🎙 Community Health Initiatives with Jacksonville's Chief Health Officer Ep. 278

Episode Transcript
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Announcer (00:00):
Welcome to MedEvidence!, where we help you
navigate the truth behindmedical research with unbiased,
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researcher, Dr Michael Koren.

Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor for MedEvidence!, and we
have a repeat visitor today.
I'm very excited, Dr.
Sunil Joshi, welcome back toMedEvidence!

Dr. Sunil Joshi (00:21):
Yeah, thank you for having me.
I'm excited to be here

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

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

It's fun.
So Dr.
Joshi is the chief medicalofficer of the city of
Jacksonville.
Congratulations on that,

Thank you, thank you.

And I know that you have a number of
initiatives that are citywidethat you'd like to talk about
today, and I'm really excited todig in because I'd like to know
more.
Our business is in Jacksonvilleand I'd like to know what the
city's doing and learn moreabout your leadership and where
these programs are headed andwhat progress they've made to
date.
So again, just for the audiencesake, just tell us a little bit

(01:03):
about your background, what youdo.
You obviously wear a lot ofhats, including seeing patients.

Yes, that's right.
So I was born and raised herein Jacksonville, Florida.
I grew up here, went to UF formedical school and did my
residency here in Jacksonvillein internal medicine before I
did an allergy fellowship.
I've been practicing since 2004.
I'm not too far from thisstudio.
So for about 20 years now I'vebeen practicing allergy and
immunology and I still do that.

(01:28):
And right at the change of theadministration here in
Jacksonville between one mayoraladministration and the other,
the incoming mayor, mayor Deegan, asked me if I would be the
chief health officer for thecity of Jacksonville, which is a
new role We've never had onebefore and it's a very rare role
in the United States.
And it was important forJacksonville for a variety of

(01:50):
reasons and we'll talk aboutsome of that here today.
But I was honored to accept itbecause I was still able to
continue to see patients and runmy practice while also doing a
passion of mine, which is takingcare of the health of the city
of Jacksonville.

That's terrific.
And again, thank you for yourservice.

My pleasure.

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

Yeah, I think it's important for people to
know that Jacksonville is 842square miles right, it's the
biggest landmass city in thecontinental United States and
extremely diverse.
You know, we look at Floridacities much more diverse than
other parts of the country andone of our biggest challenges is
our health, our health outcomeshere in Duval County.
And so if you look at healthoutcomes based on what we call

(02:40):
the premature death rate andI'll define that for you so
we're all expected to live to be75 years of age.
If you live to be 74 years ofage, that's considered one year
of life lost.
If you live to be three monthsof age, that's considered 75
years of life lost.
And the way that healthoutcomes in a community are
measured is based on thepremature death rate and you

(03:01):
look at this over a three-yearperiod, at different parts in
time, and the premature deathrate and you look at this over a
three-year period, at differentparts in time, and the
premature death rate in theUnited States is 8,000.
So 8,000 years of life loss forevery 100,000 population.
The state of Florida is 8,300years of life loss for every
100,000 population.
Duval County, jacksonville,Florida, is 11,000 for every

(03:22):
100,000 years of population, andso there's a lot of factors
involved in that, includingcertain parts of our community.
So Jacksonville is divided upinto health zones, and there are
certain health zones that havefar worse health outcomes than
others, and they're onlyseparated by a bridge in a lot
of cases not even five miles andso identifying where the
problems are, identifying whatthe problems are and trying to

(03:44):
balance those health inequitiesis what our job is here.

Oh, beautiful .
Really interesting stuff, andJacksonville has a lot of
medical resources, so it's notfor lacking, per se, of medical
resources.
I don't know if you want tocomment on that.

Oh, absolutely, and so when you look at health
outcomes and what makes somebodyhealthy and what doesn't, only
20% of that is defined by whatis happening between you and
your physician or yourhealthcare provider in the
medical center, whether it's ina hospital or a primary care
clinic.
There's 80% that's affected byoutside factors, which includes
the social determinants ofhealth, and that includes income

(04:18):
and educational status,literacy, transportation,
language, violent crime, safety,the built environment,
cigarette, smoke, alcoholism allof those things that are not
necessarily discussed in thedoctor's office can become a
problem for folks in terms ofaccessing healthcare but also
staying healthy outside of thedoctor's office.
And that's where we are mostchallenged here in Jacksonville

(04:42):
is that those socialdeterminants of health that
divide our city botheconomically and from a health
perspective.

