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{ timecode: 0, handler: 'blob', id: 1, data: {text: 'DAVE CYRA: I have a whole bunch of things to talk about before we get into the presentation, but you can see what we are talking about are reasonable addition to the family of transit services and '}},
{ timecode: 11, handler: 'blob', id: 2, data: {text: 'maybe now might be a really good time when everybody is in a bind financially and you are going to see why people enter into stretcher non-emergency. The other thing I wanted to mention, it’s '}},
{ timecode: 26, handler: 'blob', id: 3, data: {text: 'either mentioned in the thumb drive that you all have but something that’s related to it would be the Research Results Digest 75. This is a TCRP report and some of you may not be familiar with '}},
{ timecode: 43, handler: 'blob', id: 4, data: {text: 'it. It summarizes the final report cost benefit analysis of providing non-emergency medical transportation. An excellent report that was done several years ago and if you don’t have it, you '}},
{ timecode: 59, handler: 'blob', id: 5, data: {text: 'should have it. If you call TCRP, you get it free. Second thing that I believe there is at least a reference on your thumb drive, are the guidelines from Washington State, the first state, in my '}},
{ timecode: 75, handler: 'blob', id: 6, data: {text: 'knowledge, to come up with standards for stretcher non-emergency. They are still in the process but they’re at least the first state to do that. What is really kind of cool about that is if you '}},
{ timecode: 90, handler: 'blob', id: 7, data: {text: 'get a hold of this particular report, on page 12, they have a whole table on here about ambulance versus non-ambulance vehicle transportation decision tool. In other words, they lay it out for you '}},
{ timecode: 112, handler: 'blob', id: 8, data: {text: 'like for your dispatchers, or for your telephone receptionist, what is an emergency and what isn’t an emergency. That kind of information would even be good for you all even if you are carrying '}},
{ timecode: 126, handler: 'blob', id: 9, data: {text: 'just wheelchairs. Because, you know, people are funny; they try to take advantage of certain things when they are there and you have to put a stop to it. The other thing is that there is a 6-page '}},
{ timecode: 140, handler: 'blob', id: 10, data: {text: 'article in regard to what you should know about MRSA. Tim, my compadre, in regard to delivering stretcher non-emergency training, is the one that wrote it. If you have any questions about MRSA, that '}},
{ timecode: 155, handler: 'blob', id: 11, data: {text: 'is also on your thumb drive. In addition, we have just like 7 power point slides which are not too long, so it is not going to be too long. Then in addition, there is the two-day training that we have '}},
{ timecode: 173, handler: 'blob', id: 12, data: {text: 'developed for the state of Florida. Through the University of South Florida, they schedule us every once in a while and Tim and I deliver for people in the state. It is a two-day training and it '}},
{ timecode: 186, handler: 'blob', id: 13, data: {text: 'covers 16 subjects. You will an idea of looking at the agenda but then in addition, it’s training to proficiency. You don’t get the scores, you know, pass or fail; you don’t get an F '}},
{ timecode: 207, handler: 'blob', id: 14, data: {text: 'to an A or whatever, but you get various levels of training, which is a training proficiency from five levels from “T” for trainer all the way down to N which means they have some '}},
{ timecode: 220, handler: 'blob', id: 15, data: {text: 'knowledge but can’t really put it into practice. Another thing you have is, legally speaking; this is a common carrier liability for acts of third parties. For all of you transportation '}},
{ timecode: 238, handler: 'blob', id: 16, data: {text: 'providers, this really is very, very interesting. It begins to tell you where the responsibility lies for you as a common carrier. In addition, there is also a definition of Standard of Care that is '}},
{ timecode: 254, handler: 'blob', id: 17, data: {text: 'mentioned in there as well as Doctrine of Negligence. That is why you get sued if they can prove negligence. Then also Ethical Decision Making. There is also that on your thumb drive as well as '}},
{ timecode: 269, handler: 'blob', id: 18, data: {text: 'legislation regulating oxygen administration as well as several slides, several plates on what a stretcher vehicle may look like. Before we go into the slide presentation, I want to introduce our two '}},
{ timecode: 290, handler: 'blob', id: 19, data: {text: 'people up here. First of all, I will introduce Tim. Tim and I have been working together. He is an EMT and we have been working together on this stretcher course; I don’t know how many courses '}},
