So, a couple things to know as we get started, we will be recording today's presentation, it will be put into the learning management system with other videos that you see here, so if you're interested in other office videos, office hour videos, you can go there to see it. I'll be monitoring the chat as we go through, so please feel free to put questions in the chat, comments in the chat. In addition, we really will be encouraging discussion, so if you have questions, thoughts, things that you want to talk about as we go through and get started, please know that we do want to encourage that. We were going to ask today if you would just put your introduction in the chat, let us know who you are and where you're calling in from, and if you are currently doing telehealth, that would be excellent. And I think with that, we're going to get started, and I'm going to turn it over to Diane. Thank you so much for being here. Hi, everyone. Diane and I are going to kind of be co-presenting, good afternoon, this is Jana French, I, myself along with Diane and Andrea Cavanaugh work for the office, or work on the grant that's provided by the Office for Victims of Crime from 2019, and we're going to be talking to you today about Telesexual Assault Forensic Exams, or Telesafe, and that's part of the Enhancing Care and Improving Access and Quality of Sexual Assault Forensic Examinations through the Telehealth Project. So we'll go ahead and introduce ourselves, so I'm Jana, and I work on this project along with, go ahead, Diane. Yeah, hi. Hi, I'm Diane Daber, and I am a forensic nursing specialist working on this project right now, and I'd also like to introduce Nancy, who's next. Hi, Nancy Hettriss, I'm actually the VP of Nursing for Telesafe in New York, and also working on this project. Hi. I was going to say, Randy, go ahead. Thanks, Jana. I'm Randy Petricone, I'm the Associate Director of the National Tele-Nursing Center, and also the Massachusetts Tele-SANE program. I am also currently a SANE and a Tele-SANE, and I'm one of the TA partners on this grant project. Thanks, Randy. All right, so as we go ahead throughout today's session, go ahead and post those questions in the chat section, and Christina will let us know as we see them pop up. And if we unmute you, you can ask the question directly, but briefly, if you could just tell us where you're from, if we get that far. So let's go ahead and get started with a poll, so everyone get ready. Get your mice ready. Okay, which most accurately describes your current practice? I am providing care for... Can you advance that, Diane? Sorry. As a remote Tele-SANE? The next one is I'm receiving... No, can you advance it on the screen for everybody? Yeah, we don't have those listed. Oh, okay. All right. Never mind. We don't have them listed, so can you see them? No, I can't. Oh, I can see them, yes. So I guess I'm providing care as a remote Tele-SAFE. I'm receiving assistance in providing care from a remote Tele-SAFE. I work in a program that is considered offering Tele-SAFE services, and then none of the above. Okay, so let's go ahead and answer in the chat section, whether you're providing care as a remote Tele-SAFE, receiving assistance in providing care from a remote Tele-SAFE, or whether you work in a program that's considered offering Tele-SAFE service or none of the above. Looks like we're getting a lot of answers coming in. Thank you, everyone that's participating. So it looks like we have a lot of none of the above, which is fine too. We're glad you're here. I think today will be nice and full of information for you. So keep answering if you haven't answered already. We'll move ahead to the disclosure slide. Obviously, this is paid for under Grant 2019, awarded by the Office of Victims of Crime, Office of Justice Programs, and the U.S. Department of Justice. All right, Diane, do you want to go ahead and talk about this section? Sure, yeah. Thanks, Jenna. So the Office of Victims of Crime, their goal for this program is to help ensure that more victims of sexual assault have access to higher quality health care and sexual assault forensic exams, along with the inclusion of a support system through victim advocacy. So in order to do this, what OVC did is they funded four demonstration sites, which are very diverse demonstration sites, and then one technical assistance provider or TA provider. So IFN is the TA provider. And so I have been in collaboration with OVC and our project partners, which you can see our project partners are listed up here on the slide. We have been offering support and guidance for the development of patient-centered, trauma-informed tele-safe programs at each of the demonstration sites. Great, so we'll go. Oh, sorry, go ahead, Diane. I was just going to tell you a little bit about the demonstration sites since we're here. I mentioned that they are very diverse. So the first one I wanted to just tell you a little bit about is called Avera Health, and they're located in Sioux Falls, South Dakota. So Avera Health already has a very extensive telehealth presence and a wide array of specialties. So for example, they have an EICU, an EER, an E-behavioral, E-geriatrics, I mean, just the list goes on. So they have a good amount of experience with telehealth. And tele-safe was kind of a natural flow for them, but we've all realized that tele-safe is very different than telehealth. They plan to provide services in five different states. And this is a picture of their actual brick-and-mortar telehealth building, and it's called the eHelm. So their forensic nurses will actually show up, go to the eHelm to respond to the cases. They won't be doing this remote from their homes. The next one is Texas A&M College of Nursing Forensic Health Care Program. And so this is unique in that this is based out of a university rather than a clinical setting. They call themselves TEXTRAC, which is clever, and it stands for Texas Teleforensic Remote Assistance Center. They will be