you're trying to get across. So the problem you're trying to solve, what you think you might be able to do about it, what are the benefits, and then who do you think are your key stakeholders. So essentially when we presented the business case, that's at the end of this presentation. It was a executive summary, if you will. I'm taking bits and pieces of it to show you it dissected down for this presentation, but it was only two pages, bullet points, with the budget, with the ROI calculation, and that was all that was done. You could translate that into a much larger full-on presentation, but it may depend on how much time you actually get with administration. Maybe you get just a few minutes in a boardroom, maybe it's a phone call, or maybe you do get 20 minutes to show them PowerPoint slides. So a lot of times when we think of business models, I think that we kind of, or at least I do kind of naturally assume that we're talking about making money, but remember that in forensic nursing care, it can be a little challenging to focus on strictly billing potential. We're not known as money makers in forensic nursing. That's why it's so important to have research on those other health outcomes, but that it can also be difficult to track SANE-related care and then reimbursement related to SANE care. We know that the IAFN has provided a lot of TA around payment models and coding and how we have had a hard time as a profession getting reimbursement for certain services that we do provide, so revenue generation can be difficult. You do have to also consider that there are cost savings in the world of SANE care, so that's really where our business proposal focused. We, as SANEs, are just in the, you know, plainest sense, we are cheaper than the average emergency room provider. We're not only providing, you know, we know we provide better care, better outcomes that we were talking about earlier. We do have some research to say, you know, recently that SANEs ended, you know, with a better uptake of a patient being willing to do an SA kit. They were more willing to utilize an advocate, so we know those things exist, but if we get down to it, the SANE is also cheaper because of the care that's diverted when an ED provider may spend time in a SANE-related care that can take up a lot of time away from other patients who, frankly, they might be better served to take care of, and we're better served and trained to take care of SANE-related patients. That just really makes a lot of sense about breaking that down to administration to show them how much time a provider might divert from their typical ER load in taking care of a SANE patient, and then what's ultimately, obviously, better for the patient as well. So, reasons you might even want to consider making a business case is there's a lot of competition in healthcare systems for finite resources. There's only so much out there, and we do have to prove why we need to ask for it or why our program is justified in getting this money over someone else. So, it is a competition in the end, so you have to be able to back up why you might need something. Align your program with your organizational goals. So, again, I don't want this presentation to feel impersonal or that we are only concerned with how much money we can make. It's not about that. It's about sustainability as a whole, so we have to be able to justify ourselves financially. Maybe we need to justify an increase in resources, an increase, we need a certain piece of equipment. You could use a business case for all kinds of things, but ultimately, knowing your organization's mission and vision will be extremely helpful because you will tie those in to your business case. You could include those in the executive summary, reference those, and tell your system why we're trying to show you where we can save valuable healthcare dollars. We also know we provide better care for patients, and this is why, and this is how it aligns with our vision for the organization, our vision for community needs. We've relied often in our community on a community needs assessment that's done, so you can reference any of those things so that the organization sees you as part of the bigger picture. And then communicating in their language. So, we've found through the years that different administrators really react differently, so some, it doesn't take much to pull up their heart strings, whereas others want to see the hardcore data, the things that you guys are asking about, you know, where's the reference for this number? And so, those are the kinds of things they might ask you, so being able to understand what their language is and communicate in that way. So, I'm going to get into the nuts and bolts of actually creating your business case. So, these are all components of the business case. Again, there's some great resources at the end that kind of show you all the different ways people have presented those. It's not that there's a one-size-fits-all or it has to look this way, but these are the essential components that you would need, and I would preface all this by saying don't get overwhelmed. Don't think that I'm not trained to do this. We are all nurses. We're all highly qualified to be talking about these things, so just being able to speak in the language. So, remember to consider your budget before you can really go anywhere. So, you have to consider the cost of what you even need to ask for. So, the budget can look all kinds of ways. You might just be asking for a piece of equipment, so maybe that's the only thing that you need in your budget. Well, maybe that equipment also has a maintenance agreement that they will need to commit to. Maybe it has storage requirements. You get the idea, but if you're looking at budgeting for an entire state program, you'll have a lot more to consider. You'll have personnel costs, and that doesn't just include their salaries. You have to consider fringe benefits. You have to consider onboarding orientation time. So, all those things. See ongoing professional development, so you can include that in training. CEs, things like that. Supplies your program might need. How many things do you