{ timecode: 303, handler: 'blob', id: 20, data: {text: 'we have delivered. I don’t know about ten or twelve or something like that. TIM MCLENDON: About a dozen. DAVE CYRA: He brings me the operational stuff. When we were in Florida in the mid 80s '}},
{ timecode: 315, handler: 'blob', id: 21, data: {text: 'about in early 1900s we recognized the fact that there wasn’t standardized training for that, so what we did we put together these two-day programs. I don’t know; I think it is pretty good '}},
{ timecode: 332, handler: 'blob', id: 22, data: {text: 'myself. Then there is Bobby Jernigan; he is from the Commission of Transportation Disadvantage. Bobby, tell them your title and what you do. BOBBY JERNIGAN: Thank you Dave. I am Bobby Jernigan. I am '}},
{ timecode: 344, handler: 'blob', id: 23, data: {text: 'the Interim Executive Director with the Florida Commission for the Transportation Disadvantage and so we are here to kind of discuss a little bit what the stretcher transportation and what our '}},
{ timecode: 356, handler: 'blob', id: 24, data: {text: 'experience is in the state of Florida, so we have got quite a few. Just let me know when you want me to go into that detail. DAVE CYRA: I sure will. Let’s go to the next slide. Well here is the '}},
{ timecode: 367, handler: 'blob', id: 25, data: {text: 'definition for you in case you want to start writing something or get your board involved in regard to if you should really do this or not. Here is a definition: Transportation of a person, you can '}},
{ timecode: 378, handler: 'blob', id: 26, data: {text: 'see up there, in a supine position in a vehicle designed constructed or reconstructed for the purposes or safe conveyance. The person transferred has non-emergency medical conditions where no medical '}},
{ timecode: 391, handler: 'blob', id: 27, data: {text: 'assistance by the driver is needed or anticipated. A stretcher team comprising of a driver and an attendant are trained to proficiency, and of course, the training to proficiency comes from where? '}},
{ timecode: 407, handler: 'blob', id: 28, data: {text: 'ADA, right? And we have also defined what proficiency is; it is competency. Some reasons to begin to consider is stretcher non-emergency part of the family of transit services: The changing '}},
{ timecode: 430, handler: 'blob', id: 29, data: {text: 'demographics, the non-availability of emergency vehicles when used for non-emergency trips, the cost savings to purchasers of past such service. Okay Bobby, tell them about what the full cost of the '}},
{ timecode: 448, handler: 'blob', id: 30, data: {text: 'course is and also maybe what Medicaid reimburses on. BOBBY JERNIGAN: In Florida, what we find is that the fully allocated cost is about $105.00 for stretcher transportation per trip. With our model '}},
{ timecode: 465, handler: 'blob', id: 31, data: {text: 'that we use with the Transportation Disadvantage, with our commission being the broker, if you will, of Medicaid non-emergency transportation in the state of Florida, we are reimbursed somewhere in '}},
{ timecode: 479, handler: 'blob', id: 32, data: {text: 'the neighborhood of $50.00 to $56.00 per trip across the board. That means ambulatory, wheelchair or stretcher. Ambulatory fully allocated cost in our industry for the state of Florida for ambulatory '}},
{ timecode: 493, handler: 'blob', id: 33, data: {text: 'trips is somewhere around $18.00 or $19.00 per trip; wheelchair is somewhere around $27.00 to $28.00 per trip and stretcher, as I said, is somewhere around $105.00. The expense is associated with the '}},
{ timecode: 508, handler: 'blob', id: 34, data: {text: 'specialized equipment, of course as we know, and then the utilization of two people as a pretty much an understood standard across the state. A lot of our providers have taken the common sense '}},
{ timecode: 521, handler: 'blob', id: 35, data: {text: 'approach to that. DAVE CYRA: Tell them what happened in Lake County when the owner of a company did it with one person in a hospital. BOBBY JERNIGAN: That, as they say, how did that go? Not too good. '}},
{ timecode: 539, handler: 'blob', id: 36, data: {text: 'There was an individual who was being transported. The provider did pick the person up. It was a frail older female and she was consequently dropped. A few weeks or so after that, she did pass. Some '}},
{ timecode: 556, handler: 'blob', id: 37, data: {text: 'of the complications would be due to the maybe the impact but she had already had several broken bones already and then that sort of helped us complicate the problem, so it is important that you have '}},
{ timecode: 569, handler: 'blob', id: 38, data: {text: 'efficient and effective individuals and enough individuals to do the service. DAVE CYRA: And you know when you are there in a medical center, you would expect maybe some competency on the other end, '}},
{ timecode: 584, handler: 'blob', id: 39, data: {text: 'but the thing that really scares the bejeepers out of me, and all of us I think, is when you go to a residence you may be conveying a male individual that is maybe 95 years old. At the other end of '}},
