Community Health Initiatives with Jacksonville's Chief Health Officer

Transcript generated by AI.

 

Announcer: 0:00

Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr Michael Koren.

Dr. Michael Koren: 0:11

Hello, I'm Dr. Michael Koren, the executive editor for MedEvidence!, and we have a repeat visitor today. I'm very excited, Dr. Sunil Joshi, welcome back to MedEvidence!

Dr. Sunil Joshi: 0:21

Yeah, thank you for having me. I'm excited to be here

Dr. Michael Koren: 0:23

So I guess the fact that you're coming back means something good for us.

Dr. Sunil Joshi: 0:27

Yeah, it's a great conversation. It's like two doctors just talking and honestly, I don't get to do that very often, so it's good for me

Dr. Michael Koren: 0:34

It's fun.

Dr. Michael Koren: 0:36

So Dr. Joshi is the chief medical officer of the city of Jacksonville. Congratulations on that,

Dr. Sunil Joshi: 0:41

Thank you, thank you.

Dr. Michael Koren: 0:42

And I know that you have a number of initiatives that are citywide that you'd like to talk about today, and I'm really excited to dig in because I'd like to know more.

Dr. Michael Koren: 0:52

Our business is in Jacksonville and I'd like to know what the city's doing and learn more about your leadership and where these programs are headed and what progress they've made to date. So again, just for the audience sake, just tell us a little bit about your background, what you do. You obviously wear a lot of hats, including seeing patients.

Dr. Sunil Joshi: 1:07

Yes, that's right. So I was born and raised here in Jacksonville, Florida. I grew up here, went to UF for medical school and did my residency here in Jacksonville in internal medicine before I did an allergy fellowship. I've been practicing since 2004. I'm not too far from this studio. So for about 20 years now I've been practicing allergy and immunology and I still do that. And right at the change of the administration here in Jacksonville between one mayoral administration and the other, the incoming mayor, mayor Deegan, asked me if I would be the chief health officer for the city of Jacksonville, which is a new role We've never had one before and it's a very rare role in the United States. And it was important for Jacksonville for a variety of reasons and we'll talk about some of that here today. But I was honored to accept it because I was still able to continue to see patients and run my practice while also doing a passion of mine, which is taking care of the health of the city of Jacksonville.

Dr. Michael Koren: 2:03

That's terrific.

Dr. Michael Koren: 2:03

And again, thank you for your service.

Dr. Sunil Joshi: 2:05

My pleasure.

Dr. Michael Koren: 2:06

So for people outside of Jacksonville that may be listening to us, give everybody a sense. Are we an average city from a health standpoint? What are the unique features of Jacksonville vis-a-vis other parts of the country?

Dr. Sunil Joshi: 2:18

Yeah, I think it's important for people to know that Jacksonville is 842 square miles right, it's the biggest landmass city in the continental United States and extremely diverse. You know, we look at Florida cities much more diverse than other parts of the country and one of our biggest challenges is our health, our health outcomes here in Duval County. And so if you look at health outcomes based on what we call the premature death rate and I'll define that for you so we're all expected to live to be 75 years of age. If you live to be 74 years of age, that's considered one year of life lost. If you live to be three months of age, that's considered 75 years of life lost. And the way that health outcomes in a community are measured is based on the premature death rate and you look at this over a three-year period, at different parts in time, and the premature death rate and you look at this over a three-year period, at different parts in time, and the premature death rate in the United States is 8,000.

Dr. Sunil Joshi: 3:14

So 8,000 years of life loss for every 100,000 population. The state of Florida is 8,300 years of life loss for every 100,000 population. Duval County, jacksonville, Florida, is 11,000 for every 100,000 years of population, and so there's a lot of factors involved in that, including certain parts of our community. So Jacksonville is divided up into health zones, and there are certain health zones that have far worse health outcomes than others, and they're only separated by a bridge in a lot of cases not even five miles and so identifying where the problems are, identifying what the problems are and trying to balance those health inequities is what our job is here.

Dr. Michael Koren: 3:47

Oh, beautiful.

Dr. Michael Koren: 3:48

Really interesting stuff, and Jacksonville has a lot of medical resources, so it's not for lacking, per se, of medical resources. I don't know if you want to comment on that.

Dr. Sunil Joshi: 3:57

Oh, absolutely, and so when you look at health outcomes and what makes somebody healthy and what doesn't, only 20% of that is defined by what is happening between you and your physician or your healthcare provider in the medical center, whether it's in a hospital or a primary care clinic. There's 80% that's affected by outside factors, which includes the social determinants of health, and that includes income and educational status, literacy, transportation, language, violent crime, safety, the built environment, cigarette, smoke, alcoholism all of those things that are not necessarily discussed in the doctor's office can become a problem for folks in terms of accessing healthcare but also staying healthy outside of the doctor's office. And that's where we are most challenged here in Jacksonville is that those social determinants of health that divide our city both economically and from a health perspective.