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

Yeah, absolutely.
And here in Jacksonville thesocial determinants of health
are much more of a factor incertain parts of our community
than others, and those parts ofour community where it plays a
bigger role the life expectancyis significantly lower than the
parts that don't.
So if you go down SouthsideBoulevard, you come off of Main
Street Bridge, you go downHendricks onto San Jose

(05:33):
Boulevard, you're talking abouta group of people in that
3-2-2-5-6 zip code that have alife expectancy of 81, which
would make that if that littlehealth zone in Duval County was
a country by itself, it would bethe 25th healthiest country in
the world, with Denmark and theNetherlands up in that area.
But then if you go over the MainStreet Bridge into what we call

(05:53):
Health Zone 1, which is noteven five to 10 miles away from
there, you're looking at a lifeexpectancy of 68 years of age,
which will put it as the 160thhealthiest country in the world,
right there with Rwanda.
And so just a little bit of adifference from one part of town
to the other has a significantimpact in health outcomes, and
you could see some of the socialdeterminants of health just by

(06:14):
making that drive through thosetwo communities

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

Yes

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

So it's called HealthLink Jax and this is our
virtual care program for theuninsured here in Duval County.
So what we have noticed as wecame into office and we started
learning about what's happeningin Jacksonville, we noticed that
a very large percentage of ouruninsured population will
utilize the emergency room astheir source of primary care.
They may need to go there,obviously, for emergent

(06:52):
situations, but in a lot ofcases, people are utilizing the
emergency room as a source ofrefilling their blood pressure
meds or being treated for anupper respiratory infection or
for a minor skin infection,instead of going to a primary
care doctor because they may nothave insurance.
And if you don't have insurance, you could go to an emergency
room one of our not-for-profitsin town and get care for free,

(07:12):
and that's the easiest way out.
Just go to the emergency room,and so when that happens, the
hospital is not gettingcompensated, they're billing the
patient.
And now it billing the patientand now affects the patient's
credit.
So now they can't buy a car orget a house, but at the same
time the hospital needs to bemade whole.
And guess who makes them whole?
The taxpayers make them whole,and at UF Health in particular,
where we pay over $40 to $50million in taxpayer dollars to

(07:36):
UF Health.
And so we were like, how do wefigure out this problem and fix
it?
And so one of the ways wethought about that is can we
come up with a generalizedprogram that made it easy for
folks without health insuranceto get their questions answered
for free it's not costing themmoney, not being billed to them
either where they might be ableto then talk to a doctor,
virtually get their issuesaddressed If it's something that

(07:59):
is not emergent, can be treatedover the phone, can be a
prescription, can be sent in,and then they would then connect
these individuals with ourprimary care network through
JaxCare Connect, which has sevendifferent clinics that provide
free and charitable care tothose without health insurance,
and so they get them connectedto them for their primary care,
treat their emergent or urgentissue over the phone and then

(08:21):
get them the primary care thatthey need.
In the meantime, they'reavoiding this visit to the
emergency room.
These clinics have done surveysof their patients that come
through and 76% of the newpatients who come through the
JaxCare Connect system had beenin the emergency room in the
previous year between one andthree times.
And of those 76%, 48% admitthat they went to the ER for a

(08:44):
minor illness.
So by keeping them out of theemergency room and into a
primary care system, in the bigpicture we're saving taxpayers
millions of dollars, but mostimportantly, we're getting this
vulnerable population thattypically has a lower life
expectancy the primarypreventative care to help them
thrive, yeah,

So give us a little bit of sense for how it's
taking off so farhow many people have used it?
With a lot of these socialdeterminants of health, it's
also people who have thewherewithal to know how to
navigate a system.

