Episode 3 - Let's Talk Therapy! - I love that little girl! (Nursing & Therapy work together)

Ms. Kim, a nurse, joins the episode to discuss how providing skilled nursing in the home can be a truly rewarding experience. 

Transcript

Episode 3 - Let's Talk Therapy - I love that little girl! 

Stephanie: [00:00:00] Hi everybody ah, welcome to lets talk Therapy my name is Stephanie Hill I'm here with Jennifer Morgan and we are ready to have a new discussion for our podcast today we are very excited to have nurse Kim with us and she's gonna give us a Perspective private nursing in the home and also. Like to work team so welcome cam thank you for coming in and ill to my partner Jennifer who gonna in our discussion.

Okay, 

Jennifer: so i like we need an open kind of discussion question not necessarily like nursing specific okey because thats we're gonna end up doing the rest of the podcast. This es mi cuestión and i was thinking about this whenever i was thinking about miss Kim being here today because i was trying to remember how long I've known her yes it feels like I've known her for a long time like we've been in Therapy for Forever absolutely it really hasn't maybe two years i no.

Ya so that's not very long at all in the Therapy world so outside of your family like mom your dad your [00:01:00] siblings who es somebody you've known and still talk to. Regularly like 

Stephanie: the longest that i talk to that i interact with y maybe 

Jennifer: you know christmas got it 

Stephanie: so talk to you a lot i guess me thinking about just a longterm friend.

So i keep in touch with a good friend from high school we've known each other Forever she's the kind of friend that maybe we go six months without talking but 11 we talk again we're like picking up where we left off so the best kind of friend there is she is in Oklahoma where i grew up she makes a trip down probably twice a year we go shopping we just hang out and talk and you know it's just nice to have someone like that in your life so 

Jennifer: for mí es a little de.

A hotel room y all like massive crazy shop wardrobe it's 

Stephanie: intense well we call it our girls weekend and so we really just focus on having that time together and you're right we we we go all out and it's something to look forward to [00:02:00] um because we're not seeing each other day to day so for me that would be my friend shery from high school so what about you 

Jennifer: so you were a close runner for first place a close runner no people like.

In high school we had like a group of girls that we hang out with and we did everything together they would come home we would have sleepovers we would mi mom cook them dinner made them breakfast sometimes before school but i don't really like we've gone in different faces we went to different colleges so we don't really hang out that much maybe talk christmas cards we do.

Whenever i was in the hospital having Abby my daughter we had a new hire at an agency and i was doing her training while i was on bedrest. Oh my and her name was Lori and you've worked with her too and we have remained friends we even do a Friday night. 

Stephanie: Very good and she a. Speech English so again good to have people in your life so we're talking about just relationships and people that we [00:03:00] connect with and so we have nurse Kim with us today and i wanna know just how you all know each other and your experience and you know why she feels like she's a close friend even though you Guys are colleagues and you coordinate care on a case.

A history Guys know each other and then how did you talk Kim into coming onto podcast today 

Jennifer: Kim and i met at a house a patient that we treat we treated and she i needed help was a Feeding patient and i needed her help we met in day one. It was like we known each people you can just talk to like it's just at ease and sometimes with nurses i don't always have that relationship because i feel like you know PT and ot andt i feel we're kind of all under the big umbrella but then sometimes.

Nursing es a little bit over here que se function a little bit differently we're writing evals we're writing our orders they're going to the doctor they're getting information they're [00:04:00] providing information kind of a different relationship but somehow we all come together so that how miss Kim and i met at house and she was super helpful and my patient made a lot of progress because.

Stephanie: So wonderful so Kim thank you for being here with us we all work with beva pediatrics it's a pediatric home health agency that does a private duty nursing and all three of the therapies ot PT and t and so very excited to hear your experience working in home health um certainly working with the Therapy team but maybe we'll just.

Start with why did you agree to do the podcast and then we will ask you a little bit about your experience you know starting out as a nurse and then getting all the way to home health okey, 

Kim: i did the podcast because i totally respect Jennifer like she said it's in a texture she did she did ill be honest it was like probably a huge compliment to me it made me [00:05:00] feel so special.

Honestly i was so shocked when she sent that to me said that we. Basically worked as a team when she was there you know and we bounced ideas off each other en just flow you have 

Jennifer: a you you came with a lot of the experience like sometimes nurses they don't have that background Feeding and even like Feeding protocols and i felt like you were a step ahead a step ahead we could have honest real Conversations en knowing that it's all a trials not like if i say.

Do the three times a day that in a week we be eating ten ounces you knew it was a trial you knew how you were i mean your patient was lovely and you cared for her great yes and you could read her really well yes that Skill. No everybody. Pues hace mm-hmm. 

Stephanie: Can i just say i mean obviously the therapists are coming [00:06:00] in maybe twice a week uh for thirty forty Sixty minute sessions and we kind of we get to learn that patient we get to learn that family but a private duty nurse is in that home ten twelve hours a day i mean they're in.

Deep into how that family functions they get to know that patient very very well and we can get a lot of information to help us do what we do by coordinating with the nurse who's gonna give us feedback is gonna let us know hey I've already figured out these boundaries or already know these behaviors or you know what.

She looks like she's getting tired or you know he needs to do this before he can do Feeding so it very helpful we work together and that we utilize each other's skills it sounds like you Guys picked up on that pretty quickly in the particular case that you shared so. How did you start out as a nurse and then what was your progression to get into that home health [00:07:00] setting 

Kim: i started out as a nurse for i always respected the profession i felt like to me.