Dr. Michael Koren: 4:50

And it's so interesting and so important, and as a country, of course, the United States spends more per capita than any place on the planet and we don't always get the best results Right, and in large part because we're fighting the social determinants of health that have this negative impact and result in this excess mortality that you're mentioning.

Dr. Sunil Joshi: 5:10

Yeah, absolutely. And here in Jacksonville the social determinants of health are much more of a factor in certain parts of our community than others, and those parts of our community where it plays a bigger role the life expectancy is significantly lower than the parts that don't. So if you go down Southside Boulevard, you come off of Main Street Bridge, you go down Hendricks onto San Jose Boulevard, you're talking about a group of people in that 3-2-2-5-6 zip code that have a life expectancy of 81, which would make that if that little health zone in Duval County was a country by itself, it would be the 25th healthiest country in the world, with Denmark and the Netherlands up in that area.

Dr. Sunil Joshi: 5:51

But then if you go over the Main Street Bridge into what we call Health Zone 1, which is not even five to 10 miles away from there, you're looking at a life expectancy of 68 years of age, which will put it as the 160th healthiest country in the world, right there with Rwanda. And so just a little bit of a difference from one part of town to the other has a significant impact in health outcomes, and you could see some of the social determinants of health just by making that drive through those two communities

Dr. Michael Koren: 6:16

So interesting.

Dr. Michael Koren: 6:18

So let's dig into some of the specific areas that you're working on. I know, for example, you're working on something called HealthLink.

Dr. Sunil Joshi: 6:28

Yes

Dr. Michael Koren: 6:30

So why don't you explain to the audience what that is and where it stands now and what we can do to support it?

Dr. Sunil Joshi: 6:32

So it's called HealthLink Jax and this is our virtual care program for the uninsured here in Duval County. So what we have noticed as we came into office and we started learning about what's happening in Jacksonville, we noticed that a very large percentage of our uninsured population will utilize the emergency room as their source of primary care. They may need to go there, obviously, for emergent situations, but in a lot of cases, people are utilizing the emergency room as a source of refilling their blood pressure meds or being treated for an upper respiratory infection or for a minor skin infection, instead of going to a primary care doctor because they may not have insurance. And if you don't have insurance, you could go to an emergency room one of our not-for-profits in town and get care for free, and that's the easiest way out.

Dr. Sunil Joshi: 7:14

Just go to the emergency room, and so when that happens, the hospital is not getting compensated, they're billing the patient. And now it billing the patient and now affects the patient's credit. So now they can't buy a car or get a house, but at the same time the hospital needs to be made whole. And guess who makes them whole? The taxpayers make them whole, and at UF Health in particular, where we pay over $40 to $50 million in taxpayer dollars to UF Health. And so we were like, how do we figure out this problem and fix it? And so one of the ways we thought about that is can we come up with a generalized program that made it easy for folks without health insurance to get their questions answered for free it's not costing them money, not being billed to them either where they might be able to then talk to a doctor, virtually get their issues addressed If it's something that is not emergent, can be treated over the phone, can be a prescription, can be sent in, and then they would then connect these individuals with our primary care network through JaxCare Connect, which has seven different clinics that provide free and charitable care to those without health insurance, and so they get them connected to them for their primary care, treat their emergent or urgent issue over the phone and then get them the primary care that they need.

Dr. Sunil Joshi: 8:23

In the meantime, they're avoiding this visit to the emergency room. These clinics have done surveys of their patients that come through and 76% of the new patients who come through the JaxCare Connect system had been in the emergency room in the previous year between one and three times. And of those 76%, 48% admit that they went to the ER for a minor illness. So by keeping them out of the emergency room and into a primary care system, in the big picture we're saving taxpayers millions of dollars, but most importantly, we're getting this vulnerable population that typically has a lower life expectancy the primary preventative care to help them thrive, yeah,

Dr. Michael Koren: 9:05

So give us a little bit of sense for how it's taking off so far

Dr. Michael Koren: 9:08

how many people have used it? With a lot of these social determinants of health, it's also people who have the wherewithal to know how to navigate a system.

Dr. Sunil Joshi: 9:17

That's right,

Dr. Michael Koren: 9:18

And sometimes that is difficult for people quite frankly

Dr. Sunil Joshi: 9:20

That's right, and so one of the things that we did not want is for the wrong people to use the system. We didn't want to make this a system. That was that people with insurance said, hey, I'm just going to call, maybe I'll get some care for free, and I don't have to. So we are targeting the audience that we are marketing this to. We're going through the faith-based communities, into the zip codes where we typically see the highest uninsured populations going to hospitals, who are then giving us a list of individuals who don't have health insurance that can then be contacted for care in regards to Health Link Jax, and so we're targeting it appropriately.