setting up three, well, they have set up three spoke sites or remote sites in the southern rural Texas. But they do have plans for continued growth of tele-safe through other funding sources. The next one is the Tundra Women's Coalition, which actually, so they're the grantee, but they are a women's coalition. They're located in Bethel, Alaska, which, by the way, there is no way to get to Bethel other than by air or water. And they sit in the Yukon-Kushkwim Delta. I may have messed up the name of that river or that delta area. But they have an advocacy center which provides dual services. And they have partnered with the Yukon-Kushkwim Health Corporation for their clinical component. So this site, as you can imagine, has some extreme rural challenges. You know, we talk about rural in the lower 48. And until I started working with this site, didn't even realize the challenges of rural Alaska. They will be providing guidance to five of the sub-regional clinics. And what's different about this site is that the providers at the remote site or the spoke site are actually all advanced practice. So they're nurse practitioners or physician's assistants. And the last, but certainly not least, is University of Arkansas Medical Sciences. So this site also has quite an established infrastructure of telehealth services. And they are proposing a significant number of spoke sites. Over 50 spoke sites. But they're staying within the state of Arkansas. And their SANEs will be actually responding remotely. So they will not have to go to a building to respond, you know, to provide the tele-safe guidance. So what we found with the very beginning of this project, you know, we're a year and a half, a little bit more than a year and a half into it. And we have found, and I'm sure Randy and Nancy, with their experience, will certainly vouch for this. But the planning phase is imperative in order to build a strong foundation for your tele-safe program. So a lot of people might want to jump over some of the planning phases and get right into it. Let's buy the equipment. Let's do this and that. But what we have found, and sometimes very painfully, is that we really need to start with planning. And so what IFN created a needs assessment. It was absolutely an invaluable component for the planning phase. And it was based on SMART goals. So very specific and measurable, achievable, relevant, and time-bound. And it helped us to assist the sites in prioritizing their needs. And some of the needs that were identified were unique to an individual site, but others were shared by all. So across four sites. We also promoted communication between the demonstration sites. So we would have monthly meetings where we would actually communicate with each site individually. But then we started to bring them all together once they kind of were well on their way. And it really promoted great communication and identification of innovative ideas and different solutions to challenges. It's really important, we found out, to identify your community partners and your resources. Not only in the site of the hub or where the expert site is, but also in the remote site where you're going to be potentially providing services. Getting to know your partners, understanding what their desires are for this program and what they're understanding. It really does promote the community awareness, as well as promoting support for the victims in those communities. And then, of course, just to think about sustainability and how we're going to maintain this with a trauma-informed, patient-centered approach to Telesate for the good of the community. And Jana, maybe you can tell us a little bit more about implementation and maybe Randy and Nancy can help, too. Yeah, I think, Randy, if you could just go ahead and start. And can you tell us a little about the structure of your program at the National Tele-Nursing Center? Sure. I adjusted the volume a little bit. Is it good? Thumbs up? Okay. I wasn't sure if I was too loud or too low. Okay. So we're kind of unique in Massachusetts in that we have a centralized statewide program. So there's one SANE program in Massachusetts, and it's run out of the Department of Public Health. So we're sort of in six regions across the state. We have a brick-and-mortar center. We hire Telesanes and train Telesanes by pulling some of the expert nurses that work within our regions. And so that's where we recruit from. So we kind of pull from our own pool of SANE nurses to create Telesanes that travel to the brick-and-mortar center when we have a case. So our center has two exam rooms, and then we have an administrative office. So we're a fairly small operation, although we have received 461 calls to date. So we started as a grant-funded pilot project as well and worked with four national sites. We were able to establish our infrastructure. So, again, that takes a long time, as Diane was saying. So it took about two years before we even saw our first patient, and then gradually added sites as we went on and saw that we could take on more sites. So we did add two sites in our state in 2016. So we had six sites total up and running during the pilot project phase. When the pilot project ended in 2018, we were able to continue in Massachusetts and kind of expand as time went on. We have an on-call model, so our Telesanes are on call. They're not waiting at the center. They have an hour to travel to the center for cases. What else I think is important to – we pay hourly, and then we pay an additional case rate if they go to the center and perform a case. So I think that's important. We've also structured a backup list. So if there is a time where there's a simultaneous case, which we've certainly had a handful of those, we have a backup list of nurses to go through. We also have an administrator who's always on call for one week at a time, and they're available to kind of coordinate things should there be more than two cases at once. So I think it's important