That's right,

And sometimes that is difficult for people
quite frankly

That's right, and so one of the things that we
did not want is for the wrongpeople to use the system.
We didn't want to make this asystem.
That was that people withinsurance said, hey, I'm just
going to call, maybe I'll getsome care for free, and I don't
have to.
So we are targeting theaudience that we are marketing
this to.
We're going through thefaith-based communities, into
the zip codes where we typicallysee the highest uninsured
populations going to hospitals,who are then giving us a list of

(09:47):
individuals who don't havehealth insurance that can then
be contacted for care in regardsto Health Link Jax, and so
we're targeting it appropriately.
The program really did not getstarted until August 9th of 2024
, when we had our pressconference and our kickoff, and
so in that time so betweenAugust and here most recently,
over 400 to 500 patients haveutilized the service for

(10:07):
relatively minor issues, gottreated.
A very small percentage of themwere sent to the emergency room
and understanding that a minorillness in the ER can cost
between $1,300 and $3,100 forbronchitis, upper respiratory
infection, sinusitis, cellulitis, low back pain.
Whatever, this program so farhas already saved taxpayers $1.1

(10:33):
million in uncompensated care,and we've only seen between 400
and 500 patients through theprogram.
We're expecting to see thosenumbers continue to grow as more
and more people learn about it,and these patients are then
also being diverted to JaxCareConnect for their primary care
as well.

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

So we have a private partner that we work
with.
So this is a greatpublic-private, not-for-profit
partnership, and our privatepartnership is with Telescope
Health, who won the RFP for this, and they are local emergency
room doctors and, in fact, theemergency room doctors who are
the CEOs and run this particularpractice are from Jacksonville.
They practice here inJacksonville.

(11:07):
This is a Jacksonville-basedcompany, which is very important
to us as we try to getprogramming out to private
businesses.
We want them to be inJacksonville, and they are, and
so they understand some of thechallenges we face and they have
helped us go out into thecommunity and meet patients
where they are, so theyunderstand the benefits of this
program.

Interesting, interesting.
I'm going to put on my clinicaltrial hat for a second, and we
should also probably let some ofthese folks know that there are
nice clinical trials in theareas that may be of concern to
them.
So, for example, as we speak,we're doing studies in asthma,
in lipids, in blood pressure, etcetera.
And once people are in aclinical trial, they do get

(11:47):
access to resources theywouldn't have otherwise.

That's right and so I think that's a great
point is that, in particularwith our Jax Care Connect system
of free and charitable clinics,it'd be great to get your
information out there to thosefolks, because, again, you got
to keep in mind that a lot ofthese individuals are the folks
that very typically don't getaccess to the newer medications
that are out there, the cuttingedge medications, and if they're
able to do that at obviously asignificantly reduced cost, free
for the patient, you might beable to, number one, get better

(12:17):
outcomes in the study but,number two, be able to help a
typically underserved population.

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

It's terrific yes absolutely so.

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

Yeah, so you think about.
We mentioned premature deathrate, right, if somebody dies at
one year of age, that adds 75years to our premature death
rate and you can see how we'resuddenly having higher premature
death rates in the rest of thestate and the rest of the
country.
Jacksonville has a.
.
.
So if you look at the state ofFlorida, the infant mortality

(12:54):
rate, which is measured asnumber 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 theinfant mortality rate is six.
So six babies dying per every1,000 live births.
In Duval County it is 7.9,which is significantly higher

(13:16):
than the state average.
If you break that down betweenrace, if you look at
African-American babies versusCaucasian babies, caucasian
babies in Duval County are dyingat a rate of about four per
every 1,000 live births and ourAfrican-American babies are
dying at 13 per every 1,000 livebirths.
And this is regardless of zipcode, regardless of
socioeconomic status.

(13:37):
And so there is definitely achallenge in this very diverse
community 842 square miles howdo we reduce infant mortality?
And there's a lot of factors atplay, including access to
prenatal care, which is an issuehere.
Based on a lot of data, we'reabout 28 OB short in
Jacksonville.
As the population has grown,our OB population has stayed the

(13:58):
same and so we're short in thatregard, and that definitely
disproportionately affects thosewho don't have health insurance
right and those who aretypically underserved, and so
they tend to be late intoprenatal care.
But but the once the baby isborn, what happens?
25 of these babies who who diein their first year of life are
dying because of sleep relatedissues.

