#119 - Dr. Amit Agrawal MD & Kim Krueger NNP

Hello Friends 👋

We are excited to bring you a unique interview with Dr. Amit Agrawal and Kim Krueger this week. They are the creators of the innovative VINES program that helps families after their discharge from the NICU. We think that their perspective and approach is both groundbreaking and inspiring. Enjoy!

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Amit's bio: Dr. Agrawal is the Regional Medical Director in the Southwest for Envision Physician Services. He is an Arizona native, but trained at UCLA and Johns Hopkins for his Pediatric residency and Neonatology fellowship, respectively. He oversees 12 NICU’s comprising close to 25,000 annual deliveries, and has a team of over 50 providers. His passion lies in education, innovation, and program development. Amit.Agrawal@envisionhealth.com

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Kim's Bio: Kim Krueger began her career as a nursing assistant and discovered her passion for neonatology after an encounter with a baby with Osteogenesis Imperfecta. She earned her nursing degree at New Mexico State University and worked in a small NICU before moving to Phoenix to work in a larger unit and pursue her NNP degree. Kim held various positions at a Level III Regional Medical Center in Phoenix and worked as a flight nurse for seven years. She obtained her Nurse Practitioner Certificate at Beth El School of Nursing and has since worked for multiple neonatology groups. Currently, she works for Envision as a staff NNP and is a core team member supporting VINES. Kim.Krueger@envisionhealth.com

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The transcript of today's episode can be found below 👇

Ben 1:00

Hello, everybody. Welcome back to another episode of the incubator podcast. It is Sunday, we are back with a fresh set of interviews. Daphna, how are you today?

Speaker 1 1:10

Have I'm doing really well, I have really been looking forward to this interview actually. Because I, I enjoyed our interview so much, because this is something that we're trying to do where we are, that we kind of do, but not the way that they do it. So I hope that lots of people can take away a lot from this interview.

Ben 1:32

I'm not the best. At I'm pretty good at discharge planning, but I'm not the best. And no matter how hard I try, it's never it's never good enough for Daphna. So that's why you'll see why this interview is, is to her. But no, we were very excited to have on our show today. A first of all, it's great. It's the first time we're doing this work we're having on both a physician and a nurse practitioner. I think it's kind of cool that we are this tandem, always we always work with our pas and nurse practitioners really in synchrony, so so it's kind of nice to be able to showcase that relationship on the podcast as well. So, today, we have on the show, Kim Kruger, who has a very interesting story. She began her career as a nursing assistant, and she had an encounter with a baby with osteogenesis imperfecta. I won't leave, I won't give you more than that. And that really sparked her interest in pursuing a career as a provider in neonatology. She earned her nursing degree at New Mexico State University. She worked in a small NICU before moving to Phoenix to work in a larger unit and pursue her NNP degree. She held various positions at a level three regional medical center in Phoenix worked as a flight nurse for seven years. She obtained her nurse practitioner certificate at Bethel School of Nursing and has since worked for multiple neonatology groups. Currently, she works for envision as a staff nurse practitioner, and is a core team member supporting vines, which we'll talk about today. She is joined on the show by Dr. Amit Agarwal, who's the Regional Medical Director in the Southwest for Envision physician services. He is an Arizona native but trained at UCLA and Johns Hopkins for his pediatric residency and neonatology fellowship respectively. He oversees 12 NICUs, comprising close to 25,000 annual deliveries and has a team of over 50 providers. His passion lies in education, innovation and program development. Please join us in welcoming to the show, Kim Krueger and Dr. Amit Agarwal. Ahmed Agarwal, Kim Kruger, thank you so much for both being on the show with us this morning.

Unknown Speaker 3:54

It's great to be here.

Unknown Speaker 3:56

Yeah, thank you for having us.

Ben 3:59

So, we always like to, uh, we always like to start with a little bit of background and find out exactly how you got to where you you arrived. And if it's okay, I'm at I want to start with with Kim because I was reading through your biochem. And at some point, you mentioned that what's sparked your interest in becoming involved in neonatology was this incident where a doctor was brought in by the police to write feeding orders on the baby that was not to be fed in the NICU. I'm gonna try not to get into much more detail, but can you tell us what that story is?

Speaker 3 4:37

Yeah, so they saw Ahmed's eyes go no, really, hardly anybody knows this story, but I was a nurse's aide, working in a little tiny unit that was combined postpartum labor and delivery in NICU, a little four bed NICU and the nurse in there said she could not be the preemies and I have six younger brothers. I'm like blog feed one and so I Suzie in the corner feeding the preemie, and here came the police with one of the two pediatricians in town. And they made him write a feeding order for a baby that I didn't even know is there in the corner. It was a little baby with osteogenesis imperfecta. And apparently, there was some, someone had reported him. And then we had to start feeding the baby and I was on night shift. So the parents were there. Nobody. It was kind of a small to do. But the RN was kind of standing in the back with her arms crossed, she was in charge of all three units. And I had a feeling she's the one that did it. But I never researched it any further. But then I, it just became fascinating to me to that baby that was born with all the broken bones. And yeah, that's what got me started.