to kind of layer your on-call staff or to have a backup plan, depending on how many sites you have and what your patient volume is going to be. And we've just decided that brick and mortar is best for us, but I know there's a lot of other structures out there for different programs. But that's sort of us in a nutshell. Thanks, Randi. I appreciate that. And Nancy, I know you have experience with program development too. Can you explain how United Concierge Medicine is structured and a little bit more about that? Sure. So that needs assessment was probably one of the things that we worked on for two years before we even went to OVS or our legislators and tried to see how we could fund it. And once we got the pilot grant from Office of Victim Services, it was a three-year grant that we received. And, you know, like Randi mentioned, it's been two years and now we're really in the flow of seeing patients. You know, where it was originally, when we had looked at our grant, we looked at providing services for small rural hospitals that did not have a SANE program. And that was where we started. And then we realized that there are larger hospitals that don't have 24-7 coverage or hospitals that have SANE nurses, but those SANE nurses wanted the support. So we started to, you know, kind of expand. So right now we're in 22 hospitals, we have about 12 more that are going to be signing on within the next three months. In our first year, just of seeing exams like last year, we saw 15 for the entire year. And we've already seen 30 so far this year. So, you know, we know that it's working and people are using it and we love it. Our structure is, originally it was just a physician and myself. And then he went back to working in the ER, so I was kind of like, okay. So right now we actually have a director, we have myself as the VP of nursing, and we have a community outreach person who really is constantly on the phone talking to hospitals, talking to advocacy groups, talking to law enforcement, anybody who wants to listen. I give her a lot of credit, she's keeping busy. And we have 20 providers, we have nurse practitioners, we have one PA, and we have registered nurses. They are on call, and they do the call from their homes. So we supply them with all the equipment that they need. We have a primary and a backup person on call, so that if somebody is in the middle of a call and another case comes in, the backup will take that. We have a call center that manages our calls for us. And, you know, like I said, it's wonderful to actually see it come to life, and people using it. The responses that we get from people make it all worthwhile. There's no doubt about it. Thanks, Nancy, for sharing. Yeah, one thing we noticed a lot, of course, over all the demonstration sites is that each site has faced such different and unique situations that they've needed to adapt to for program development. The pandemic obviously affected, you know, all of the sites in some way, shape, or form as far as that implementation phase. But really, we found that flexibility to adapt to unforeseen circumstances was really key and sort of a shocker along the way, even more so than sort of regular program development, non-telehealth style. So kind of the classic program. Yeah. And with COVID, we did get more hospitals signed on because they were finding that their same nurses didn't want to come into the hospital, especially in New York City. So we were, you know, assisting with that, which was, you know, one of the ways that we got into a lot of the larger hospitals. That's, I guess, a good thing. That's great. All right, Randy and Nancy. Randy, we'll have you start, but what do you wish you had known before you began your program? Well, I feel like I'm always coming across things that I wish I had known even, you know, a month ago or a year ago. I think one of the things is about the brick and mortar center. So having a physical space, having one location that the nurses can travel to, I think it's great. You have a lot of control, right? You have a lot of control over your aesthetic, over the security, over everything, the Wi-Fi, the computer, what the background looks like, all of that, which is great. But for us, as I mentioned, it does limit recruitment a lot. So Massachusetts isn't a particularly large state. But the way that this region is structured and where our brick-and-mortar space is, which is sort of maybe 15 minutes outside of, like, Boston proper, so it's a little Metro West, is what we call it, it limits us to only three regions. So we can only access expert SANEs in three of our six regions. So I think maybe having multiple, like, satellite brick-and-mortar centers and who knows what the future may hold, but I think that's one of the things that, I guess if we could do it again, maybe two brick-and-mortar sites that are spread out a little bit better. I think the other challenge has been on the sort of the remote or the spoke site end, making sure you always have a champion. So we try to do the same thing every time we do a needs assessment, we do a site visit, we make sure that all the sites, even though we're responding and taking into consideration the unique needs of that hospital, we want them to kind of be very similar in their resources that they have access to and what their logbooks look like, all of those kinds of things, but you're not there. So you have to give up a lot of control, which is, I think, hard for nurses. And so that's one of the things that's really important is making sure you have a consistent person on the other end that you can rely on to get things done because you don't have your hands there. You can't reorganize their resource binder. You can't do some of the tech troubleshooting. You're like, it's so simple. I just want to reach across and do things, but you can't. So there's that thing. I definitely think a champion. One of the other things, which was sort of a big wow moment, at least for me, an expert