(14:18):
This is simple, educationalissues that that can be shared
with young families, moms anddads before, before pregnancy,
during pregnancy and afterpregnancy, to make it easier for
the baby.
And so this all goes back tothe social determinants of
health.
So it's easy for somebody to saywho has 4,000 square feet, that
how could you possibly haveyour baby sleep in an unsafe
environment?
Well, when you have six peopleliving in a one-bedroom

(14:41):
apartment because of our housingcrisis, it becomes very
difficult.
You have three people sharing abed, the baby's sharing a bed
with their mom or dad.
There may be things in thebassinet that can choke the baby
.
There's so many factors that canbe at play, and so we need to
come up with a strategy toidentify these women who are at
risk, these babies who are atrisk, and then go into the

(15:02):
community and help educate them.
And we are doing that withsomething we call community
health workers, which I know youknow well.
These are folks who have sharedlife history, a shared life
story with the population thatwe're targeting, people who may
have had similar outcomes withtheir babies, people who look,
live and breathe, just like thepatient target population looks,

(15:24):
lives and breathes, and theyhave developed a trust as a
result of that and are able tocome into the houses and review,
kind of what's happening inthere and try to educate moms.
I think that's the key isgetting into the homes, getting
into the homes and into theenvironment so that you can,
number one, have the trust ofthe person you're talking to and
identify some of the areas thatcould be of concern.
And so we identify these ladiesbecause there's a Florida

(15:46):
statute that requiresobstetricians to provide a
survey, a questionnaire, toevery pregnant woman, and
pregnant women who answered in acertain way get flagged and
that information goes out to thedifferent not-for-profits in
town to try to connect withthese women, to make it so that
we're less likely to have notjust infant mortality but

(16:07):
maternal mortality as well.

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

So we put out an RFP for some of the
not-for-profits that are lookingfor community health workers
and the Northeast FloridaHealthy Start Coalition won this
RFP and we are funding twoadditional, maybe even three
additional, community healthworkers for them and they've now
hired those two and in thefirst quarter that they had them
they did 129 programs ortouched 129 different

(16:34):
individuals through multipledifferent programs, including
programs at housing communities,low-income housing communities,
church events, communitygatherings, and they've referred
54 people for home healthservices.
So, by identifying these folks,these are now 54 moms, dads,
young families that either areprenatal or have already
delivered, who may have been atrisk of having infant mortality,

(16:57):
who are now getting somesupport and educational
resources to hopefully get themthrough this first year.
And so the baby doesn't justsurvive, the baby thrives as we
go forward, and so just thinkabout that If 10% of those 54
would have had a bad outcome, wewill significantly improve our
infant mortality rate.

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

Right, right, exactly, and so that's the key
point here is that these folksare not employed by the city of
Jacksonville.
They're employed by a trustednot-for-profit that's in the
community already with their owncommunity health workers.
What we have done is we'veadded additional workforce for
them to be able to get their jobdone, because you get
overwhelmed very quickly.
Each community health worker ina year can touch over 200

(18:00):
patient lives, and so, asthey're going around trying to
work with the 842 square miles,it becomes pretty challenging by
adding two or three additionalfolks on board.
If we can now touch anadditional 600 lives because of
these two or three additionalcommunity health workers, we can
make a significant impact andoutcomes, and so I think there's
trust built in, because it'snot the city of Jacksonville

(18:21):
government officials coming in.
It's folks that have a job withnot-for-profits whose job it is
to help improve outcomes andallow babies to live and thrive.

That's terrific.
It's terrific.
So we're going to go from theyoung to the old now, and I know
another thing you're working onis food insecurity in the
elderly.

That's right

And this is a paradox.
I was a president of the localchapter of American Heart
Association for a while andthere was a lot of talk about
food insecurity.
Yeah, on one hand.
On the other hand, really, whatwe're dealing with in clinical
practice in cardiology, internalmedicine and allergy and
immunology and other places iswe have an obesity epidemic.

(19:02):
So we have this incredibleparadox.
Is that quote on one hand,we're talking about food
insecurity would make me want toeat more, and in many cases and
, quite frankly, in a lot of ourpatients, we need to have them
be more selective in terms ofwhat they eat.
That's right.
So how do you balance it?
Of course, there are peopletruly that are worried about
where their next calories aregoing to come from, but it's a

(19:24):
tricky situation because it'sparadox.

It absolutely is.
And now we're an underservedpopulation which also has a
tendency to be food insecure,also has a high degree of heart
disease and diabetes.
Right, and that's because wherewe have food deserts, we have
what we call food swamps.
Where it's the bad food, it'sthe fast food, it's the highly
processed and preserved foodsthat they are able to eat
because those are less expensive.

(19:46):
And so, understanding that ourfood insecure, elderly in
particular in this communityface similar challenges.
Our program was set up throughan RFP to be able to provide
healthy, what we call theAmerican, the Older Americans
Act-based nutritious foods.
So these have to be nutritiousfoods that are also specific for
those individuals.