Ben 5:53

What year was that there was that before? All the details are in the

Speaker 3 5:57

LED? Oh, yeah. It was before the baby Joe, it was probably at six.

Ben 6:03

I also want people not to get the feeling that they're somewhere in this country that would know, I think because I think thankfully, we've moved past that stage of newborn care and so on. So oh, man, what a fascinating story. We

Speaker 3 6:16

were probably five years later, when I had moved to Phoenix, a bigger unit to get some experience when the everyone talked about the baby doula. And I'm like, oh, yeah, I know where that came from. Partially,

Speaker 1 6:28

I'm familiar with the with the proud that problem by how?

Ben 6:32

Well, I'm a data, I want to maybe ask you a similar question. Maybe Maybe you do have a story where a police officer forced the physician to write some orders. But other than that, like what, what what what led you to pursue a career in neonatology? What was sort of the inspiration there?

Speaker 4 6:49

Yeah, I definitely don't have anything to match Kim story. But you know, I, for me, it was when when you're going through medical school, you have so many options, right? And you're, you're at those deliveries from an OB rotation. And my eyes would always turn away from comparing the PC autonomy and focusing on the mom to what's going on with the baby. And the reason I think is, there is no other subspecialty that you can interact with a family before a very, very tense, crucial moment, at and during, and then after, and we're talking about the delivery. So you're really in so many different phases of, of support and comfort for this family. So you're not only medically able to support them, and care for very sick babies, but you're also you're also interacting with them very vulnerable times across the continuum of what you know their experiences. So it's, it's very unique, also unique because no other ICU allows us to have a baby or have a patient in there for 7080 days, 100 days, we've all seen that and you look at adult care, and most patients were there for four or five days, sometimes they'll get trach G tubes, whatever it is, they'll get sent over to skilled nursing facilities. So we have such a blend of acute care and chronic care, and I think that differentiates the NICU very well.

Speaker 1 8:19

It's so interesting that one of the things that actually drew to neonatology is the fact that you are participating in those transitions of care. That's because that's why we have you on today is really to talk about the discharge home. But I it's it's interesting, because it seems like the neonatal community is just kind of really focusing on these transitions of care, really putting a lot of energy and research. Obviously, individuals have been doing this for decades, but really, as a community saying, you know, the prenatal consults is a huge part of our neonatal care, not just something nice that we do, setting up the medical home at discharge, it's not just something nice that we do it, you know, changes outcomes. And so what do you think is maybe lead this shift for, for our intensivist colleagues to say, we got to think about the book ends the admission?

Speaker 4 9:15

Yeah, I think it's a great question. And I would say that altruistically, I would hope that it would come from us as neonatologist and say, yep, yep, we are thinking about the right things on both hands and the holistic approach to care of these neonates, but I honestly think there's so many other pressures in the medical community right now, right? And cost is a big one. And when we think about how we optimize care prenatally and postnatally, we really are trying to limit length of stay readmissions, urgent care, Edie visits, so all of that cause contributes to cost in our offense care model. And so I feel like that at least some of the initial All progress towards an attention towards us is driven by some of the pressures that were fueling as a medical community. But that doesn't take away from the, the importance of the work, and the need for the work. And you're right, this is this is nothing new. We've been talking about this for so long, and but I'm not sure we've optimized it, as well as we could have. And there's so much that's leaving the hospital, meaning, you know, the the hospital is very good at acute care. But once you start transitioning to care more chronic, those patients may not need to be in the hospital, or they need different support structures once they leave. I don't think that's what we've really established Well, for the NICU.

Ben 10:41

It's very interesting that you say that, because it does feel like it especially as we go through fellowship training, as we go through our early years, we kind of get this realization that we are really focused on the Intensive Care part of the admission. And then as the recovery starts happening, it's like, well, you know, out of the woods, and things will sort themselves out, but it's really nervous, like they don't just sorted themselves out. And,

Speaker 1 11:07

yeah, I mean, it's really just the beginning for these families, right? When you think about a life with with any child, but especially a child medical complexity,

Ben 11:18

and without creating too much controversy, but you can see it in the variability when it's Brady watches and stuff like that. Was it 30 days is it fight is like, number one, it's been pretty well established that we have no clue way to monitor these babies prior to discharge. And we're not really prioritizing that either, right? I mean, it's not like this is a big focus of making sure like, hey, we need to know what is the proper monitoring periods that statistically, a baby with a really cardiac event can actually be safely discharged. We sort of like, like, whatever, just be consistent. And we'll figure that out. So I think, I think this is, this is very interesting. We are big fans of of the vines. Yeah, I guess the I guess, of vines, the virtual neonatal support program that you both are spearheading? And for people who may not be familiar, what is what is vines and what led to its inception? And I'll let you decide who wants to take this question?