SANE does not make a good telusane, like not all expert SANEs make good telusanes. And I think it sounds, it seems like a no brainer, like their documentation is perfect. They've done a lot of cases. They're really passionate about this work. But that doesn't necessarily mean that they're going to be a great telusane. I think it's really a unique skill set. And we've sort of started focusing on the fact that it really is precepting. They really need good precepting skills. So we've always kind of taken people who are preceptors in their regions, but we really focused on hiring and retaining those quality preceptors. It's not just about taking care of the patient and making sure that the right evidence is collected. You are spending a lot of time constantly reassessing and assessing that patient. But you're also spending a ton of time assessing and reassessing that nurse and what they need from you. And you're doing both at the same time all the time, which is great. Right. You get to flex your SANE muscles and your precepting muscles and new and exciting ways. But it can be challenging. And one of the things that I think maybe we didn't do enough of in the beginning, and that we've sort of changed as we've done more trainings and learned more about this process, is focusing on that pre-encounter or that pre-conference or that huddle that we recommend you do with the nurse before you get into the room with the patient. So you don't want to all be meeting for the first time when the patient's ready to have evidence collected in an exam. You really want to meet with that nurse ahead of time. So having the hub nurse and the spoke nurse, that tele-SANE and that ED nurse, for example, they're meeting together talking about how they're going to take care of the patient together, because it can't be this kind of beautiful dance, as I refer to it as, if people don't know their roles in the room. And I think that's one of the things we've really focused on is making sure we have expert, high quality SANEs, but that they're also preceptors and that champion at the remote site. I think those are kind of the two big things for us. Thanks, Randy. Nancy, do you have any additions to what Randy may have mentioned? Definitely that champion. You just have to have somebody at that site who's rooting and really pushing it. But for me, I wish that we had started more with that outreach person, a full time outreach person, because that is really the person who keeps everybody on the same page. So it's every community agency knows about us. So it's not an advocate walking in the door, not knowing that tele-SAFE is going on or law enforcement, but really letting everybody in the community know, the district attorney's offices, really making sure that they're aware. And I guess the time that it takes to get a hospital up and running, if I had only known that it would take that long to get everything going because the needs assessments first. But then it's a matter of you may have, you know, the hospital administration saying, go, go, go. Yep, this is great. But it's those frontline workers that we really want to be talking with and making sure that they're comfortable with us and that they're using us to the best of their ability, you know, that we're there. And so that they understand every reason to use us. So, you know, I think those would be the couple of things that I would have kind of wanted to do in the beginning. Thanks, Nancy. Yeah, I would agree with you. Those are very important elements, especially from the binder thing is just like debilitating across across all the sites is the resource binder and making sure that the right forms and everything are all present for for the local spoke clinicians. So I hear you. For those of you that might be practicing currently, if you would like to chime in here, we would love to hear your thoughts and feedback. I know that I I spoke with a couple of colleagues in the field and they all brought up the fact that it's a different. Well, you can be being a good saying does not necessarily translate to across the screen and across across technology. And that was one thing that we sort of have heard across the board from those that are practicing in the field. So I was glad that you brought that up, Randy. So would anyone else like to chime in? Just unmute yourself. All right, Diane, why don't we talk about the toolkit and then we'll open it up for more Q&A. Sure. Anyone wants to chime in during the Q&A, we would love to have you chime in during the Q&A as well. Absolutely. Actually, I was going to say something about the champion and how important it is. And we're starting to see that now with our demonstration sites because they are beginning to launch and they've done trainings with the spoke sites and the spoke clinicians. But not only are they realizing the value of having this champion who's engaged in this project, but also to have the rest of the nursing staff, like it's not working well if the nurses are just voluntold that this is what they're going to do. They're not engaged with this. They don't want to take care of this patient population. They maybe shouldn't be taking care of this patient population. And it's unfortunate because they are ER workers and cases come in through the ED. But what our sites are really learning firsthand is that it is important to have not just a clinician with a pulse, but actually a clinician that is engaged in the process. So, yeah, let me talk a little bit about our toolkit, which is the final deliverable for the IFN. It is going to be an online toolkit. It will be a comprehensive compilation of all the resources and references that we have gathered and used, and that we will share so that it can aid whoever is developing a tele-safe program, whether it's a clinician that's taking the lead on it or MDT partners or even a facility administrator in this planning of a program. So that's coming. But prior to that, I'm just going to, well, let me just