Dr. Sunil Joshi: 9:53

The program really did not get started until August 9th of 2024, when we had our press conference and our kickoff, and so in that time so between August and here most recently, over 400 to 500 patients have utilized the service for relatively minor issues, got treated. A very small percentage of them were sent to the emergency room and understanding that a minor illness in the ER can cost between $1,300 and $3,100 for bronchitis, upper respiratory infection, sinusitis, cellulitis, low back pain. Whatever, this program so far has already saved taxpayers $1.1 million in uncompensated care, and we've only seen between 400 and 500 patients through the program. We're expecting to see those numbers continue to grow as more and more people learn about it, and these patients are then also being diverted to JaxCare Connect for their primary care as well.

Dr. Michael Koren: 10:43

Nice, and who are the physicians who are taking these calls?

Dr. Sunil Joshi: 10:46

So we have a private partner that we work with. So this is a great public-private, not-for-profit partnership, and our private partnership is with Telescope Health, who won the RFP for this, and they are local emergency room doctors and, in fact, the emergency room doctors who are the CEOs and run this particular practice are from Jacksonville. They practice here in Jacksonville. This is a Jacksonville-based company, which is very important to us as we try to get programming out to private businesses. We want them to be in Jacksonville, and they are, and so they understand some of the challenges we face and they have helped us go out into the community and meet patients where they are, so they understand the benefits of this program.

Dr. Michael Koren: 11:26

Interesting, interesting. I'm going to put on my clinical trial hat for a second, and we should also probably let some of these folks know that there are nice clinical trials in the areas that may be of concern to them. So, for example, as we speak, we're doing studies in asthma, in lipids, in blood pressure, et cetera. And once people are in a clinical trial, they do get access to resources they wouldn't have otherwise.

Dr. Sunil Joshi: 11:54

That's right and so I think that's a great point is that, in particular with our Jax Care Connect system of free and charitable clinics, it'd be great to get your information out there to those folks, because, again, you got to keep in mind that a lot of these individuals are the folks that very typically don't get access to the newer medications that are out there, the cutting edge medications, and if they're able to do that at obviously a significantly reduced cost, free for the patient, you might be able to, number one, get better outcomes in the study but, number two, be able to help a typically underserved population.

Dr. Michael Koren: 12:22

And we'll put a show note in for people to make that connection.

Dr. Sunil Joshi: 12:25

It's terrific yes absolutely so.

Dr. Michael Koren: 12:26

let's move on to the next topic. I know you're also working on the problem of infant mortality.

Dr. Sunil Joshi: 12:32

Yeah, so you think about. We mentioned premature death rate, right, if somebody dies at one year of age, that adds 75 years to our premature death rate and you can see how we're suddenly having higher premature death rates in the rest of the state and the rest of the country. Jacksonville has a... So if you look at the state of Florida, the infant mortality rate, which is measured as number of infants dying from day zero after birth to day 365. So in the first year of life, if a baby dies, that adds to our infant mortality rate. In the state of Florida the infant mortality rate is six. So six babies dying per every 1,000 live births. In Duval County it is 7.9, which is significantly higher than the state average. If you break that down between race, if you look at African-American babies versus Caucasian babies, caucasian babies in Duval County are dying at a rate of about four per every 1,000 live births and our African-American babies are dying at 13 per every 1,000 live births. And this is regardless of zip code, regardless of socioeconomic status. And so there is definitely a challenge in this very diverse community 842 square miles how do we reduce infant mortality?

Dr. Sunil Joshi: 13:45

And there's a lot of factors at play, including access to prenatal care, which is an issue here. Based on a lot of data, we're about 28 OB short in Jacksonville. As the population has grown, our OB population has stayed the same and so we're short in that regard, and that definitely disproportionately affects those who don't have health insurance right and those who are typically underserved, and so they tend to be late into prenatal care. But but the once the baby is born, what happens? 25 of these babies who who die in their first year of life are dying because of sleep related issues. This is simple, educational issues that that can be shared with young families, moms and dads before, before pregnancy, during pregnancy and after pregnancy, to make it easier for the baby. And so this all goes back to the social determinants of health.

Dr. Sunil Joshi: 14:31

So it's easy for somebody to say who has 4,000 square feet, that how could you possibly have your baby sleep in an unsafe environment? Well, when you have six people living in a one-bedroom apartment because of our housing crisis, it becomes very difficult. You have three people sharing a bed, the baby's sharing a bed with their mom or dad. There may be things in the bassinet that can choke the baby.

Dr. Sunil Joshi: 14:52

There's so many factors that can be at play, and so we need to come up with a strategy to identify these women who are at risk, these babies who are at risk, and then go into the community and help educate them. And we are doing that with something we call community health workers, which I know you know well. These are folks who have shared life history, a shared life story with the population that we're targeting, people who may have had similar outcomes with their babies, people who look, live and breathe, just like the patient target population looks, lives and breathes, and they have developed a trust as a result of that and are able to come into the houses and review, kind of what's happening in there and try to educate moms.