Speaker 4 12:23

Well, I'll tell you. So my wife's a general pediatrician. And, you know, we we've had many dinner table conversations where she sees patients we discharged from the NICU. And so, so we've actually just one conversation, and I remember very specifically, but she was asking me, what, what do I do with these ng feeds? Like, what what do I do with them? And I said, What do you mean, what do you do with them, you, you know, advance the volumes as the baby grows, you, you know, you make sure the baby's gaining weight, like all the normal things that we do in the NICU but and this is coming from a woman who's far smarter than I am, but but in the moment. And that wasn't the only example. But in the moment, I was like, wow, there, there is a disconnect between what we do in the hospital, and what we expect our pediatrician partners to do. And then how that whole transition looks in that first month, two months of life for these patients. And there has to be a solution where we as neonatologist or nurse practitioners can get out of the mindset of the four walls of a hospital. How do we impact patients beyond the four walls of a hospital and that's how vines was was really started. If you think about a vine it needs support to grow. And so our patients are a little support club a little vines that needs support time and in our growing and if you ask him I mean acronyms is like what I spend every evening trying to figure out is what what's the next acronym that we

Speaker 1 13:55

love acronyms. I think this one is in our top 10 For sure. Yeah,

Unknown Speaker 13:59

I will take that.

Unknown Speaker 14:01

No logo is fabulous, too. Yeah, it's

Unknown Speaker 14:04

adorable. It's adorable.

Speaker 4 14:06

But yeah, that's how it started. It started with understanding there's a need based on what we were talking about at the dinner table every night and and then really growing that to say, Well, how do we how do we support patients once they're discharged from the hospital to to meet that need Kim, you do want to definitely add of what you where you can

Speaker 3 14:27

well and I think that a piece that a lot of people don't know is our company offers if you think of a good gig and it makes you know, make some money we'll help you with it or split profits. And that's always interesting to me because I've come up with lots of ideas in my lifetime that just got integrated into the system. You know, you don't ever get real credit for um, you just start a program it runs people run it, you go on and do something different. So I think that's an opportunity for people today that are interested in At, but I believe care really starts when they go home. The biggest difference is their developmental follow up everything that's done at home. And so when Ahmed proposed this to us and needed a couple of people to help him get it off the ground, I was jumped right in there. It was perfect, perfect idea. And a lot of people think, well, I don't know, pediatric care, I have to learn a lot. But you don't. It's just the things that you do every day. The questions they have are, are something you can easily address.

Ben 15:37

This episode is proudly sponsored by rocket meat Johnson. Recognized Johnson is dedicated to the research and development of nutrition products that help support baby development at every stage, including an extensive and female portfolio for premature and low birth weight infants learn more at HCP dot meet johnson.com. So let me let me try to tease apart a little bit some of this project because I think you're all very familiar with it, we are somehow familiar with it as well. But for the audience member of we're trying to wrap their heads around what does that mean when we're trying to provide support to babies as they're transitioning care from inpatient to outpatient? So what is the model that you ended up settling on when it comes to? So do you bring in the pediatrician who, who are going to be following these babies outside into the unit? Or are neonatologist going out into the community? And how did you decide what was the best framework for that?

Speaker 4 16:38

Yeah, that's it's a good good opportunity to level set him a little bit here. So So Vines is a virtual program. So everything is done virtually and, and I think we all understood the pressure of the pandemic, and it probably helped us at least the parity laws within the state in terms of, you know, payers, etc. You know, a lot of that helped get get this off the ground, but it's a virtual program that has two arms, two distinct arms. One is a virtual NICU urgent care. Okay, so patients have 8am to 8pm, Monday through Friday, and then at am to 2pm, Saturday and Sunday full access to a nurse practitioner, neonatal nurse practitioner or a neonatologist every day, so. So they have they have the ability at 8pm at night, for them to say, You know what, I have a question. Within the first month of leaving home, I'm not going to go run to the emergency room or urgent care. Instead, I'm just going to call call vines and it's all virtual, meaning they just go to a website, and they enter their name, and they get put into a waiting room. And then the physician or the nurse practitioner who's actually taking that shift will then get a text message and say you have baby James and in the waiting room so so that NICU urgent care, because we can't predict when it will happen when families will have

Unknown Speaker 18:00

it's always in the middle. It's always in the evening.