jump ahead here just to show you what we actually do already have on our website. So there's a tele-safe website, tele-safe at forensicnurses.org. That's an email. And if you have any questions, you can just email that and one of us will get back to you. Or you can email Andrea, who is project manager of this project. Then we have this tele-safe webpage, which is a portion of the IFN webpage. And on this webpage, we have linked archive webinars that are free, and some of them have CE associated with them. So things like considerations for conducting research and evaluation with sexual assault survivors. It's a fabulous webinar. Quality caring model, also fabulous. You know what that means for tele-safe programs. Quality improvement, peer review, and case review. What's the difference? How to use a tele-safe quality assurance tool. And also then our newest one is trauma-informed communication about confidentiality and consent in the tele-safe setting. So as we have more webinars, we will be adding materials. We have other materials that we're willing to share. Some of them are not up on that site yet. So you just reach out to us. So do we have any further questions? Let's see. I'm going to say there's a couple participants who look like they're working in the field. Not to call anyone out. But for anyone that is working in the field, we'd love to know if you had any thoughts on any of this or anything else that you would think would be helpful to share with people that are considering working with this. I saw Danny. I see you're a coordinator up there in Maine, I believe, which is awesome to see. There's the contact list. I'm going to ask for that, too. Did you see that? So Leslie Hansen. Yeah, starting next week. It says you're going to be starting a new job. You want to talk about that? I was muted. I really don't know what to tell you because I haven't started yet. I was hired with Colorado to do their Telesafe program. And I start next week. And I think they've started with two sites already, but they're trying to expand to six. And so I'll be overseeing two of the sites that they initiate. Is this the state of Colorado? Yeah. Oh, okay. And then I'll be overseeing the grant that they received to start a Telesafe program. Very interesting. So have you done some Telesafe? Do you have experience? No, I've been trying to get it established for a long time. I actually work in Wyoming, live in Colorado, and I've been trying to get grants for Wyoming to start such a program. So I'm really excited to get the experience with Colorado and then perhaps take it to Wyoming. Oh, good for you. Congratulations. If you have time, you should take a look at some of those webinars. The quality caring model is for sure one I would look at. Thank you. And you also asked about the toolkit. When will it be available? Yes. Are we looking months out? No, it'll be closer to the end of this project, which is going to be September of 22. Okay. But we have pieces and parts that we're willing to share that OVC is happy to have us share with you. That would be wonderful. I'd like to gain as much knowledge as I can as I'm starting up and take what I can into the program. Absolutely. I'll be getting in touch with you. Great. It looks like, Danny, you guys have the Telesafe program going up in Maine. Anything to share with kind of your lessons learned along the way or pearls of wisdom, knowledge bombs you can drop? Dang, no pressure. Yeah, so I think the purpose of our Telesafe program is to really have preceptorship available for the nurses in training so that they're implementing best practices when caring for the survivor. We have such an imbalance between nurses and training, and those are preceptive. So we're trying to credential the ones that are in need of support. I think lessons learned would be that patience is a virtue. You know, it may be pandemic-related, but patients don't just flood through the door for that opportunity to implement telecine. And so that's been a take-home for me. And I think scripting to engage for a patient to elect these services is very important to really demonstrate the importance and, you know, efficacy of the program. So that's been a barrier, but also a win at times. I work in tandem with Polly, so I don't know if she has any take-homes as well. I was about to call her out next. She was integral in the planning stage of it, which happened before I signed on. So she did all the grunt work, and I got to take some glory. The only thing I would add, Dana, you did a great job of giving an overview. I didn't have a full understanding of telecine when we started, and I'm ever so grateful to Massachusetts for helping us get our program off the ground. We were in contact with them a lot, and they were very generous, as was Diane. I was on the phone with her quite a few times. I think one of the most important things is to have your preceptors really know what they're getting into, because I agree with Randy. Not everybody can do that. You know, it's like nurses are, they can be fabulous nurses, but they're not teachers. So being able to have a really good preceptor training program is imperative. So that's the only other thing I'll say. I think we'll all second, third, fourth, fifth that, Polly. Thank you. And if anybody has actually an agenda for a preceptor course, I mean, we do have sort of a teaching process, but I would love to see anybody else's if they're willing to share. I'll put my contact information in the chat box. I think that'd be great. It's great to see you both, Polly and Danny. You know, that's one of the things when you're talking about, you know, how not everybody can teach. Not everybody is, you know, able to come across in the way that, you know, they need to. And one of the things that I think about is we never kind of stop to think, why aren't all the ER nurses saying nurses? You know, we don't know. You know, they may have their biases or they may have reasons why they're not. And