(20:07):
So, for instance, if this was avegetarian, we would have
vegetarian options, veganoptions, kosher options, people
who don't eat pork or don't eatrice, diabetic options, heart so
it's specific for theindividual and so just to give
you a big picture on foodinsecurity in Duval County, so
this has been an issue for usfor years.

(20:28):
In 2015, 20% of our populationwas considered to be food
insecure, so it's very highpercent of our population.
Through a lot of differentprograms, including Feeding,
northeast Florida, the JTA,right to Share programs, urban
farms that we have here inJacksonville, we have reduced
our food insecurity down to 10%.
A significant decrease just inthe last 10 years.

(20:49):
But what we do and-

How do you define that, just from my
knowledge?

So, food insecurity, remember.
If you do not have a grocerystore within one mile of your
resident, if you have at least3,000 people in your zip code,
or if you live in a, which iswhat an urban center would be
considered, and in a ruralcommunity it would be between
five and 10 miles.
Okay, so we had 20% of ourpopulation defined as being food
insecure, I see, over time,because we've been able to

(21:12):
develop these urban farmsthrough the work of a lot of
farmers here in town feedingNortheast Florida has been
around.
And Blue Zones, of course, isgetting people out into the
community.
That perception of being foodinsecure has dropped by about
50%, which is significant herein Duval County, and the state
has pretty much stayed the sameif you look at the food

(21:34):
insecurity numbers, and we havegone down significantly.
So what we're doing inNortheast Florida is working.
So it's like we want to do now.
As we go forward, we thinkabout okay, things are working,
let's let those things work.
Where it's not working is withour elderly community, and our
elderly community has otherchallenges.
Right, so it could be aneconomic thing, but it could be
a disability thing as well.
Right, you can't see, you can'tdrive, you can't hear, you

(21:54):
can't drive, you're too old.
Now People are taking away yourkeys from you and you could be
someone who worked your wholecareer as a CEO and are
incredibly intelligent, but youcan't leave your house.
They don't know how to use thephone for Uber, eats and
Instacart and things of thissort.
So our ElderSource communityhere in Jacksonville, Elder
Source, which is anot-for-profit, came to our

(22:16):
office and let us know thatthere were over almost 3,000
people on a waiting list elderlyfolks for food, and they also
had already been serving 800people a day, five days a week,
elderly people over the age of65 who were food insecure.
800 of them were being servedevery day, but we had 2,800
people on a waiting list.
They couldn't get to the 2,800people.

(22:37):
So what we did is we workedtogether through a
public-private, not-for-profitpartnership to find a vendor who
can help produce food for usquickly still go with the Meals
on Wheels program who coulddistribute the food
appropriately and increase thenumber of elderly folks that
we're getting a hot meal to atleast once a day, five days a
week.
And so this program, which alsostarted in July late July of

(23:01):
2024, through two quarters sofar, has been able to reduce
that waiting list by 63%.
So we've gone from 2,800 peoplewho are looking for a meal and
were food insecure down to 1,000.
And they've served over 100,000meals during this time period.
And again, this is all citydollars.
The patient, the personindividually, is not paying a

(23:22):
cent for this, and so how theybenefit is number one they get a
hot food, which is somethingthat they enjoy because they ask
for the vegan food, thevegetarian food, the Asian food,
whatever they want, but is donein a healthy way.
And number two, they also get ahome check.
So when it's the same persondelivering the food to the same
address every week, so they'realso going in seeing how Mr

(23:42):
Smith is doing they let themcome in and set the food up in
their kitchen for them.
They could see what theirenvironment looks like and they
could report back.
And so the data from the peoplewho have utilized this program
is remarkable 93% no longer feelinsecure and over 90% feel a
sense of community More so thanthey did before they entered
into this program, because nowsomebody's even visiting their

(24:03):
house and seeing how they'redoing and you know they get
contact information for theirloved ones and so if something's
going on they could also reachout to the loved one if they
need to to help Mr Smith withhis challenges.
And so there's so much benefitto this program and we're only
not even two quarters into it.
We do expect to reduce thatwaiting list so low that more
people are going to want to jumpon and get these food services.

That's great.
Well, you mentioned the factthat Duval County, which is
Jacksonville, is very, verylarge, and so there's a
challenge just because of thedistance.

Absolutely.