think you'll turn over in a year, and typically a budget. I didn't say that. Typically, a budget is made a year at a time, and many of you are saying program managers, so you do this all the time. Maybe you need some IT help. Maybe you need marketing or a communications budget and consultants. So, there's all kinds of things you need to consider. There is a toolkit provided through AHRQ. They provide a toolkit on ROI that is a little bit more broad to all health care needs, not just SANE. The OVC TA website does focus just on SANE, but AHRQ is more broad, but I found both of those resources very helpful in detailing all the things you need to think about if you're trying to either budget for a new program, you're budgeting for an expansion of a program, maybe you need to add staff, you need to justify bringing on full-time staff. So, that's kind of where we landed, was we're trying to bring on a full-time staff member. So, you may find that your program's growing, you need to bring on full-time staff, things like that. So, the return on investment, remember, is the amount of money per dollar that we're getting back. So, it could be any positive ROI would be anything over that dollar. So, even if it's a dollar and one cent on every dollar, we're still making money for every dollar invested. The basic formula for that is net profit divided by your cost and investment, and you can multiply by 100 to get your percentage, and we'll go into ROI examples toward the end of the presentation. We do know that there are limitations on ROI. I'll explain some of what we ran into when I get into our calculations, but a huge limitation can be just access to the data you need, and that was really one of our biggest challenges, and it can be a challenge in getting your ROI as fine-tuned as possible, but it shouldn't stop you from at least calculating an ROI. You can use other sources of data as close as you can get it, and I'll talk about that a little bit more as we go on, and then we know, again, I just want to keep emphasizing that I'm a forensic nurse, too, and I know that ultimately sometimes it's hard to show a positive ROI, and so we have to think about also what we're providing back to the community and balance the two. So, maybe your ROI is not great, but you're able to show a pretty positive balance in the community, and your administrators will be open to that. A break-even, we'll also calculate at the end of the presentation, but it's a fixed cost divided by the revenue per unit minus any variable cost per unit, meaning that some things require a once-per-use cost, and so you do have to factor that in. A lot of times, a lot of times that focuses more on equipment than on anything else, but every situation's a little bit different. Ashley, so sorry, you may be addressing this at some point already, but there is a question whether the benefits calculator is still around 30 percent. She mentions it's a rough number. She can't quite remember the percentage. For fringe, is that what we're talking about? Not only would you like to clarify, we can take you off audio or off mute if you'd like to clarify your question. Yes. Yes, fringe, around 30 percent. That what she said? Yeah, that was a question. Okay, yes, I would use, I would say that's a good rough number. We use 33 percent here, so I would say that's pretty accurate, especially if you're unsure. So, I put in here a few strategies that I just felt like were things that we've used in our communication with leaders. We speak their language, knowing your facts. Thank you, Sarah. I just saw you dug up that reference for me. It was at the end of the presentation, so it was going to take me a minute, but knowing your facts, being able to seek those out, know exactly what you're asking for, and being willing to negotiate. So, I can tell you one of the biggest examples for us, our current CNO, the CNO we originally started working with last year actually got promoted, and so we have a new CNO who's learning really everything about saying. She doesn't come from forensic nursing, but she's one of the best people that I've ever worked with, and I love communicating with her because it is so, we've kind of found this groove where we know what she likes to, how she likes to communicate, and that makes it easier, and she's just honestly a wonderful person, but with her, what we found is she always wants everything in SBAR format. So, going back to your really basic nursing school days, she loves talking in SBARs and communication, and even if we come to her and she needs to take that, escalate that concern or resource even higher to our CEO, she will write up an SBAR or ask us to for that as well. So, if you're not remembering what SBAR is, it's a situation background assessment, and then your recommendation. So, being very clear with what you're asking for, and within those SBARs, I can think of a few recently that we've written for her. She wanted, you know, a few, or I don't even know that she had to ask, but our SANE coordinator jumped on it and put in there, you know, this is the data to support or ask of administration, and so being very clear with what you're asking for and knowing that how they like things to be communicated can make this, the relationship really work well for you. I brought up the SWOT analysis earlier. I know this can be a little difficult to read, so I apologize if it's small. It's a word infographic, and so I couldn't make it too much bigger, but what I wanted you to see if you weren't familiar with SWOT is just how it's usually designed. Usually, there are four quadrants, and each one of the components is listed in those quadrants. This can be really helpful in detailing why you might need to pursue a problem, what threats might be out there in the community, but is it an opportunity for the organization as well, and so this can really help to frame what you're asking for so that it's very clean cut. Again, it can be part of your presentation if you're able to do a full-on presentation, or you could include it even a small part of your exec summary. Okay, so I'm gonna quickly hopefully kind of go through our own experience with making a business