{ timecode: 599, handler: 'blob', id: 40, data: {text: 'the stretcher you want a 95-year-old woman helping you with that stretcher or do you want to be capable of doing it yourself? Believe it or not, there are still people doing it in Florida with one '}},
{ timecode: 614, handler: 'blob', id: 41, data: {text: 'person largely because the reimbursement rate for Medicaid is so low. BOBBY JERNIGAN: That is correct. DAVE CYRA: Okay, let’s go continue on. One other thing in regard to cost savings is what is '}},
{ timecode: 629, handler: 'blob', id: 42, data: {text: 'the cost of an ambulance trip? Anybody got any ideas out in the audience? AUDIENCE: (Inaudible.) DAVE CYRA: How much was that Steve? AUDIENCE: (Inaudible.) DAVE CYRA: Well, I do not necessarily agree '}},
{ timecode: 649, handler: 'blob', id: 43, data: {text: 'with that figure. I think it is probably close to maybe less than half. Just by rule of thumb, we are looking at a stretcher team of maybe $150.00 and an ambulance trip of like $500.00. For every '}},
{ timecode: 671, handler: 'blob', id: 44, data: {text: 'trip, you have got a little bit of a savings there, eh? Okay, the relatively basic training requirements necessary for its implementation, again continuing with the reasons, and then a coordination '}},
{ timecode: 685, handler: 'blob', id: 45, data: {text: 'measure that is effective and efficient. Something else that is coming into play, and that is emergency evacuation, those vehicles are going to be used to the hilt. Going back to Dale’s first '}},
{ timecode: 702, handler: 'blob', id: 46, data: {text: 'comments, we are probably, you know, if in your emergency evacuation plan, you don’t have a use for the funeral parlor vehicle, you are really missing the boat I think because in an emergency '}},
{ timecode: 717, handler: 'blob', id: 47, data: {text: 'evacuation, you are going to be using all the vehicles that you possibly can. If you have stretcher non-emergency or NEST as part of your resources, I think you are in much better shape. '}},
{ timecode: 732, handler: 'blob', id: 48, data: {text: 'Implementation guidelines: Preferably established state standard for state operation. Again, I think Washington State is certainly going about it in the appropriate way because with state standards, '}},
{ timecode: 751, handler: 'blob', id: 49, data: {text: 'it covers the state as you can see. In Florida, we have 68 counties and, Bobby, 70 counties? BOBBY JERNIGAN: 67 counties. DAVE CYRA: 67 counties. And how many of those counties are delivering '}},
{ timecode: 767, handler: 'blob', id: 50, data: {text: 'stretcher non-emergency either with public or private nonprofit operators? BOBBY JERNIGAN: We have 56 in the state. DAVE CYRA: 56 out of 67. To me, that is the highest frequency in any state, okay? '}},
{ timecode: 788, handler: 'blob', id: 51, data: {text: 'The state of Florida hasn’t grabbed the bull by the horns yet to develop state standards but I think it would be a good idea if they start looking at that. In lieu of state standards, what '}},
{ timecode: 801, handler: 'blob', id: 52, data: {text: 'happens? Each county develops their county ordinances and I think you have it on thumb drive as well or a reference to it. If you are interested in what those ordinances might look like, get a hold of '}},
{ timecode: 819, handler: 'blob', id: 53, data: {text: 'the Lake County ordinance. Tim, what is the website that people can go ahead and look at county ordinances? TIM MCLENDON: The website is municode.com and this is a city-based search engine. It is not '}},
{ timecode: 840, handler: 'blob', id: 54, data: {text: 'just for Florida; it can be used throughout the country for your county, for you neighboring county. You search by state and by the county and keyword search and you can search pretty much any county '}},
{ timecode: 854, handler: 'blob', id: 55, data: {text: 'ordinance in the United States. DAVE CYRA: That’s great. And being an operator, so we have an operator and administrator, caretaker here. Tim, for being an operator, when you have different '}},
{ timecode: 868, handler: 'blob', id: 56, data: {text: 'standards in each county, what kind of impact does that have on the stretcher team or the company that represents the stretcher team? TIM MCLENDON: It is confusing and limiting. A very good example of '}},
{ timecode: 884, handler: 'blob', id: 57, data: {text: 'this is two of the counties that we service. Our home county has no ordinance. They lump it in with wheelchair service. Our neighboring county has an extremely restrictive ordinance that does not '}},
{ timecode: 903, handler: 'blob', id: 58, data: {text: 'allow stretchers in it. Even though our vehicles are dual-purpose vehicles, meaning that I can provide transportation for wheelchair transports and I carry a stretcher in the vehicle so that that '}},