Speaker 4 18:04

It's always in the evening after the clinics closed after their pediatricians gone home. But you know, the unpredictability of what why do these things always happen on nights, I mean, think about NICU shifts were like, if it just happened during the day, we'd have more people, but we don't have all the resources at night. So the unpredictability of when a mom or a dad will be worried about their baby is real. And so that that's the urgent care piece. And then the second piece is really more of a proactive piece, which is scheduling visits with these patients. So we schedule a couple of visits, so that they can already get into the system, we can help transition that piece of care from in the hospital to home. And then we're sending all of this information back to the pediatrician. We've actually had pediatricians on calls with us. We've had pediatricians call us after their clinic and say, hey, you know what, I saw a 32 weaker today, the baby's not growing. What should I do? I mean, we talk formula and feedings and growth and nutrition every single day. But this is the if you look at even just a prematurity rate of 12% or 10 to 12% nationally. And you're this is such a small subset of our pediatrician patients. Right? Yet it it has a it takes a disproportionate amount of time for them. And so if we can help with that, that's really you know, what we're there for so it's the two arms strategy of one being available when and where patients need them and and need the support and then to proactively trying to help them through that first month with some scheduled visits. Yeah,

Speaker 1 19:44

I think it's such an incredible program because just like we talked about earlier in this show of discharge, coordination and planning and discharge, quote, unquote, teaching is becoming a much more hot topic that that hospitals are really working on, but at all almost seems like no matter what planning and teaching we do, there are just some things we cannot anticipate, right that are going to happen after the babies go home. And, and this seems like a great model for for bridging that scary for families but also dangerous transition for babies.

Speaker 4 20:23

Yeah, and I think how one of the things we've learned, and it's been, it's been so eye opening, there's so many different aspects of the program that we get that insight now into, into the to the familial stresses that happen at home, we can see them in their home. But I'll tell you that, out of all the visits we've we've done, we've done over 100 visits, we three quarters of the time, a family feels that the visit has prevented an emergency room or, or urgent care visit. So 76% of the time a family after the visit will say yep, that did prevent me from going to to the hospital. But if you look at the physician or the nurse practitioner side, it's only about 26%. So it's actually inverted. The physician or the nurse practitioner feels that only a quarter of the time did I prevent the patient from going to the IDI or urgent care. So when you try to try to get into the psychology of that it's actually really interesting, because I think when we went through peds residency, we were in the emergency room, there were many times we asked, why did this patient come in for this? Why are they here, they didn't need to come in for this. And, and so patients will go into the hospital for constipation, because they have for 90 days, seen a nurse change their diaper every three hours and document stools in your NS and and do that in a very, very scheduled environment. And now that environment doesn't exist. And so if it's different than what they experienced in the hospital, they think something's wrong. So you know, it's really interesting. And I think that's why we see so many patients bounced back to our hospital and we don't even see all the ones that go to the IDI but just get readmitted. And that's still significant number. So it's it's really teaching us a lot about the psychology of what stress is, or how much stress these parents feel when they go home.

Speaker 3 22:35

It really helped us to feed back into our discharge planning. So now every day I tell the nurses when they come to me with no stool in 24 hours, I'm like, don't tell the parents this. Tell them it's a couple of days because we do get a lot of that mimicking behavior. They see what we're doing and can they feel that's what they need to do.

Speaker 1 23:00

Yeah, that was one of my next questions was was that that you guys have learned so much. And some some hospitals some units will never be able to do what you guys are doing but we could do a better job of discharge teaching. So what are some of the Yeah, major pearls that you've learned that are the you know that like you told us constipation was one one of the things you get the most you know calls for? Or quote unquote constipation, right? It's not really constipation, it's just that they didn't get glycerin after 24 hours or something.

Speaker 3 23:35

feedings I think is our biggest question. And also, stomachache, stomach. The parents are very concerned when the babies are crying and they're pulling their legs up and they're in pain and I did as in I did it and gas you know, so I did ask the nurses Why do all the babies at home have all these gas problems and we don't have that much here and they're like those parents are terrified to birth the baby they never tap them hard enough and so that gas is a big one I would do got this death of what are but feeding issues is our most our most common weight on a garage to or ng fiends when do I advance? You know, the baby seems hungry all the time. While they're still on the same feed. They were two weeks ago. A lot of feeding.

Speaker 4 24:26

Yeah, and I think we we again, we psychologically trained parents. It's volume based, right? We 150 160 per kilo, right that

Speaker 1 24:35

we advance every two days. Right? Some units. Yeah,

Speaker 4 24:38

we answer every couple of days we increase the feeds. And then I don't know what what you guys practice, but I think you know, a lot of places within a couple of days of discharge. Once that baby's eating a good percentage, pull the NG and then usually within 4872 hours, they're out the door. But that's again, an average baby under 1500 grand existing about 7072 days in the NICU. So, so we're trying to model home behavior in two or three days that we've really, you know, haven't undone what we've done for 7070 plus days in the NICU. So volume based is really is a big focus that we try to undo in our vines visit saying no, let let the baby add live means I live means him baby can eat what, what he or she wants when he or she wants, and you don't have to do the 50 every three that we were doing in the hospital. A lot of especially as we hit a, you know, national formula shortage, we were getting a lot of questions about what are alternatives? What do I do if I feed my baby? And, you know, nutritionally, I think we have a lot more insight into calcium Foss and protein and macro micronutrients that certain formulas can or can't provide. And so we were able to guide them quite a bit more in terms of what is an analogue for this brand, or this type of partially hydrolyzed or, or elemental formula? So I think, I think it was it was feeding is the big, big bucket. But we've definitely done a lot of counseling and work on medications to not really understanding what to take when to take a vitamin multivitamin with iron without iron. Parents have a lot of choices when they go home. And they don't always read the big stack of discharge paperwork that that sent home at time. So I would say those are the the definitely the big buckets.