Dr. Sunil Joshi: 15:33

I think that's the key is getting into the homes, getting into the homes and into the environment so that you can, number one, have the trust of the person you're talking to and identify some of the areas that could be of concern. And so we identify these ladies because there's a Florida statute that requires obstetricians to provide a survey, a questionnaire, to every pregnant woman, and pregnant women who answered in a certain way get flagged and that information goes out to the different not-for-profits in town to try to connect with these women, to make it so that we're less likely to have not just infant mortality but maternal mortality as well.

Dr. Michael Koren: 16:08

Interesting and how many of these folks do you have deployed right now?

Dr. Sunil Joshi: 16:13

So we put out an RFP for some of the not-for-profits that are looking for community health workers and the Northeast Florida Healthy Start Coalition won this RFP and we are funding two additional, maybe even three additional, community health workers for them and they've now hired those two and in the first quarter that they had them they did 129 programs or touched 129 different individuals through multiple different programs, including programs at housing communities, low-income housing communities, church events, community gatherings, and they've referred 54 people for home health services.

Dr. Sunil Joshi: 16:47

So, by identifying these folks, these are now 54 moms, dads, young families that either are prenatal or have already delivered, who may have been at risk of having infant mortality, who are now getting some support and educational resources to hopefully get them through this first year. And so the baby doesn't just survive, the baby thrives as we go forward, and so just think about that If 10% of those 54 would have had a bad outcome, we will significantly improve our infant mortality rate.

Dr. Michael Koren: 17:16

Interesting. Any feedback yet from people who may push back against this intrusion on their home life, et cetera. I know that you mentioned trying to create this position for people that can identify with the folks who are at risk, but I can imagine Still, people may not love the fact of somebody coming into their home, especially if they're a "government worker.

Dr. Sunil Joshi: 17:37

Right, right, exactly, and so that's the key point here is that these folks are not employed by the city of Jacksonville. They're employed by a trusted not-for-profit that's in the community already with their own community health workers. What we have done is we've added additional workforce for them to be able to get their job done, because you get overwhelmed very quickly. Each community health worker in a year can touch over 200 patient lives, and so, as they're going around trying to work with the 842 square miles, it becomes pretty challenging by adding two or three additional folks on board. If we can now touch an additional 600 lives because of these two or three additional community health workers, we can make a significant impact and outcomes, and so I think there's trust built in, because it's not the city of Jacksonville government officials coming in. It's folks that have a job with not-for-profits whose job it is to help improve outcomes and allow babies to live and thrive.

Dr. Michael Koren: 18:32

That's terrific. It's terrific.

Dr. Michael Koren: 18:33

So we're going to go from the young to the old now, and I know another thing you're working on is food insecurity in the elderly.

Dr. Sunil Joshi: 18:40

That's right

Dr. Michael Koren: 18:41

And this is a paradox. I was a president of the local chapter of American Heart Association for a while and there was a lot of talk about food insecurity. Yeah, on one hand. On the other hand, really, what we're dealing with in clinical practice in cardiology, internal medicine and allergy and immunology and other places is we have an obesity epidemic. So we have this incredible paradox. Is that quote on one hand, we're talking about food insecurity would make me want to eat more, and in many cases and, quite frankly, in a lot of our patients, we need to have them be more selective in terms of what they eat. That's right. So how do you balance it? Of course, there are people truly that are worried about where their next calories are going to come from, but it's a tricky situation because it's paradox.

Dr. Sunil Joshi: 19:26

It absolutely is. And now we're an underserved population which also has a tendency to be food insecure, also has a high degree of heart disease and diabetes. Right, and that's because where we have food deserts, we have what we call food swamps. Where it's the bad food, it's the fast food, it's the highly processed and preserved foods that they are able to eat because those are less expensive. And so, understanding that our food insecure, elderly in particular in this community face similar challenges. Our program was set up through an RFP to be able to provide healthy, what we call the American, the Older Americans Act-based nutritious foods. So these have to be nutritious foods that are also specific for those individuals. So, for instance, if this was a vegetarian, we would have vegetarian options, vegan options, kosher options, people who don't eat pork or don't eat rice, diabetic options, heart so it's specific for the individual and so just to give you a big picture on food insecurity in Duval County, so this has been an issue for us for years.

Dr. Sunil Joshi: 20:28

In 2015, 20% of our population was considered to be food insecure, so it's very high percent of our population. Through a lot of different programs, including Feeding, northeast Florida, the JTA, right to Share programs, urban farms that we have here in Jacksonville, we have reduced our food insecurity down to 10%.