{ timecode: 921, handler: 'blob', id: 59, data: {text: 'vehicle can immediately switch over with two people and begin stretcher transportation because I carry a stretcher in that second vehicle, I can’t send that vehicle into the neighboring county. '}},
{ timecode: 933, handler: 'blob', id: 60, data: {text: 'If I do, they can fine us and in some situations the county will actually arrest the personnel and impound your vehicle. They do not play games with it, so we had to be very careful about where that '}},
{ timecode: 950, handler: 'blob', id: 61, data: {text: 'vehicle goes, what that vehicle does and it really hampers the ability for inter-county cooperation and transportation. DAVE CYRA: Okay, if anybody has questions, just raise your hand. We are going to '}},
{ timecode: 965, handler: 'blob', id: 62, data: {text: 'take them where ever we can and I am moving this along pretty quick so that we get out of here around 4:30. We are almost done. The third one down is Public, Private, Non-Profit and Private for Profit '}},
{ timecode: 975, handler: 'blob', id: 63, data: {text: 'Organizations willing to provide this type of service, the utilization of a training regimen that minimizes risk and enhances safe operation and then seeking assistance from local emergency medical '}},
{ timecode: 989, handler: 'blob', id: 64, data: {text: 'providers. In Florida’s case, I know for fact that the EMTs in the area went basically begging some of the public or private non-profits to take this over because they were really in a bind in '}},
{ timecode: 1006, handler: 'blob', id: 65, data: {text: 'regard to administering to non-profit, non-emergency type trips or an emergency trip comes up and a vehicle is out. It really incapacitated them and so therefore, they wanted to train, in fact, they '}},
{ timecode: 1021, handler: 'blob', id: 66, data: {text: 'even volunteered to train some of the people in regard to how to actually do it. Okay, barriers, state and county reluctance, lack of legislative ordinance, ambulance constituents. For instance, in '}},
{ timecode: 1035, handler: 'blob', id: 67, data: {text: 'California, man, the lobby has really rapped that thing up. They don’t want to see anybody do stretcher non-emergency other than ambulance and you can sort of understand why. Lack of qualified '}},
{ timecode: 1048, handler: 'blob', id: 68, data: {text: 'providers, lack of appropriate funding, lack of data providing information on risks and benefits. Some states where NESTS are operable, and NEST is non-emergency stretcher transport, Alaska, Florida, '}},
{ timecode: 1060, handler: 'blob', id: 69, data: {text: 'New York, Oregon, Washington and Virginia, the contact information is over there. One question for Tim, why don’t you explain a little bit about MRSA and also what impact MRSA may have even in '}},
{ timecode: 1079, handler: 'blob', id: 70, data: {text: 'regard to carrying people with wheelchairs. TIM MCLENDON: I guess the first question to ask is if anybody in here knows what MRSA is. I have one hand, two hands, 3, 4, Oh no! MRSA is an abbreviation '}},
{ timecode: 1098, handler: 'blob', id: 71, data: {text: 'for methicillin resistant staphylococcus aura. Or aurea, however you wish to pronounce the last word. Now you understand why you call it MRSA. Basically it is a bacteria that is resistant to '}},
{ timecode: 1116, handler: 'blob', id: 72, data: {text: 'methicillin which is one of the strongest antibiotics that are out on the market. What a lot of people don’t realize is that in today’s society MRSA has become a very, very common bacteria '}},
{ timecode: 1129, handler: 'blob', id: 73, data: {text: 'that people can get into. Historically, it has been a bacteria that you had to be very, very ill in order to contract or to have grow within you. Not so much anymore. It is becoming a little more '}},
{ timecode: 1145, handler: 'blob', id: 74, data: {text: 'aggressive and you find it a lot in individuals whose immune systems have been beat up, people who have spent extended stays in hospitals and in some cases nursing facilities and we are starting to '}},
{ timecode: 1160, handler: 'blob', id: 75, data: {text: 'see it progress through all modes of transportation, mostly with ambulance-level transportation; stretcher is seeing quite a bit of it. We are seeing a lot more of it in wheelchair and even ambulatory '}},
{ timecode: 1174, handler: 'blob', id: 76, data: {text: 'transportation, so one of the things that we really try to do with the class that we teach we try to enlighten people about the need for some additional training for all of their employees whether it '}},
{ timecode: 1193, handler: 'blob', id: 77, data: {text: 'is driving a sedan, a city bus, stretcher vehicle or ambulance on how to minimize the risk for catching diseases or illnesses that are out there. DAVE CYRA: Tim, give them that statistic in regard to '}},
{ timecode: 1211, handler: 'blob', id: 78, data: {text: 'health care providers. TIM MCLENDON: The statistic…. DAVE CYRA: This is scary. TIM MCLENDON: The statistic, and I have looked for a long time to try to back this up, so I guess the unofficial '}},