Ben 26:37

What are some of the biggest challenges you faced in setting up this program?

Speaker 4 26:44

Yeah, I think you know, when we when we look at one that I don't think everybody can do this program unless you have a team that's committed. And you know, I'm so fortunate to have Kim, we have two other core providers, Abby, Caspar, and Regan, Rosslyn. And they there, they have been kind of the heart and the mind of the program, you have to have people that are committed, who are willing to say, You know what, I will cover it as a pm on demand. Because we can't pay hourly for, for when we have two or three visits a day, because that's just not a sustainable program. So having the right team I think, I was very blessed with and we we do but in terms of other other barriers, nobody understood how these visits would be conducted, who would schedule them? How are they going to be reimbursed? Right? So who's who's doing all the backend work? As physicians and nurse practitioners? It's very, it's much easier, we can do a 2030 minute visit. We can counsel we can document we're good at that stuff. But who's organizing it? Who? How are where are we storing the data? I mean, there was a lot of integral work that happened initially that that we had to do a lot of provocative thought to try to understand well, isn't is our national company storing this data? Is somebody else locally? Who else can we partner with? How do we get patients from NICUs that we aren't even at, because it can become very, very territorial, when you have other competing groups in the community, right? So so we paired with a state based organization called smooth way home, and smooth way home was already already in interested in the transition of Nikki patients from hospital at home, but they were doing a lot of the care coordination, rehab, community community integration, but they didn't have the medical piece, right, they didn't have a neonatologist or nurse practitioner to be able to support them, when they do a home health visit, or they do a home visit. And they they feel like this patient actually needs to see a physician or nurse practitioner. So So pairing with them, I think, allowed us really access to all that NICUs crossed the state of Arizona, that's great. And in once those patients are discharged, they're not excuse patient, or, or a more a neonatal providers patient, they're the community's patient. And at that point, you know, we should provide them the support that he does.

Speaker 1 29:21

I think that's an important point when we talk about, like buying, right, because, because I think parents feel that they feel like for some moment of limbo, they don't belong to anybody. Right. And and so I think definitely getting buy in in your community is is vital. So I'm hoping you can speak to some of those things. Specifically, you touched a little bit on the staffing model, but I'm sure people have more questions about that. And and then the buy in, right, how do you bring a project like this to the quote unquote, C suite? Right. And then you have a add on question.

Ben 29:58

No one's gonna say you're so right to have We've all experienced this where the ER calls for like a patient that like, was recently discharged. And definitely I talk about this all the time, like the smile on the parents face when they see you who they know, is almost therapeutic. And it's like, you don't have anything yet. But they got somebody who knows my story. Right. So I completely understand what what you're saying, Daphna, in terms of these parents, the Dubai in and everything? How important that is. So yeah, but But again, I think your question is excellent. So I don't want to intrude? Yeah. How do you how do you pitch that to the C suite? Is the topic?

Speaker 4 30:37

Yeah, it's, it's a good question. And I'll let you know, can chime in here as well, from from the community buy in, I think when you look at, you know, I think how medical care is going is we really need to provide services outside of the walls of the hospital. So I would think how we approach this was we don't need to involve the hospital directly. Because this is a community service. And it makes it makes us more relevant, it actually is a differentiator in the community when it comes to the value proposition that we have as a as a group. And, and I think we engage with community partners to keep us sustainable, so financially, helps us keep sis stasis, sustainable, from a integration within the community. I mean, they're talking about buying smooth way home and southwest human development. They're talking about Bynes, in every meeting that they have, we've engaged payers. So we've gone straight to payers and say, Look, this is value based care in the world. And I think that's, that's the direction that we're going but but I think to get buy in, you have to show specially for any, any C suite, whether it's you know, our larger company, or even hospitals. And the return can't just be patient satisfaction, which is through the roof or likeliness. To use. But it has to be there has to be some monetary to value in there. And I think the long term play here is a value based care approach, where we can go to a payer and say, Look, if we did, if we cut 76% of your emergency room visits. That's a lot of money. And so and we've modelled this, actually even through through our team, and you know, there, there are over one $1.5 million in savings and just you know, partial amount of the visits that we did. And so when you go to the payers, you can actually now talk about some some shared shared identity there. So I think that's really well built in the adult world. But in the new NATO world value based care is not we're very service were bundled rates in the NICU. But I mean, really, from a value standpoint, we're not really seeing that. Be too consistent. So I think this is this is that step and not in the right direction.