Dr. Sunil Joshi: 20:46

A significant decrease just in the last 10 years. But what we do and-

Dr. Michael Koren: 20:50

How do you define that, just from my knowledge?

Dr. Sunil Joshi: 20:52

So, food insecurity, remember. If you do not have a grocery store within one mile of your resident, if you have at least 3,000 people in your zip code, or if you live in a, which is what an urban center would be considered, and in a rural community it would be between five and 10 miles. Okay, so we had 20% of our population defined as being food insecure, I see, over time, because we've been able to develop these urban farms through the work of a lot of farmers here in town feeding Northeast Florida has been around.

Dr. Sunil Joshi: 21:20

And Blue Zones, of course, is getting people out into the community. That perception of being food insecure has dropped by about 50%, which is significant here in Duval County, and the state has pretty much stayed the same if you look at the food insecurity numbers, and we have gone down significantly. So what we're doing in Northeast Florida is working. So it's like we want to do now. As we go forward, we think about okay, things are working, let's let those things work. Where it's not working is with our elderly community, and our elderly community has other challenges. Right, so it could be an economic thing, but it could be a disability thing as well. Right, you can't see, you can't drive, you can't hear, you can't drive, you're too old. Now People are taking away your keys from you and you could be someone who worked your whole career as a CEO and are incredibly intelligent, but you can't leave your house. They don't know how to use the phone for Uber, eats and Instacart and things of this sort.

Dr. Sunil Joshi: 22:09

So our ElderSource community here in Jacksonville, Elder Source, which is a not-for-profit, came to our office and let us know that there were over almost 3,000 people on a waiting list elderly folks for food, and they also had already been serving 800 people a day, five days a week, elderly people over the age of 65 who were food insecure. 800 of them were being served every day, but we had 2,800 people on a waiting list. They couldn't get to the 2,800 people. So what we did is we worked together through a public-private, not-for-profit partnership to find a vendor who can help produce food for us quickly still go with the Meals on Wheels program who could distribute the food appropriately and increase the number of elderly folks that we're getting a hot meal to at least once a day, five days a week. And so this program, which also started in July late July of 2024, through two quarters so far, has been able to reduce that waiting list by 63%. So we've gone from 2,800 people who are looking for a meal and were food insecure down to 1,000. And they've served over 100,000 meals during this time period.

Dr. Sunil Joshi: 23:17

And again, this is all city dollars. The patient, the person individually, is not paying a cent for this, and so how they benefit is number one they get a hot food, which is something that they enjoy because they ask for the vegan food, the vegetarian food, the Asian food, whatever they want, but is done in a healthy way. And number two, they also get a home check. So when it's the same person delivering the food to the same address every week, so they're also going in seeing how Mr Smith is doing they let them come in and set the food up in their kitchen for them. They could see what their environment looks like and they could report back.

Dr. Sunil Joshi: 23:50

And so the data from the people who have utilized this program is remarkable 93% no longer feel insecure and over 90% feel a sense of community More so than they did before they entered into this program, because now somebody's even visiting their house and seeing how they're doing and you know they get contact information for their loved ones and so if something's going on they could also reach out to the loved one if they need to to help Mr Smith with his challenges. And so there's so much benefit to this program and we're only not even two quarters into it. We do expect to reduce that waiting list so low that more people are going to want to jump on and get these food services.

Dr. Michael Koren: 24:26

That's great. Well, you mentioned the fact that Duval County, which is Jacksonville, is very, very large, and so there's a challenge just because of the distance.

Dr. Sunil Joshi: 24:35

Absolutely.

Dr. Michael Koren: 24:36

And this quote food truck idea is a very attractive way to deal with it

Dr. Sunil Joshi: 24:41

Yep, yep.

Dr. Michael Koren: 24:42

And, interestingly, I think it's also a little bit of a marketing issue is like food trucks are cool,

Dr. Sunil Joshi: 24:47

Yeah, yeah. Yeah.

Dr. Michael Koren: 24:48

Meals and wheels isn't quite as cool

Dr. Sunil Joshi: 24:51

That's right

Dr. Michael Koren: 24:52

-and it doesn't have that same connotation. So if we can marry those two concepts, I think we'll be in really good shape.

Dr. Sunil Joshi: 24:56

Yeah that's actually a really good way to look at it too, and provide other options for folks who can afford to pay but still are food insecure, right? So you can have the program in place for those who can't afford it and are getting it subsidized by tax dollars. And then you can also have a program in place where those food trucks, as you say, which can provide other food options, are available into communities and people just have to go down and get it Right and combine those.

Dr. Michael Koren: 25:23

So the thing I like about that I believe in utopian capitalism. So if you can get small business people to run the food trucks and figure out a way where they can get some city contracts to also provide food to people that may not be mobile, or get to their, their apartments or homes yeah even better yeah, that's great.