case for forensic nursing coordinators so you can see what actually happened in real time about a year ago, and I hope that it will kind of bring to light how this could be helpful in your practice and what you might need to be asking for to either start a program or sustain a program. So again, just reminders for background with us. We were really at risk of losing our, I'll go back to this less busy slide for a minute, we were at risk of losing our forensic nursing coordinator entirely. We had a part-time coordinator for a lot of years who functioned in a full-time very busy nursing role and then did same coordination as her part-time job. She was managing a team of all independent contractors who were not considered employees of the hospital, and we were really at risk for losing the program completely if we did not have a stable coordinator. The growth as you saw in ERs all over the country is apparently skyrocketing, and we definitely feel that here in South Alabama. So our numbers were growing and we needed someone who could manage the program more full-time. Again, that was all done in the community, which was fairly disjointed because all the services were provided in the hospital setting and sometimes, you know, the two entities, it was, you know, a little disjointed between them. And so it really became obvious that we needed to integrate the services more with the hospital, but how do we do that? We needed the health system to commit to having a same coordinator full-time, so we were asking them to commit to her salary, and that was not something they previously had to do. They were kind of a little bit out of the loop before, so we're asking them to do a little bit more. So as a part of that, we built this forensic coordinator model, and I'll preface this with saying exactly what I told you a little while ago, that it's only, you can only really do with what data you have. So we were, we also kind of ran into a roadblock where because our sayings had been charting on paper and this data had been, you know, scanned in, nothing was really tracked consistently for a lot of metrics, we have a hard time with tracking down data. That led to a whole nother project that's still ongoing. We're building out an entire EMR suite of documentation because this very thing, because it's so important to be able to have our data, such a large program, and we really needed that, but because we hadn't had an in-house coordinator, it just didn't, I don't think it had just ever happened. So I took the numbers that I could find, either through experience, because I've been in the ER for eight years, I've witnessed the growth of the program over time. Our ER has transitioned a lot in the eight years I've been there. It looks completely different now than it did before. We weren't even considered an ER when I started there. We were an evaluation center and we did women's health too and now we're only doing pediatrics and so it's a big change for our hospital. And so I've seen what goes on as a provider. I've seen how much time these patients can take of our providers. I've seen how much time SANE spend in there. And then I was able to track down metrics from Alabama data sets that were at least the most representative of our system. So I found the ER physician salary. I estimated that the care of a patient requiring forensic care usually takes between three to seven hours. I think we would, most of us probably agree this sounds familiar. ER physicians would typically see an average of two to five patients an hour when not providing care to a SANE patient. We know that through reported data that a high acuity PDR visit, again we're talking PDR because the coordinator was focused in that. She's housed in that hospital so that's where we're focusing in. And I know that might be a little confusing but that's just how it works out in our system. All SANEs used to be seen in our hospital until recently. And so that visit might cost an average of $3,655. The RN average salary in Alabama was $39 an hour. And it could be estimated that a provider might spend a minimum, and I would say that lightly, a minimum of two hours to a patient with forensic nursing needs in addition to about four hours of dedicated nursing care. And I felt like those were very conservative estimates. Again, over the amount of time I've watched this play out, whether there was a SANE available or a SANE not available, I had kind of seen all of the different varieties of what that looked like. Because our SANEs used to be, all of our SANE patients, including adults, used to be managed in the pediatric emergency department. I was able to kind of see that play out over time. But difficult because we couldn't track any of this data down in our EMR. So I encourage you if you have programs where you're tracking data or you think you might need something to put a plug in that that data is super valuable and think about how you might track discrete data. We're hopefully going to be able to do a lot more with the data we're collecting now. And then these costs only account for direct patient care. We're not talking about any of the other things, all that population health and all the things that can happen outside of just the initial visit. Those could account for a pretty massive ROI, but really beyond what I could calculate. That takes a lot of statistical modeling that I just don't have the capability to do. And then there are also other times when the provider might spend time talking to CBS if it was an underage minor victim, or they might spend time in testimony or preparing for depositions, things of that nature that are really outside of their duties that they would typically do in the ER. So, the original budget, I use these exact numbers that we just went over to calculate how much revenue are we actually diverting. Remember that we're focusing on cost savings in this case because we were worried if we lose the same program entirely, we don't have a coordinator, we don't have anyone to organize the SANEs. Potentially, you know, worst case scenario, the program falls apart and you don't have SANEs at all versus having a well-established adult