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

Yep, yep.

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

Yeah, yeah.
Yeah.

Meals and wheels isn't quite as cool

That's right

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

Yeah that's actually a really good way to
look at it too, and provideother options for folks who can
afford to pay but still are foodinsecure, right?
So you can have the program inplace for those who can't afford
it and are getting itsubsidized by tax dollars.
And then you can also have aprogram in place where those

(25:17):
food trucks, as you say, whichcan provide other food options,
are available into communitiesand people just have to go down
and get it Right and combinethose.

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

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

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

Yeah, you know.
I go to groups all the time andI ask them do you know what 988
is?
And you'll get maybe 10 out ofa hundred people raise their
hand, and there's datathroughout the country and
survey data that only 13% of thepopulation knows what the 988
number is.
988 number is the suicideprevention hotline.
Everybody knows what 911 is anda lot of people utilize 911

(26:25):
when they're in a mental healthcrisis, and that is not where
you need to go.
You need to be going to 988.
Our 911 callers are alreadyoverwhelmed, right, and so if we
also put the burden of mentalhealth on them, that would be
very difficult.
And so the 988 number.
Here in Jacksonville, they do awonderful job and so between
the years '22 and '23, they hada somewhere around 40% increase

(26:47):
in call volume during that timeperiod, where they're getting
between 600 and 800 calls everymonth for people who are calling
in mental health crises.
What's amazing about our 988Call Center, which is housed by
the United Way, by the way, isthat they are able, if they pick
up the phone which they pick upthe phone in the previous years
82% of the time and, just soyou know, the other 18% go to a

(27:08):
national call center and thenthey'll pick up the phone, but
we like to keep the calls local.
So they had been picking up thephone 82% of the time and when
they picked up the phone theywere able to deescalate the
crisis 98.7% of the time.
Only 1.3% of the time did theyhave to send somebody to be
Baker acted or go to thehospital.
And that's a big deal for usbecause in Jacksonville we have

(27:29):
13% more hospitalizations formental health illnesses than the
rest of the state.
So we want to keep these folksout of the hospital and into
mental health resources.
And the 988 folks can not onlydeescalate the crisis but also
set you up with those mentalhealth resources.
Because they have thoseresources, they know where
people can go and then even inthe days to weeks following,

(27:49):
they follow up with the callerto see if they did go get those
resources and where they are inthe process.
And so we realized that,realizing that the awareness of
the 998 number is gonna continueto increase, their call volume
is gonna continue to increase,but if their pickup rate was
going to decrease, then we'regonna have a problem because the
National Call Center successrate at deescalating is 75%,

(28:11):
significantly less than local,because they don't know our
resources.
So if you know that there's aresource available, you might be
able to keep that person out ofthe hospital.
It's like I can set you up withChild Guidance Center or the
Mental Health Resource Centerbecause you know that they're
available.
Some guy sitting in Topeka,kansas, doesn't know that about
Jacksonville and so we want tokeep those calls local.

Nothing against Topeka by the way.

No, we love Topeka
Kansas, middle America, right,and so we want to keep those
calls local.
Knowing that the call volume isgoing up, we're like we need to
add at least two more crisismanagers.
So the city of Jacksonville issupporting the addition of two
more crisis managers.
They have hired and I will tellyou their numbers are amazing.
So I mentioned earlier in '23,in the same months between

(28:55):
August and September, they wereaveraging on average between
seven.
They're answering on averageabout seven to 800 calls a month
.
It's now over 1,100 calls amonth.
It's a 40% increase in callvolume, but their pickup rate is
still is now 96% because weadded the two additional crisis
managers.
So they've had an increase involume, but the answer rate is

(29:17):
even higher.
They're still at a 98.7%de-escalation rate as we speak.
But the time to pick up isanother big question.
Right, if you're in a mentalhealth crisis and you call 988,
the average time to pick up in'23, 2023 was 26 seconds.
Okay, think about that whenyou're calling your loved one on
the phone 26 seconds have goneby.

(29:38):
You're gonna hang up they'renot available.
Now the time to answer is 2.2seconds.
So we've gone from 26 secondsdown to 2.2 seconds an 89%
decrease in time to wait whenyou call the number, and on top
of that, they pick up the phone96% of the time.
In the month of August, theypicked it up 100%.