I think that that's one of the things that we really had to stop and make sure we were taking care of that nurse. Because is there a trigger that is affecting that nurse that we're not paying attention to? You know, and it did happen with us where a nurse didn't come back to work for two days after she did the exam. And I reached out to her personally to talk to her. And, you know, that really made us stop and say, wait a second. You know, we really need to be looking at who's going in to do these exams. May I just add something in response to Nancy? Yes, please do. We have started a couple of years ago, we started Sane Tele Echo. And our purpose is to try and help nurses not suffer that compassion fatigue, that burnout, that vicarious trauma. And data so far, and we don't have a lot of it. It's only been since August of 19. But the data so far is showing that this is working. We developed a template that the nurse completes to present at Tele Echo. But what we're finding is that many nurses are saying, I'm using that after every case, and it makes such a difference for me. So it takes away the kind of the stigma of, you know, I'm a SANE nurse, I can take anything, to really being able to acknowledge their own vulnerability and talk about it. I just want to put that out there. And if you're interested in knowing more. Yes. We actually started in New York State doing the Echo. And it is absolutely wonderful. And it is thank you to you because we saw your presentation that you did. And there wasn't one nurse that watched it that said, hey, New York needs that, you know, doesn't need this. We all were like, we got to get this going. This is great. So kudos. I'm so happy to hear that. Thank you for sharing that, Nancy. And thank you to IAFN for allowing us to do that presentation. I actually think it's saved in the LMS from that presentation, I believe. So for anyone that is curious, yeah, from the conference, I believe the Echo presentation is in there. And we've been accepted to do another one, a two years later one, for this conference. Okay. Great. Adriana, there's a question from Cheryl Nooner about reimbursement. Cheryl? Do you want to ask your question? Yeah. We are looking into, well, we're starting a program here in our region. We don't have one in our region. And I'm with a large hospital system. And we have several outlying facilities within our system that serve the more rural areas of our state, because we do have, not rural like Alaska, but rural nonetheless, in terms of patients being able to get access simply. So we're looking hard at telehealth. And I've checked with our compensation folks at DCVC, and there's been no provision made. They have not yet begun to look into reimbursement for telehealth services. And I just wondered how you all navigated through that, what you did, and how that is looking for those who have had a program up and running for a while. Any responses from the field there? We're still under OVS grant. So that is actually how our nurses are getting paid. We still make sure that the hospitals are following the guidelines for the forensic reimbursement for New York State, and making sure that that's being offered so that the hospitals on their end, are following what they need to for their reimbursement. But that's one of the things that we look at. It's one of the things that we do look at is, that's sustainability. And is that something that we need to look at? It's a tough one. Is anyone from Nebraska? Yes, Kate Buehler and Heather Nichols are on from Nebraska. Okay. Do you want to talk about that a little bit in Nebraska? This is an ongoing conversation in Nebraska about sustainability and with our business plan and how to market ourselves and also be fair to our rural partners. We are an active contract negotiation. So if anyone has any price point that they think is fair, we came up with ours based on our call pay and response time and to a break-even point. And we figured that with 24 hour coverage, we would have to charge by month for our services and probably not by kit to have a break-even point. So with 24 hour coverage at $1,800 a month per site, we would need three sites to break even. It's kind of where we're at with our negotiations. If anyone has any suggestions or would like to provide feedback, we would welcome that. I think that's an interesting way of looking at the reimbursement piece. I'm very curious on the sustainability of that. I do think that that could be very successful that way. I think as far as Nebraska, we were looking at case volume and we're at a large healthcare organization, but we still have to be at least about as close to cost neutral as we can get. So that's what we're aiming for. And I can tell you one of the, when we started with our program, the UCM is a for-profit telemedicine company. And so in order to have the grant, we were under St. Peter's Health Partners. So it was a merge and sometimes I feel stuck in the middle of a for-profit and non-for-profit and trying to explain to them, no, no, no, you can't do that, we're on a grant. It gets very confusing, but their minds are always looking at, well, how can this be sustainable and what's the business plan look like and how much do we have to charge to be able to do that? So I would love to talk with you about that because that is something that they are constantly looking at and how many facilities they would need on board. And it definitely would be more of a monthly fee that they would get. So one of the things that always kind of circles back in my brain is that just all these other telehealth opportunities are being reimbursed by CMS. And because we're nurses, we don't meet those qualifications for Medicare reimbursement. And I mean, as a group, could we not make some changes in that? Could we not like look towards having that changed for this kind of specialty care? When we- Go ahead. I'm sorry, this is Kate again from Nebraska. I'm curious, when we think about other nurses that