Speaker 1 33:05

Yeah, I think too, when you talk about value based care, like we know that the ER and the urgent care is like, not even the right place for most of these complaints, like you you mentioned, and bless our ER doctors and our urgent care physicians, but most of them don't don't rightfully so how would they have learned what to do with these premiums? So it's not just er admissions, they're probably readmitted at much higher rates because nobody feels comfortable sending them home from the ER or the urgent care. And that's a huge cost proposition, then when you're not just looking at the ER admission, but maybe a hospital hospital ambulance transfer to the nearest Children's Hospital and then in admission, I mean, the cost is exponential. Really, when you think about it.

Speaker 4 33:56

Yeah, and I think just to add to that, I would, I would say that even general pediatricians who have cared for these patients, and I've heard my wife again on the phone and if a 24 week baby former 24 weaker who's now you know, just got discharged from the NICU that mom calls and says, this baby is breathing kind of

Unknown Speaker 34:15

setting up right? What

Speaker 4 34:18

to say. He's gonna say go to the emergency room. She's on the phone, he can't triage those things and the situation is too high risk and so you know, that's a situation where we can see that directly. You know, this is audio video we can we can talk to the mom we can you know, ask her about changes we can understand what the baby's feeding or how the baby's been breathing, we can call back in an hour and check on it again. And so we've done that where we've we felt like we really have prevented Edy visits but we've done the opposite to where we've been worried about kids and and fast tracked them to to the IDI and to got admitted that Kim Do you want to share some of that?

Speaker 3 35:03

Yes experience. And that's something we're not used to as sending a kid to the ER. So you get a call and I bought a big screen, you know, to make sure I could see the babies and we can take call from our phone, you know, because we can't be at our home all the time. But really just a visual of the baby, you can tell how they're doing. It doesn't take a huge screen to do it. But you can see a baby's breathing a little bit harder, you know, nodding, you know their hand and send them into the ER, and we were able probably everybody in our team will say Where were you born? Let's get you back to that hospital. If it's one that has a P Genda. We've called forward to the hospital warn them that the baby's coming in, ask them if they can take the baby right away. So essentially, it made sure there was a room in that peds unit before we sent them, because we do have a couple of choices where send the babies. But that piece is just super valuable. And you're right, Ben, when people see our face on the screen, they're like, Oh, yay, you know? And we'll just say, you know, don't could you answer our questionnaire but didn't take him to the hospital?

Ben 36:17

So that's something? Yeah, that's something that I wanted to, I guess ask you because it is sort of the elephant in the room. And I can hear some of the skeptics saying the liability Oh, my God like you This is why would I take this on, etcetera? Can you talk about that? And how? I think, personally, I think I've done a lot of, of outpatient follow up. And I think I think we tend to mystify a little bit, some of that, because people think that Oh, my God, they could patients gonna call me and all hell's going to break loose, when it really isn't true. But how do you appease, like you said, the people you're working with to say, well, this is something that can easily be managed. And I guess, to that point, there's the liability standpoint, but there's also this, we talked about psychological biases, but the other one is like, we tend to think as neonatal provider that like, as soon as they leave the NICU, I don't know how to take care of these babies anymore. Like they're like these different animals that I can now I don't know anything, and it's so untrue, that you, you do have to still have that expertise. So how do you reconcile these two things were number one, the providers feel comfortable answering questions after a baby has left the NICU. And the other one where they feel comfortable that this is not going to put their licenses on the line. And this is not going to be the death of their career, because they've they've triage the patient over the phone?

Speaker 3 37:35

Well, I could just start with when we started this program, I don't remember how many of us there were eight or 10. That said we would take the calls, we had no training, we didn't even really know how the Doxy MediCal program platform work. Maybe we practice with each other for a hot minute, but we the people that said they would do it just did it, there was no training really. And so fast forward now a year later into it I'm we're needing extra people we know are people we have are getting exhausted of taking the call. And some people jumped in, but a lot of people are like, Oh, I'd have to do a pinch review. Or I'd have to take pals or, and it seriously, you know what they're calling about, you know, the feedings this kind of thing. And as far as medical liability, I feel like if you have the confidence and you know what you're doing and you're seeing the baby, if you have any questions at all go ahead and send them to the emergency room. It's not are fatigued doing that. And I know one time I was on the phone with omelet with a baby I was worried about in his wife's in the background going, why are you guys so scared to send it to the ER just didn't

Unknown Speaker 38:48

just do it?