team we have and then growing into pediatrics completely. And so, those physicians would end up seeing these patients and spending a lot of their time in these patients' rooms or dealing with consults or phone calls or all the things that go on in SANE-related care in addition to the nurse that was tied up with that patient as well. So, we saw during this time period, just before this business model was calculated, we had seen 681 patients that required forensic nursing services. So, again, we're a pretty busy area and that accounted for the total annual expenditures you see here. And I did report this as a range mainly because I wanted to account for pretty low-end estimates of two patients per hour for ER physicians. We all know that's pretty low all the way up to what is possible. So, then we wanted to account for the forensic nursing coordinator's salary. Again, that was our ask. So, specifically what we were coming for, knowing that that was really the backbone of the entire program. And they, it would allow for the SANE-A call team to continue in their current fashion and then ultimately, hopefully, onboard as hospital employees was kind of our ultimate goal, but that really didn't make a difference in what we were asking for at this time. Her hourly wage resulted in about $33 an hour. I'll show you that in the budget coming up. And currently, our SANE-A call members are being compensated about $300 for each case, which is recuperated through Crime Victims Comp. And they haven't historically been reimbursed for time on call or time spent in deposition or court testimony. Again, we're working on positive improvements on all fronts and so that being one of the identified needs, but at this time, they were not being compensated. And the providers would still obviously need to step in in any emergency medical care that was needed. So, we have to compensate for the SANE, who was providing forensic nursing services for each one of these 681 patients, assuming they were able to continue in their role. And then we also needed someone to coordinate them in their day-to-day duties. And so, that budget came out to $93,100. Again, using our fringe of 33%, I saw somebody in the chat said their program uses 35. So, you can see it's kind of right in that range. We use 33%. So, this is just simply how I calculated her salary with fringe included. And that brings us to the ROI. So, remember that ROI is that net profit. So, and then divide by how much we're actually investing into the ask, whatever the ask may be. Again, it could be a lot of things. It could be a piece of equipment. It could be salaries. It could be an entire program. It just depends on what you're shooting for. You don't have to shoot for it all at the same time either. So, remember that there was a low-end estimate because we could have our providers see as few as two patients per hour. Again, I felt like that was very low for us. Conservative, we could see up to five an hour. Again, that may not even be completely accurate, but I was trying to get in that middle range of where I've seen us be consistent through the years without being able to pull all of our EMR data. This had to be done fairly quickly, and we just did not have the data. We didn't have the resources to pull the data at that time, but we definitely identified that as somewhere we want to improve on. So, I pulled in those numbers, which I'll show you in just a second where I got these from. So, you can see, going back to those annual expenditures, how much money we were diverting from simply taking away an ER provider who could have been providing care to ER patients of all varieties who ended up providing care to SANE patients if the SANE was not able to come in. Then, we want to think about the cost of investment or how much it costs to pay our SANEs who are coming in for the case and also pay our coordinators. So, I did include the SANE pay because I think it's an important part, but a lot of our ask had to do with the salary. Because the numbers were so magnanimous, it really didn't matter too much either way. So, if we are diverting roughly a little over $5 million on a low-end estimate, our ROI would be around 1,600%. The high-end estimate would be around 4,100%. You can see those are massive numbers only because of the amount of money or revenue we're seemingly going to divert from taking care of other ER patients. Thoroughput leads to more turnover left without being seen. Patients who don't get seen perhaps because the providers are more tied up with a more complex patient who would be better served by a SANE. In the break-even, I did calculate in this case because I felt like it was helpful to know how many patients we would have to see a year for her salary to even make sense. So, remember the break-even is your fixed cost. So, in our case, it was just the budget for the coordinator salary divided by your price, which I'll show you on the next slide where that number came from. And then, I subtracted the cost of the coordinator salary. I did it two ways. Per day ended up coming out about the same as hourly. So, either way, we landed on about 13 patients every year that we would need just to break even on her salary. So, if our program could continue to see at least 13 patients, we were at least breaking even with her salary. As you can see from the other slides, we saw 681 in the previous year. So, that really wasn't as big of a concern for us in a big program with pretty high volume that only seems to be growing as we grow. So, I brought this slide in just so you could see where, again, where that number came from. These are all snippets of that two-page executive summary. You're seeing like pieces of it throughout this presentation. So, that's why I wanted to keep going back to them so you could see where the numbers came from. But, ultimately, we started with a budget or what we were asking for. We started with how much money was just going to be diverted if we were to choose the other option, right? So, we have to consider both options. So, if they chose not to hire her, the program dissolves. Then, this is potentially what you're diverting versus this is what you