provide a specialized service, at least here at Nebraska Medicine, we think about like wound nurses. Wound nurses provide a very specialized service that is reimbursed to a certain extent. So they would have a like interest in this as we do of how do we sustain ourselves? We offer a service that our patients need. And I don't know, I think there's a conversation there and that's kind of how we looked at it here in Omaha. And I do, you know, I have a couple of jobs, which I'm sure like everybody does. But my other job is running 17 counties for child advocacy centers. And in seven of those sites, we do telemedicine. And we actually do bill CMS rates. You know, we went through Medicaid rates with CMS and because most of them are nurse practitioners, bless you, we wind up doing, you know, Medicaid rates to at least get that reimbursement from, but there has to be a way, there really does have to be a way. There needs to be sustainability beyond grant funding for this specialty care that we're giving. I mean, we're the experts, but we are involved with that patient care. So we are giving care and there needs to be reimbursement. We're professionals. I wonder if Jessica from Missouri would pop on and well, unmute yourself and share a little bit about the bill to utilize a tele-safe looks like facilities by 2022. Jessica, are you out there? I'd really like to hear about that. I know, she said, Missouri is implementing a bill that will require us to utilize a tele-safe program by 2022. I'm currently working in a facility that has only one SANE nurse from St. Louis to Memphis. Any help with implementing tele-SANE would be greatly appreciated. That's interesting. So they'll have to utilize a tele-SANE if we do not have a SANE nurse on staff. I'd be interested to hear more about that. Yeah, and if you had to leave, just reach out to us. And Susan, it looks like you mentioned you're starting tele-safe services soon. Are you on and would like to share at all about that? So we actually have a program here, but we are gonna use tele-safe. We haven't actually, I think we talked about it today with them as well too, that we are gonna implement it at our hospital based on just probably for the purposes of like education material, educational, and just like with the precepting for nurses who haven't seen a case in a while and things like that. And if they happen to be on call, rather than- Susan, where are you located? Sorry. In Rochester, New York. Okay, great. Upstate New York. Yes, we've been in communications a lot lately. Yes, yes. So they're signing on with our hospital system because some of us don't have SANE programs. My facility happens to just have one within our system, but we're still gonna take the services and utilize them in other ways. Right. Right, and we also, in our program, we started off with adult adolescents, and then we realized that every facility we went to would say, well, what about pediatrics? So all of our providers are pediatric trained, so able to assist with pediatrics also. So I know that's one of the ways, Susan, they were talking some help with pediatrics also. Okay, awesome. I wanted to go back, because Aiden from Dublin is on. Aiden, can you talk a little bit about what's going on in Dublin? It's Aileen, Aileen. Oh, it's a D. Oh, I have a D, sorry. Sorry, I think it auto-corrected. Aileen from Dublin, are you on? And I will gladly go and help with anything that they need. I thought I saw her on here. I did too. Right, well. We wanna go to Liana. So, hi, Liana. Hey, yeah, yeah. Good to see your name. I'm hiding behind the screen, so. Yeah, so my question was, how long did it take to train a nurse to be a tele-sane? And then a knock-on to that is, how much experience should they have in the field before they actually change their practice to being a tele-sane nurse? I think we ought to ask Randy what you, if you all have an opinion on that. We sure do. So, in general, we feel like people should have three years experience being a sane. That being said, some of our regions are busier than others. So if they work in a busier region and they have two years, but, you know, enough cases. And it really depends on also what their manager in their region gives for recommendation. The quality of their paperwork, those kinds of things. So I would say two to three years, I think of pretty regular robust practice is good. And we usually have two days of training. So it's not a ton of additional training. It's more, how can you do both things at once, right? Support that nurse through the computer screen and support that patient. How they can help with troubleshooting, how they can precept remotely, because again, these nurses have great precepting experience but it's when there's a new sane nurse right next to them, not when there's a nurse that doesn't have any forensic nursing experience or background on the other end that they're working with. Talking about the messaging, I think nurses on sort of that remote end who are taking care of the patient. So not the tele-sane. Sometimes they don't know how to word the whole process to the patients. They don't wanna seem like they're not competent to take care of them. They might feel kind of weird having another nurse watching their work. So some of that messaging we work on with them as well, so they can help that nurse feel comfortable with letting them in the room to take care of the patient with them. While you're gonna get those nurses that are like, yes, please help me. You're also going to get some nurses that push back a little bit. And also, to a certain extent, rightly so are protective about their patients. We don't record exams, we don't take screenshots, things like that, but they might be worried for their patients. Like how, I don't know if my patient is going to like this service or accept this service. So again, it's kind of a messaging piece and working together with them. One of the things we spend a lot of time on are mock exams. So