Dr. Sunil Joshi: 25:43

That's actually something to think about we love to support small businesses in jacksonville. So that that's. That is an outside the box way to think about it sounds great.

Dr. Michael Koren: 25:52

So, moving on to the next thing, you mentioned that there's not a great awareness of the city of Jacksonville. 988 number, yeah, so why don't you tell us more about that?

Dr. Sunil Joshi: 26:03

Yeah, you know. I go to groups all the time and I ask them do you know what 988 is? And you'll get maybe 10 out of a hundred people raise their hand, and there's data throughout the country and survey data that only 13% of the population knows what the 988 number is. 988 number is the suicide prevention hotline. Everybody knows what 911 is and a lot of people utilize 911 when they're in a mental health crisis, and that is not where you need to go. You need to be going to 988.

Dr. Sunil Joshi: 26:31

Our 911 callers are already overwhelmed, right, and so if we also put the burden of mental health on them, that would be very difficult. And so the 988 number. Here in Jacksonville, they do a wonderful job and so between the years '22 and '23, they had a somewhere around 40% increase in call volume during that time period, where they're getting between 600 and 800 calls every month for people who are calling in mental health crises. What's amazing about our 988 Call Center, which is housed by the United Way, by the way, is that they are able, if they pick up the phone which they pick up the phone in the previous years 82% of the time and, just so you know, the other 18% go to a national call center and then they'll pick up the phone, but we like to keep the calls local. So they had been picking up the phone 82% of the time and when they picked up the phone they were able to deescalate the crisis 98.7% of the time. Only 1.3% of the time did they have to send somebody to be Baker acted or go to the hospital. And that's a big deal for us because in Jacksonville we have 13% more hospitalizations for mental health illnesses than the rest of the state. So we want to keep these folks out of the hospital and into mental health resources.

Dr. Sunil Joshi: 27:37

And the 988 folks can not only deescalate the crisis but also set you up with those mental health resources. Because they have those resources, they know where people can go and then even in the days to weeks following, they follow up with the caller to see if they did go get those resources and where they are in the process. And so we realized that, realizing that the awareness of the 998 number is gonna continue to increase, their call volume is gonna continue to increase, but if their pickup rate was going to decrease, then we're gonna have a problem because the National Call Center success rate at deescalating is 75%, significantly less than local, because they don't know our resources. So if you know that there's a resource available, you might be able to keep that person out of the hospital. It's like I can set you up with Child Guidance Center or the Mental Health Resource Center because you know that they're available. Some guy sitting in Topeka, kansas, doesn't know that about Jacksonville and so we want to keep those calls local.

Dr. Michael Koren: 28:31

Nothing against Topeka by the way.

Dr. Sunil Joshi: 28:32

No, we love Topeka

Dr. Sunil Joshi: 28:33

Kansas, middle America, right, and so we want to keep those calls local. Knowing that the call volume is going up, we're like we need to add at least two more crisis managers. So the city of Jacksonville is supporting the addition of two more crisis managers. They have hired and I will tell you their numbers are amazing. So I mentioned earlier in '23, in the same months between August and September, they were averaging on average between seven. They're answering on average about seven to 800 calls a month. It's now over 1,100 calls a month.

Dr. Sunil Joshi: 29:05

It's a 40% increase in call volume, but their pickup rate is still is now 96% because we added the two additional crisis managers. So they've had an increase in volume, but the answer rate is even higher. They're still at a 98.7% de-escalation rate as we speak. But the time to pick up is another big question. Right, if you're in a mental health crisis and you call 988, the average time to pick up in '23, 2023 was 26 seconds. Okay, think about that when you're calling your loved one on the phone 26 seconds have gone by. You're gonna hang up they're not available.

Dr. Sunil Joshi: 29:41

Now the time to answer is 2.2 seconds. So we've gone from 26 seconds down to 2.2 seconds an 89% decrease in time to wait when you call the number, and on top of that, they pick up the phone 96% of the time. In the month of August, they picked it up 100%. Every single local call was answered locally, and so what we're doing there and we expect to see these numbers over time show is that our hospitalizations for mental health related illnesses should go down. We should now be below the state average as we go forward, because we are answering these folks who are in crisis and getting them set up with mental health resources

Dr. Michael Koren: 30:20

Interesting,

Dr. Michael Koren: 30:22

Fascinating, so a lot of the things are floating in my mind. Sometimes. I think about conspiracy theories and how you have unintended consequences, so I'll throw two out. Okay. First congratulations. It's terrific the progress that's been made so far.

Dr. Sunil Joshi: 30:38

Yeah, yeah.

Dr. Michael Koren: 30:38

But when you do something really, really well, people sometimes try to exploit it. So I don't think any of us have a healthcare system that answers a phone call within three seconds, Right.

Dr. Sunil Joshi: 30:48

That's right. That's right that answers a phone call within three seconds.