Speaker 3 38:49

She was right. But um, so I it questions are so basic, they just don't have an understanding really, after being in the NICU for four months, and going home. And sometimes I think you've had people in the program that have just been in the NICU a week, and they're traumatized by that. And sometimes those patients that haven't had enough connection with us that really have some valid questions, and they just need to know how to care for their beanie. But you always have the option of bringing them in or being

Ben 39:23

You're being too kind can because I remember so my residency program, we did a ton of yard like an excessive amount of Yeah, we had like one of the busiest er in Queens, New York. And so it was busy. And then I think what, what you're alluding to is that people go to the ER for some things that are really, really benign. So we did also phone triage. And so for example, you would have a parent calling say, hey, my baby didn't stall this afternoon. And it's like, okay, they don't come to the front. Yeah, you do not need to come to the ER for that. And I think like you said, if anything is a little bit feels off sounds off to you. And that's it. I'm not dealing with this on the phone, bring the baby over and we will take a look. So I think there's, there's this. It's not, I think there's not a gray, I think what we were taught as resonant is that there's no gray area either it's clearly nothing, right? And then you tell them, just watch it at home and go to your doctor tomorrow, if you have any concerns, and then anything else, then come and get assessed, right, you don't have to take the burden of taking that on over the phone over over video call. And I think that's what people I think tend to get stuck on. It's like, oh my god, they're gonna call me saying this baby is having jittery movements, maybe it's a seizure, and I'm gonna have to manage this. Now, if that's the call then, but

Speaker 3 40:38

when it's luxurious to have the video, because I can say, let me see their tummy poke on their tummy with your finger. I was super nervous that I didn't have a stethoscope. But I don't have to listen to breast sounds to see somebody's head bobbing. And to kip, Nick. You can see that I mean, you can see it right. But it that is a part that I wish I mean, I want people to understand because I would like more hospitals to pick a program up like this and do it. It's been so valuable to the community and to the families. It is not difficult to look at a baby and no, you're fine. Or, you know, let's, let's go check this out and then speed him into the ER, because I don't want him sitting in the lobby.

Speaker 1 41:22

Yeah, right. Right. And we're, that's such an important, I think your peer coordination, I think is so valuable for the baby and the families and the other providers who are receiving them right to get information in advance. I know we are getting close to the end here. And we spend a lot of times a lot of time on the one arm really this urgent care. But I hope you can talk a little bit about this collaboration with smooth Wade home about the kind of scheduled visits for the second arm of the program.

Speaker 4 42:03

Yeah, you know, I think one of the the other just to add on to some of what Ben was talking about, we we're a pediatrician, right? So we are not their primary care doctor. And we have been very clear from the gecko that we are, we're there to enhance their transition from hospital to home and to support them but ultimately, their care in terms of you know, weight checks and whether they're thriving or not well, labs etc, that's that's going to be directed by the peds. And about half the time, we are able to even within our conversations, give recommendations to pediatricians I think we've we've all experienced, or we've probably heard about situations where patients are discharged, we work so hard on getting them to grow, right, we discharge them on 2426 Calorie they're on. You know, they're on the right regimen finally, and then they get to their pediatrician, and they have like a week or two of good growth and then they get put on 20 salary like Oh, turn formula is fine, no problem. And it's like, well, no, I mean, there, there's a lot of work that went into this. So we sustaining what we do in the NICU beyond, you know, beyond discharge is really important too, because I think that validates all the work that we do in the NICU. So as a part of that we we felt, you know what, we can leave this completely into the arms of the families, but at the same time, if we schedule a couple of visits with them once they're discharged, and they're usually the first visit is usually within that first week of discharge. And, you know, and I think what we what we've learned is parents will often say, No, I'm good, I don't have any questions. And then by the but 30 minutes into it, we're like, Well, no, you've got more than more than one question. And it's one more thing, let me ask you about this. Let me ask you about this. And so, you know, I think we understand the limitations of a pediatricians office, there's, there's a lot of churn and you know, 10 to 15 minute visits. They don't always have the time and the energy and the effort to spend as much time as patient needs. And we do. I mean, we and our pediatricians are just

Ben 44:14

right to to, to see as Oh, patients as possible.

Speaker 4 44:18

Absolutely. Volume is what's driving their, you know, their production. So, for us, it's really just to be there that support. So scheduling a couple of visits has allowed us to one get families familiar with a program to say, hey, you know what, you can use this even this weekend, when your pediatrician is closed, you are able to use this but to let's talk about things that you may not even know. Let's make sure that you know, do you understand why you need this? The follow up? Yeah, I mean, boy, I'm lucky so surprised. We talk till we're blue in the face in these NICUs about the whys, you know, and your baby had a intraventricular hemorrhage. This is why it's important to do this and watch Developing, your baby has ROP This is why it's important. But mean again, absorption and you know, understanding is such a small percent. And so it's really nice to be able to reinforce some of the whys because that just lead to compliance that will lead to patients and you know what it is important that I go to this, this eye appointment six months after I'm discharged, just to make sure that even though I was cleared, it's important that I follow up or, you know what, I need to make sure I keep those physical therapy, occupational therapy appointments, because, you know, my baby's development is at risk. And, you know, I may not feel that because now the baby's home and she's normal baby. But we know that's not not always the case. So the scheduled visits really gives us an opportunity to be proactive about about issues in a very non tense you know, situation.