that's during their orientation training and also when we hire them. So yes, they get an interview, but then they also have to do something. They have to teach us something new over the equipment so we can see how they are on screen. So I think that piece of watching them on the screen when you're planning on hiring them and having that again during the orientation training is really important. You don't want to just send them out there never having watched them before. It's a really good idea to do that during your training. But yeah, we have about a 16 hour training. So it's not very much once they're an expert sane to become a tele-sane. Thanks, Randy. Randy. Appreciate that. Got a couple more questions flying in here, which is great. Kaylee asked, can you please explain how tele-sane works? Kaylee, do you want to add to that question or do you? Do you see my whole explanation below? I work at a small town hospital. It's only me and one other sane. We both have very young children. So in the last few years, it has been very difficult that if we get called in, I might have a newborn or been on maternity leave. Our physicians do not like doing the exams themselves because they either are not good with pelvic exams. They don't know how to explain things in a way that me and the other sane do. So they prefer us. But like I said, we've had difficulties over the last couple of years that neither of us can get there. So I don't know anything about tele-sane. That's great. Nancy, do you want to go ahead and take that? So the way that the tele-sane works for us in New York is when we go and meet with the hospitals and do education, we look for sane nurses that are in the program that either want to use us as a second set of eyes or any kind of consult. We also look at how many nurses they may have on orientation that need precepting so we can precept. And then we look at working with an emergency room nurse. So we want to make sure that every nurse that goes into the room is feeling comfortable and competent. Because I always say, it's not our exam, it's their exam, we're there to help. And so it's a lot of conversation that we have prior to the nurse going into the room with the nurse that's there. We want to make sure that, again, they're comfortable going in. And then we would be on with them. We can see them. We use the mobile ODT copescope. That's how we actually talk through and we can do the photographs through there. But we'll talk with them and be there however they want us. If they want us to speak up, if they want us to just wait until the very end, and then we'll help them with documentation, collection of evidence, reviewing photographs, packaging up evidence until they're ready to get off, talking with us, we're on there until the very end. Thanks. Thanks, Nancy. Kaylee, did that answer your question? Do you have any follow-up questions with that? So an RN that is not a SANE can still not do the exam? Yes, they could do the exam. They could do the exam because the TELUS SANE is helping them. Correct. Present. The only portion that we would have the physician come in for would be the speculum exam if they were not comfortable, not trained on doing a speculum exam. So again, that's conversation we would have prior to going in the room. And normally what I do is have them introduce me to the physician who may be going in to do the speculum exam so that they're not walking in and saying, who is this person here? And I may wanna just talk with them about how comfortable they feel in doing it. Okay, thank you very much. Kaylee, we also have, if it was a non-SANE that was in the room completing the exam, we also would, of course, we have some things we recommend. At baseline, they would have that two-hour no-SANE in-site training at a minimum. Like they may not be a SANE, but that would help give them a little bit of baseline about what we do. Obviously, it's nowhere near a 40-hour training, but that is something that some facilities are using to help provide that, for the providers that are in the room doing that. Okay, thank you very much. Great question. Thank you, Kaylee. And Julie asks, are there tele-SANE programs located by particular states or do specific organizations provide services in multiple states? Julie, your answer to that question is yes to both. It is being done kind of on a statewide basis in places like Maine and then other associations, or other places it's a specific organization providing services. Like the demonstration site that we talked about, yeah. Avera, they're providing services in up to five states. Randy, you all provide in a couple different states as well, right? No, right now we are strictly Massachusetts, although we have kept Hopi Healthcare Center in Arizona on in kind. We haven't seen any patients with them since the pilot project ended, but we have had one consult. They're very low volume, so they're an easy lift, but we have expanded from two to 10 sites in Massachusetts. So I think it's important to go slow and steady and have patients as we mentioned, because it does take a long time, but we only work with Massachusetts hospitals primarily. Thanks, Randy. All right, I think we got to everyone's question. Oh, I think we got to everyone's questions, but if there's anything else that we missed or you have more questions that come up, please feel free to email us. Diane will pop up the web addresses maybe again, just so that you, the safety website, and we encourage you to visit the website on IAFN under the, which tab are we under? Uh-oh. Resources, we're under resources. Thank you, under the resources tab. Yeah. Oh, dear. All right. Yes. Diane's not doing that just yet. Okay, all right. Thank you for everyone who participated and please feel free to reach out if you have any more questions or see our websites for other webinars that are recorded under that resources tab. Thanks, everyone. It's great to see you all.

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