Dr. Sunil Joshi: 30:50

Right, that's right, that's right.

Dr. Michael Koren: 30:51

Is this gonna become something where everybody call 988 and say I need to make an appointment with my obstetrician and I can't get anybody else on the phone?

Dr. Sunil Joshi: 30:58

Well, yeah yeah, let's hope that's not the case, and so what we're trying to do with our 988 calls is also educate them about the other resources we have, so they can send them to 211, which is a great resource here in Jacksonville, and findhelp. org, which is a great resource for other non-mental health even mental health resources, in fact and also our.

Dr. Sunil Joshi: 31:19

HealthLink Jax. So they call because they're like ah, you know, I'm having hypertension. I'm calling 988 because I can't get in my provider. Well, we can get you connected with our virtual management for health care here in Jacksonville with HealthLink Jax, and so we're trying to cross-pollinate all of these things. So HealthLink Jax is cross-pollinating with our mental health resources, who cross-pollinates with our infant mortality space, so that we're all knowing what everyone is doing, so we're not working in silos. That's one of the biggest complaints we had when we first started, and which is what we're trying to do is break down the silos as much as possible. Is people not knowing what the other people are doing, what the right hand's not knowing what the left hand is doing? But if we know what everyone's doing and we can connect each other not compete right Collaborate without competing Everyone wins, because our goal is to help the community.

Dr. Sunil Joshi: 32:04

And if we stay laser focused on helping the community not competing but collaborating then we will do it and we will all be able to get the grant dollars that everybody wants and all this stuff, because you'll be able to show the success that you have.

Dr. Michael Koren: 32:23

That's terrific. I love that. So we're going to go to a fifth point. I have to say that I'm amazed that you have five initiatives. Quite frankly, if you had just one to present, that'd be impressive. But now we're talking about five initiatives, which is just absolutely off the charts. But there's a website I think that you're promoting as well that you want people to know about. So why don't you tell us a little bit about that?

Dr. Sunil Joshi: 32:40

So one of our biggest programs that we started right when we got into office was Get Covered Jax, you probably have seen it and heard of it, and this is our really just our way to allow people to understand that there is a process to getting onto marketplace health insurance Affordable Care Act insurance, otherwise known as Obamacare we took the word Obamacare out of it and just call it marketplace insurance and there's an open enrollment period between November 1st and January 15th of every year.

Dr. Michael Koren: 33:08

It wasn't originally Obamacare, by the way.

Dr. Sunil Joshi: 33:09

Right right. It became like you know that was-

Dr. Michael Koren: 33:13

-and we weren't sure if that was derogatory or complimentary

Dr. Sunil Joshi: 33:15

Right and people look at it

Dr. Sunil Joshi: 33:16

the wrong way so some people, you know it's like it becomes political and they're like let's just look at what's out there for you and if you take the politics out of it, you would be interested in signing up for health insurance that otherwise thought they couldn't afford it and that it was too cumbersome.

Dr. Sunil Joshi: 33:32

And so what we did is we developed-

Dr. Michael Koren: 33:33

-they're very similar to commercially available plans.

Dr. Sunil Joshi: 33:35

And they are commercially available plans. They are just subsidized with tax dollars to make it more affordable. And so, depending on whether or not you qualify. And so, by understanding that, what we did is we developed a website, developed some communication strategies, did some phone banks as well, and started to work with, collaborate with the Health Planning Council of Northeast Florida, which has federally trained navigators who help people navigate through the Affordable Care Act plans, and some of our licensed insurance brokers who have a keen interest in the Affordable Care Act plans, and we set them up on our website and we had links there and so people can talk to somebody who is trained in helping folks navigate through the process.

Dr. Sunil Joshi: 34:19

Because if you go to the healthcare. gov website, even those of us who do healthcare for a living will be confused and will have no idea what to do. So when you're confused about something, you choose not to do it. Our mayor says, all the time a confused mind says no. So if you're like confused, you're like forget it, I'm not going to do it. If we can have somebody help walk you through the process and understand how easy it is and how this can change your life, then suddenly it becomes an easier fit for you, and so people did not know that if you were on Affordable Care Act insurance, your primary preventative care is covered.

Dr. Sunil Joshi: 34:52

Your blood work to screen for cholesterol and diabetes is covered. Your PSA is covered. Your colonoscopy screening test is 100% covered You're not paying out of pocket for that. Your mammograms are covered. Your pap smears are covered All of those things that help keep you healthy. Your preventative care is covered. You didn't have to pay for that. And then you have your health plan that can help you with your prescription drugs and you can choose the right one. If you have someone helping you. Understanding your income level, your race, where you're located, your zip code, your family situation, can set you up for Cadillac plans that you're paying significantly less premiums for. And so in our first year so that 2023 into '24 year where we had our numbers back, we were able to so our uninsured rate going into our administration was 120,000. So in 120,000, people in Jacksonville,

Dr. Sunil Joshi: 35:40

Florida without health insurance. Okay, we were able to reduce that number by 34% in those eight weeks of Affordable Care Act signups. So we increase the number of people on Affordable Care Act insurance in Duval County by almost 50%. The state average is 31%, so a significant increase. Just by educating people, that's all. We did not use a single cent of local taxpayer dollars in the process.