Ben 45:54

And so to get some buy in from people who are listening who may be interested in in joining the program, starting up a program like this, what is the cut off where after which you say, Okay, this baby is now has aged out of the vines program, just so that people also understand that you're not getting a call for like a seven year old with a call. Well, we're

Speaker 3 46:09

frequently was a premium for you guys. And I had one mom, I seven month old and she goes I thought it was for the first year and I'm like, no, no, no, it's an I did send her to the RSV, and he was really working hard to breathe and I can see that but and we also have frequent fliers who call us. We're like, oh, it's Jo van again. She said days on it gets on and says hey, it's two lights. We're good. And you know, it's pediatrician starting to take over and

Ben 46:41

so it is two months.

Speaker 4 46:44

So 30 days. Yeah, 30 days is our is our window. And I think this kind of goes back to what you were asking about Ventoux in terms of liability. We, we are not nickel providers, we understand that and, and, you know, to add to what Tim was saying to when we first started this program, there were so many questions that came up on how to manage and how to talk to families about some of these outpatient issues. And yeah, you're right. The reality is, is they they're not general, pediatricians, a lot of our nurse practitioners have done general peds, if you think about their training, right, so So it did take, you know, even though there wasn't formal training, I think there was a lot of on the on the spot training, have, you know, they have, what do I tell this family? How do I, you know, engage them. And so, you know, I was involved in a lot of those conversations early on, but 30 days, the first 30 days, I think we're all very comfortable with with trying to help families transition and, and really just extend our neonatal hands, because they all the problems don't change that they go home. They're all the same ones that we were just rounding on with our sheet, you know, the day before so and,

Ben 47:51

and to that end, I mean, and I want to close up by mentioning also something else. But I remember as a resident, I did a lot of high risk follow up and, and William Malcolm's book Beyond the NICU is a great book, because you can have a lot of the issues that come up after baby leaves the NICU, and then you also realize that it's like, Oh, I know how to manage all these static, it's pretty much the continuation of what we were doing in the NICU, which somehow should be self evident, but it isn't, it isn't. And as we're getting to the end of the hour, I wanted to mention that a lot of the things that you presented today were beautifully displayed on this poster that you presented at Vaughn. I think it was either this year or the last and so if that's okay with you, it's okay if we post that on the on the episode page that people can see a little bit some of that information because they are great. It's a great poster number one, if you're a trainee, and you want to see how to make a good poster to take, take notes, but it does have a lot of the questions that we address today, which are sort of what are the most prevalent topics that are being brought up during these visits? What are some of the effects on ER visits and so on, and also have a nicer section on patient comments with a nice little word cloud with how patients felt about this. So I thought, if it's okay with you, well, we'll post that so that people can can take a look. Definitely anything else before we close out the show,

Speaker 4 49:08

though, it'd be very, now that we appreciate you guys, you know, being able to talk to us about vines and, and just what you've created with innovation in the podcast here is phenomenal. And I think it's a good. It's actually an incredible model for anybody to say, You know what, if you want to think outside the box, you're out to me, there are different ways to do things. And that we all have a social responsibility to be innovative to think outside the box and to bring new things to the craft that we we practice every day. So thank you guys again. And we really, really appreciate it. I

Speaker 1 49:46

mean, I had three or four more questions, but I don't think we could end on any better note this way you just closed us out with so I'll email you my questions. Thank you guys so much for being here. Thank you so much for what you're doing in your community and again, you just are so hopeful that this will serve as a model for for other communities because there's an obvious, obvious need,

Speaker 3 50:09

and it's a huge benefit to them. I mean, feel free to put my email in the area to go, I'll be happy to answer your questions, and we'll get other people on and I appreciate what you to do. It's wonderful. I think I've listened to every podcast.

Unknown Speaker 50:26

We appreciate. So yeah, absolutely. That's

Speaker 3 50:31

my friends asked me how many hours following these to have and so I couldn't figure that out. Because you're in so many platforms. Do you have any idea?

Ben 50:40

Well, so we are very proud. We're very proud to say that the podcast is getting approximately on average, about 5000 listens a week, from all around the world. And, and we we could not be more thankful to the community for a number and it's growing. So, no, it's, we're very, I mean, it's what, um, it was just talking about, we tried something, we had the thought of saying, If this doesn't work out, we'll move on to something else. But the need was there. And the response was there as well. So, yeah, but thank you for giving us an opportunity to

Unknown Speaker 51:14

we did not play in that quest. Thanks so much.

Ben 51:24

Thank you for listening to the incubator podcast. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcast, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address, Nicu podcast@gmail.com. You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot d dash incubator.org. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns. Please see your primary care professional. Thank you

Transcribed by https://otter.ai