can do in the solution. So, you're giving them two choices and making it very clear what the data shows on those two choices. So, again, the break-even calculated here was her full salary plus fringe minus just the low-end estimate of diverted revenue minus just that variable cost per day. So, even if more than one patient per day, if we just say one per day, we only needed 13 patients to break even. And I think that brings me to the resources. Now, I think that we found the reference we were looking for earlier, but I did want to make sure you guys could see these slides as well. And happy to take any further questions that I might have missed. Somebody asked, Sarah, if they're allowed to get a copy of these slides. I'm perfectly comfortable with that if you guys are. So, I'll defer that one to you. Awesome. Well, we'll go ahead and make those available after today. Oh, and Natalie asked about what was the diverted revenue. So, in our case, we were specifically looking at the revenue that could have been diverted if an ER physician provider, if you will, using generic terms, if they were to see a forensic nursing patient that could have been seen by a SANE, but there was no SANE program in existence if it was to dissolve, that revenue is being diverted from patients they could have seen in a typical course of an ER day. In our area, we have, yes, I can go back to the second page of references. So, in our ER, we have a very large volume, both in PEDS and in the adult world. So, if our providers are getting pulled into those rooms, it's very likely that the ER will slow down, that they won't turn over as many rooms, and that less patients will be seen. We do also have a couple questions in the Q&A. Okay. I saw one from Janelle. Is the 13 patients for your break-even an annualized number? Yes, break-even is always calculated as an annual number. And please explain the comment of one patient per day. So, I calculated the break-even based upon if we just saw, that would just technically only account for one patient per day. But with our numbers of 681, we're seeing, you know, on average more than that. And so, really, you could account for that. But again, the numbers were such a big difference. When you're doing the calculations, you'll see, like, if you were to add that back in, you'll end up around 13 patients anyway. So, no matter which way I calculated it, I still ended up at about 13 break-even. I'm trying to see if I can, oh, here's the Q&A. It's hiding from me. Yeah. How many hours of direct patient care versus program management were allocated? That's a great question, Camden. We did, technically, I guess, technically, it was supposed to be program management. But I don't know that that was, that's a great question. I don't know if it was ever written down or verbalized which way she would have to go. In reality, she ends up getting pulled into a lot of direct patient care because she's in-house, and it's kind of evolved into that. But in the beginning, I don't know that that was what was specified, or, you know, it just kind of came with the territory. If you're trying to expand a community SART to a neighboring county, are you reaching out to hospitals? Who should I target? The ER director or CNO? Jenny, I assume you're trying to offer your services in the ER, or are you maybe wanting them to join your SART as like community advisors? I don't know if she's able to come off mute. Jenny, if you'd like to come off mute, I can be here. Yeah, there we go. Can you hear me okay? Yes. Yeah, just like we have an outpatient community SART center. It is located within a hospital in like LA County, but there's no outpatient community SART center in San Bernardino County. So, we're trying to like create another one. So, I'm reaching out to the hospitals within this other county, but I'm trying to see who I should be targeting just to like line up a meeting and go over with whether, you know, would they even be open to this idea or not? I would say if you could get the CNO, that would be the best bet. Or some other, maybe if it's not CNO, if there's a comparable administrator, but I would go with someone at the administrative level. Okay, thank you. You might also consider like the development office. We've had some luck with that as well, especially in community initiatives where if we connect with development at the hospital level, they're interested in that because it benefits them from a visibility standpoint. Okay, thank you. We have one other comment in the chat, and then I think that's all we'll have time for. I'm trying to make sure I under, is it Kaylin's question? I'm trying to make sure I understand her question. And Kaylin, I took you off mute as well if you'd like to. Hi. It's Kaylin. Hey, how are you? Good. Thank you so much for your presentation. I am doing a lot of work on this, so this was very impactful for our program. What it, like I'm working on trying to find the costs per patient to look at a total revenue from our program standpoint, and like, as you mentioned, our programs don't bring in a lot of money, but what are you finding that it's a, that your cost per patient, um, for your program, meaning how much we're bringing in and revenue or, um, so far we've been able to bill. We're in Alabama, so our rates are really low. I would say we get about $500 in reimbursement and about 300 of that goes to the same from crime victims comp, um, and then having to consider on top of that, that now we have a coordinator salary to fund. So it's definitely a, it's hard to go the revenue route in, especially in our state, our reimbursement is so low. Um, and we know that's an issue. So going at it from the other direction really helped us because we knew that our ERs were busy enough that we were holding up providers from doing other things if we didn't have SANEs. For sure. Okay. Thank you. And on behalf of the International Association of Forensic Nurses, we thank you for joining today and we look forward to seeing you all in a future webinar.

forensic nursing

business case

coordinator

ROI

budgeting

break-even

financial sustainability

organizational goals

cost analysis

health outcomes