Dr. Michael Koren: 36:04

These are just programs that are out there. People just didn't know about them.

Dr. Sunil Joshi: 36:07

They just didn't know about them, and so now, our challenge is to keep that momentum going, you know, because last year it was easy. We got a lot of media buy-in. They helped us promote it. Media tends to fall off over time, you know, looking for TV ratings and whatnot, and so it's still a challenge for us to get that information out there. But I think as long as we're able to have that relationship with our healthcare navigators, we're going to make this work for people and we're going to continue to push it.

Dr. Michael Koren: 36:33

And we'll put a show note to help people navigate that and know where to go oh that'd be fantastic, absolutely.

Dr. Michael Koren: 36:38

So let me ask you a last provocative question. A lot of these programs that you mentioned require human resources, and pretty well-trained human resources, which is probably going to be a limitation at some point. It may already be. And there's always discussion about artificial intelligence, and where do you think AI bots will come in? Will it be an AI bot that gets on these 988 phone calls, for example, and help out with the burden as this gets more and more popular?

Dr. Sunil Joshi: 37:06

Yeah, and I think you and I know, as physicians, the one thing AI cannot do is take that humanistic part of medicine and put it into play. You can take all of the different logarithms and make it work so that you can come up with a proper outcome, and so I would say that AI should be augmented intelligence for us. We should utilize it for us to target communities that might need our help more than others, and use it that way, as opposed to being the one that's trying to be humanistic on the other end of the line of somebody who might be suicidal.

Dr. Sunil Joshi: 37:37

That becomes very, very difficult and in particular, if you knew you weren't talking to a person, that might make it even more challenging for the individual or trying to help.

Dr. Michael Koren: 37:45

Well, some of the advocates of AI say that there's actually more empathy that comes from the bots than from the average physician.

Dr. Sunil Joshi: 37:50

Yeah, you know, and then there may be some average physicians that need to go back to training, right, and I do think you know, being able to sit in on some medical school interviews here over the last few years I do see that medical schools are looking for more empathetic and humanistic applicants compared to our days, you know, or just all about your MCAT scores or whatever. I think it is very important to look at that humanistic aspect as we go into medicine down the road.

Dr. Sunil Joshi: 38:14

But I think-

Dr. Michael Koren: 38:16

Well, ai bots don't have actual empathy.

Dr. Sunil Joshi: 38:18

That's right.

Dr. Sunil Joshi: 38:19

They can't, right? And so the AI aspect of it is I always look at is how does this help me as a physician, how does it help me as a public health manager here in Duval County? Is, how does it augment my ability to do our job? Because ultimately, it's men and women who feel the pain and suffering of other men and women and can move mountains. But we can utilize AI to get us to the places we want to go, to target things more effectively, so that we're not wasting resources. We're utilizing resources more effectively and streamlined.

Dr. Michael Koren: 38:51

But for now, we're old school and these are real human beings that actually care about the people that are doing these processes and part of these various programs.

Dr. Sunil Joshi: 39:01

Yeah, and I think part of what makes these programs work are the people, of course, and so you're self-selecting. Somebody who wants to be a community health worker wants to do it for a reason right. I mean you have to want to do it.

Dr. Sunil Joshi: 39:13

If you want to be a crisis manager and be on the other line as somebody who's suicidal. There has to be something in your life that made you want to do that Maybe your own personal experience or some sort of passion that you have towards mental illness that's going to allow you to do it. The same thing with our emergency room doctors that are working through HealthLink Jax. I mean, why would you do that when you normally would be working in the emergency room? That's how we got trained. But there must be something that says, hey, I need to help these uninsured people out there who are otherwise coming to our emergency rooms and we're providing very expensive care for them that they don't need. And so the people who are part of these programs are self-selected to want to see these programs be successful.

Dr. Michael Koren: 39:51

Well, Sunil, that was incredibly enlightening for me. Thank you for sharing all this information.

Dr. Sunil Joshi: 39:55

Thanks for giving me the opportunity.

Dr. Michael Koren: 39:56

Yeah, congratulations on being the chief health officer. Thanks for your good work for our community. And if there's anything we can do in evidence to get the word out, we're happy to do that, because these are really important programs that make a difference.

Dr. Sunil Joshi: 40:09

And I do think that as we get more data or we come up with more programming, I would love to come and talk about that too. Down the road

Dr. Michael Koren: 40:16

Sounds great, we'll have you back, thank you.

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