(29:58):
Every single local call wasanswered locally, and so what
we're doing there and we expectto see these numbers over time
show is that ourhospitalizations for mental
health related illnesses shouldgo down.
We should now be below thestate average as we go forward,
because we are answering thesefolks who are in crisis and

(30:19):
getting them set up with mentalhealth resources

Interesting, Fascinating, so a lot of the
things are floating in my mind.
Sometimes.
I think about conspiracytheories and how you have
unintended consequences, so I'llthrow two out.
Okay.
First congratulations.
It's terrific the progressthat's been made so far.

Yeah, yeah.

But when you do something really, really well
, people sometimes try toexploit it.
So I don't think any of us havea healthcare system that
answers a phone call withinthree seconds, Right.

That's right.
That's right that answers aphone call within three seconds.
Right, that's right, that'sright.

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

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

(31:19):
HealthLink Jax.
So they call because they'relike ah, you know, I'm having
hypertension.
I'm calling 988 because I can'tget in my provider.
Well, we can get you connectedwith our virtual management for
health care here in Jacksonvillewith HealthLink Jax, and so
we're trying to cross-pollinateall of these things.
So HealthLink Jax iscross-pollinating with our
mental health resources, whocross-pollinates with our infant

(31:39):
mortality space, so that we'reall knowing what everyone is
doing, so we're not working insilos.
That's one of the biggestcomplaints we had when we first
started, and which is what we'retrying to do is break down the
silos as much as possible.
Is people not knowing what theother people are doing, what the
right hand's not knowing whatthe left hand is doing?
But if we know what everyone'sdoing and we can connect each
other not compete rightCollaborate without competing

(32:01):
Everyone wins, because our goalis to help the community.
And if we stay laser focused onhelping the community not
competing but collaborating thenwe will do it and we will all
be able to get the grant dollarsthat everybody wants and all
this stuff, because you'll beable to show the success that
you have.

That's terrific.
I love that.
So we're going to go to a fifthpoint.
I have to say that I'm amazedthat you have five initiatives.
Quite frankly, if you had justone to present, that'd be
impressive.
But now we're talking aboutfive initiatives, which is just
absolutely off the charts.
But there's a website I thinkthat you're promoting as well
that you want people to knowabout.
So why don't you tell us alittle bit about that?

So one of our biggest programs that we started
right when we got into officewas Get Covered Jax, you
probably have seen it and heardof it, and this is our really
just our way to allow people tounderstand that there is a
process to getting ontomarketplace health insurance
Affordable Care Act insurance,otherwise known as Obamacare we
took the word Obamacare out ofit and just call it marketplace

(33:03):
insurance and there's an openenrollment period between
November 1st and January 15th ofevery year.

It wasn't originally Obamacare, by the way
.

Right right.
It became like you know thatwas-

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

Right and people look at it
the wrong way so some people,you know it's like it becomes
political and they're like let'sjust look at what's out there
for you and if you take thepolitics out of it, you would be
interested in signing up forhealth insurance that otherwise
thought they couldn't afford itand that it was too cumbersome.
And so what we did is wedeveloped-

-they're very similar to commercially
available plans.

And they are commercially available plans.
They are just subsidized withtax dollars to make it more
affordable.
And so, depending on whether ornot you qualify.
And so, by understanding that,what we did is we developed a
website, developed somecommunication strategies, did
some phone banks as well, andstarted to work with,
collaborate with the HealthPlanning Council of Northeast

(33:57):
Florida, which has federallytrained navigators who help
people navigate through theAffordable Care Act plans, and
some of our licensed insurancebrokers who have a keen interest
in the Affordable Care Actplans, and we set them up on our
website and we had links thereand so people can talk to
somebody who is trained inhelping folks navigate through

(34:18):
the process.
Because if you go to thehealthcare.
gov website, even those of uswho do healthcare for a living
will be confused and will haveno idea what to do.
So when you're confused aboutsomething, you choose not to do
it.
Our mayor says, all the time aconfused 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 helpwalk you through the process and

(34:38):
understand how easy it is andhow this can change your life,
then suddenly it becomes aneasier fit for you, and so
people did not know that if youwere on Affordable Care Act
insurance, your primarypreventative care is covered.
Your blood work to screen forcholesterol and diabetes is
covered.
Your PSA is covered.
Your colonoscopy screening testis 100% covered You're not