{ timecode: 1222, handler: 'blob', id: 79, data: {text: 'statistic that we were trained with years ago is that a health care provider, if a health care provider is in the field for more than one year there is a 70% chance that they have MRSA. It does not '}},
{ timecode: 1237, handler: 'blob', id: 80, data: {text: 'mean that they are infected with it; you can have it and not be affected with it meaning that it makes you sick but there is a 70% chance. I have been in the field for 15 years. DAVE CYRA: Do we have '}},
{ timecode: 1248, handler: 'blob', id: 81, data: {text: 'a question back there? Okay, Steve. AUDIENCE: (Inaudible.) TIM MCLENDON: A lot of that is going to based on your standard written policy. A lot of places will in fact turn that down as requiring '}},
{ timecode: 1272, handler: 'blob', id: 82, data: {text: 'specialized isolation precaution. If that is in your policy, then yes. Unless your people are trained in infection prevention and decontamination, which they should have some of that training as a '}},
{ timecode: 1285, handler: 'blob', id: 83, data: {text: 'basic part of their orientation, I would recommend it because you can actually spread it very easily and what happens is that your employees won’t get sick but they handle this individual who '}},
{ timecode: 1299, handler: 'blob', id: 84, data: {text: 'has MRSA and then the next five people that they put in their vehicle for that day, they pass it on to them and take it into the nursing home and they pass it along their wing who then pass it on to '}},
{ timecode: 1310, handler: 'blob', id: 85, data: {text: 'the next nursing home or to the adult living facility when they get transferred out. AUDIENCE: (Inaudible.) TIM MCLENDON: It will have the isolation equipment which is basically gloves. It is '}},
{ timecode: 1327, handler: 'blob', id: 86, data: {text: 'primarily spread by contact and there are exceptions like anything else but it is spread by contact so using standard gloves and a basic 10% bleach solution will kill the nasty little bugger and '}},
{ timecode: 1343, handler: 'blob', id: 87, data: {text: 'actually works better than stuff that you will pay $50.00 and $60.00 for out the supermarket. DAVE CYRA: I will tell you a funny story and then we can quit. Charlottesville, Virginia has a hospital '}},
{ timecode: 1356, handler: 'blob', id: 88, data: {text: 'that specializes in MRSA and one day the demand responsive vehicle goes to the hospital. They were dispatched to the hospital to pick up a patient and take the patient back, so the driver gets there '}},
{ timecode: 1371, handler: 'blob', id: 89, data: {text: 'to the door of the hospital and here is the potential passenger with this hospital attendant in the full garb, okay? He has the mask, the whole rubber suit on and everything and if you were the '}},
{ timecode: 1387, handler: 'blob', id: 90, data: {text: 'driver, what would you be thinking right? It just so happened that that hospital attendant was actually catering to somebody who had MRSA inside and he was just there babysitting until the vehicle '}},
{ timecode: 1403, handler: 'blob', id: 91, data: {text: 'came, but can you imagine the driver, you know, “Dispatcher help!” Right? Any other questions and then we can quit. Go ahead, Nancy. NANCY: (Inaudible.) DAVE CYRA: Oh, absolutely! You can '}},
{ timecode: 1421, handler: 'blob', id: 92, data: {text: 'certainly, you know, all we have to do is just think about what happened the first time we heard of AIDS, right? NANCY: (Inaudible.) TIM MCLENDON: Actually, I will tell you what, I am more concerned '}},
{ timecode: 1433, handler: 'blob', id: 93, data: {text: 'about MRSA than I am AIDS but it is a classic case of using a cannon to kill a fly. You don’t need all of that, just some standardized training will go a long way and the biggest thing that I '}},
{ timecode: 1450, handler: 'blob', id: 94, data: {text: 'would recommend for people to understand in general about non-emergency stretcher transportation is your vehicles can be easily, in many cases, can be easily equipped to perform a dual function. They '}},
{ timecode: 1462, handler: 'blob', id: 95, data: {text: 'can carry wheelchairs and they can carry the stretcher stored in the vehicle. It does not necessarily have to be used but it can be stored. And then when you need it, your vehicle is easily '}},
{ timecode: 1473, handler: 'blob', id: 96, data: {text: 'transferred over with literally the turn of a couple of knobs into a stretcher vehicle and you have increased the utilization of that vehicle and you have increased the service potential that you have '}},
{ timecode: 1487, handler: 'blob', id: 97, data: {text: 'to provide your community. DAVE CYRA: Any other questions? Well thank you very much for sticking in here and we will see you guys later.'}},
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