(34:59):
paying out of pocket for that.
Your mammograms are covered.
Your pap smears are covered Allof those things that help keep
you healthy.
Your preventative care iscovered.
You didn't have to pay for that.
And then you have your healthplan that can help you with your
prescription drugs and you canchoose the right one.
If you have someone helping you.
Understanding your income level, your race, where you're

(35:27):
located, your zip code, yourfamily situation, can set you up
for Cadillac plans that you'repaying significantly less
premiums for.
And so in our first year sothat 2023 into '24 year where we
had our numbers back, we wereable to so our uninsured rate
going into our administrationwas 120,000.
So in 120,000, people inJacksonville,
Florida without health insurance.
Okay, we were able to reducethat number by 34% in those
eight weeks of Affordable CareAct signups.

(35:48):
So we increase the number ofpeople on Affordable Care Act
insurance in Duval County byalmost 50%.
The state average is 31%, so asignificant increase.
Just by educating people,that's all.
We did not use a single cent oflocal taxpayer dollars in the
process.

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

They just didn't know about them, and so
now, our challenge is to keepthat 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 overtime, you know, looking for TV
ratings and whatnot, and so it'sstill a challenge for us to get
that information out there.
But I think as long as we'reable to have that relationship

(36:27):
with our healthcare navigators,we're going to make this work
for people and we're going tocontinue to push it.

And we'll put a show note to help people
navigate that and know where togo oh that'd be fantastic,
absolutely.
So let me ask you a lastprovocative question.
A lot of these programs thatyou mentioned require human
resources, and prettywell-trained human resources,
which is probably going to be alimitation at some point.
It may already be.
And there's always discussionabout artificial intelligence,

(36:55):
and where do you think AI botswill come in?
Will it be an AI bot that getson these 988 phone calls, for
example, and help out with theburden as this gets more and
more popular?

Yeah, and I think you and I know, as
physicians, the one thing AIcannot do is take that
humanistic part of medicine andput it into play.
You can take all of thedifferent logarithms and make it
work so that you can come upwith a proper outcome, and so I
would say that AI should beaugmented intelligence for us.
We should utilize it for us totarget communities that might

(37:28):
need our help more than others,and use it that way, as opposed
to being the one that's tryingto be humanistic on the other
end of the line of somebody whomight be suicidal.
That becomes very, verydifficult and in particular, if
you knew you weren't talking toa person, that might make it
even more challenging for theindividual or trying to help.

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

Yeah, you know, and then there may be some
average physicians that need togo back to training, right, and
I do think you know, being ableto sit in on some medical school
interviews here over the lastfew years I do see that medical
schools are looking for moreempathetic and humanistic
applicants compared to our days,you know, or just all about
your MCAT scores or whatever.
I think it is very important tolook at that humanistic aspect

(38:12):
as we go into medicine down theroad.
But I think-

Well, ai bots don't have actual empathy.

That's right.
They can't, right?
And so the AI aspect of it is Ialways look at is how does this
help me as a physician, howdoes it help me as a public
health manager here in DuvalCounty?
Is, how does it augment myability to do our job?
Because ultimately, it's menand women who feel the pain and
suffering of other men and womenand can move mountains.

(38:41):
But we can utilize AI to get usto the places we want to go, to
target things more effectively,so that we're not wasting
resources.
We're utilizing resources moreeffectively and streamlined.

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

Yeah, and I think part of what makes these
programs work are the people, ofcourse, and so you're
self-selecting.
Somebody who wants to be acommunity health worker wants to
do it for a reason right.
I mean you have to want to doit.
If you want to be a crisismanager and be on the other line
as somebody who's suicidal.
There has to be something inyour life that made you want to
do that Maybe your own personalexperience or some sort of

(39:22):
passion that you have towardsmental illness that's going to
allow you to do it.
The same thing with ouremergency room doctors that are
working through HealthLink Jax.
I mean, why would you do thatwhen you normally would be
working in the emergency room?
That's how we got trained.
But there must be somethingthat says, hey, I need to help
these uninsured people out therewho are otherwise coming to our
emergency rooms and we'reproviding very expensive care

(39:42):
for them that they don't need.
And so the people who are partof these programs are
self-selected to want to seethese programs be successful.

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

Thanks for giving me the opportunity.

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

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

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

Announcer (40:17):
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To learn more, head over toMedEvidence.
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🎙 Community Health Initiatives with Jacksonville's Chief Health Officer Ep. 278

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