When you feel horrible when you're not at your best i think such a great thing and i always respected la profession so you know i can do this and i actually had a toddler when i started nursing school but i did it you know so that got me started there and then blue at matern oh, guau. Ah the. No LD no.

Nursery but postpartum and absolutely loved it you know i got to meet so many people um, i was i was only there for like a year 

Jennifer: so how sorry el postpartum be different than la labor and delivery and like labor and delivery 

Kim: is when [00:08:00] you're going in preparing. Have the baby you know that's before the baby postpartum is antium postpartum is after you have the child so 

Jennifer: basical feel really awful

Kim: when tell you okay, you gotta get up baby what you're gonna get up a walk now that was what i did. Yes youre like no en honestly it was first nursing job and as a on you know what i mean yout. Super amount of confidence but it was still a good experience and then after that i moved to new York. Oh, wow.

Yeah upstate and i started a state job taking care of developmentally disabled individuals i did that for twelve years en that job. Taught me so much [00:09:00] a tough setting to be in yes i mean you're talking every spectrum okay, that's where i learned also with the whole speech Therapy you know we had a pure foods we.

We have people on tubes or different consistencies you know total care that 

Jennifer: population when it comes to meeting yes like now we're all worried about aspiration and we do sws all the time but i know whenever i work with my adults now and i see somebody Feeding them I'm like that is like an aspiration pneumonia nightmare right there and 

Kim: obviously that was something we heard a lot as far as aspiration pneumonia in that population.

You know a of ' were elderly total care so ya even with even with g tubes or j tubes. You can get aspiration pneumonia in common so yeah i it was hard hard work but you know what i loved it and it was also like a [00:10:00] longterm setting because they were in a house but that was their home and they stayed there unfortunately until.

Le passed away so i did that you become so attached so attached and then i ended up deciding it was time to come back home to Texas where all my family is where i grew up and don't you know shortly after i got here COVID hit. Oh, wow. Yes. Ahí my nieces boyfriend actually. He told me about viva i had never really done pediatrics before and hes such a great guy and he gave me de in and out of you know so i applied and.

There we are and i have to say. Oh, oh my gosh it's been a great experience and the patient i took care of just a great [00:11:00] experience absolutely 

Jennifer: amazing your background like even though you never like graduated College and you're like I'm wanting to work in pediatric health your background totally led you into.

This area you know working with the babies when they first born yes and then going up there and working with for me as a speech service i hear like Feeding and all. A lot of our Guys like sometimes theyre well they're all medically fragile right right times we will not be the ones that are transitioning into College i mean sometimes we do im never but a lot times we are the ones that will will need the extended care throughout life en some capacity so de fact you got that experience.

Mm-hmm. So what happens ones yes y you that side and then also like being in the home.

Stephanie: I was gonna say so what kind of adjustments did you have to make because you were in such different settings [00:12:00] hospital and state placement so now you're in somebody's home yes so how is that different 

Kim: it's very different when i had to. Get used to the idea of not being on my feet constantly because let's face it in a hospital and even the longterm setting it is you are busy half time you don't eat lunch that's just la reality constantly busy and you have coworkers also.

Right en private duty you don have that right i was lucky that when Jennifer came in it was amazing oh you know i have another person to work with and bounce ideas off of so that's that's 

Jennifer: even a r. We would nursing from the same company from the company a home i's a tru.

Kim: To go from do having all these years twelve years of working having coworkers [00:13:00] and just being constantly busy that's a huge adjustment a huge adjustment and i think probably another thing it can be really intimidating being in private nursing because you do have a family there so youre always. Wanna make sure you do a good job you know youre doing your job the best you can and listen you can't have those moments of frustration that we all have you know what i mean you always have to be on point i feel like.

Oh especially es 

Jennifer: que there's cameras and all yes wes en every single 

Kim: Therapy that was so intimidating Mike. Eh it was very Strange to me because other settings i in that's a huge no, no obviously so im like this is so weird so weird i completely understand it i completely understand the parents doing that i would do that as well that's their child [00:14:00] of course y wanna make sure your child is safe en being well taken care of 

Jennifer: the strategy or technique.

They're filming it yes they've got you know which is nice but i can imagine like i mean it just creates a different dynamic great it can 

Kim: also be a good thing i to say the camera can be a good thing because. You can show hey, i was doing what i was supposed to be doing I'm taking great care of your child i genuinely care about your child i really 

Stephanie: so what is something things that are positive about being in that home health setting.

Kim: Ah, my goodness for me honestly is the Bond its i mean i mean just gonna say absolutely. How can you not you're there i mean i was there four days a week okay, all the time and you [00:15:00] buy it's a one twelve hour shifts forty eight hours a week one-on-one patient scenario so of course you're gonna form those bonds and when you walk in the door and then when you leave that child is so happy en.

Gives you by ask about you when you're not there that's amazing 

Jennifer: and also yes ya 

Kim: yes, eh, just amazing and a positive for me too well is to see that progression of how far that child. Has come right i mean its amazing and I'm gonna tell you compar to this from my last setting we didn't have that because they were kind of at their end you know they were very where this was a completely different scenario 

Stephanie: child is developing changing all 

Kim: the [00:16:00] time this child went from not walking.

Eh, i mean. Tu oh my goodness running a mile a minute talking eating my mouths just night in day its been a great experience honestly and it makes me feel proud i feel no. I did right. I think that's definitely a positive and I've also formed bonds with the family even the the grandparents the aunts the uncles I've met both sides of that family and they ask about me and they wanna keep in touch and i think that's Awesome 

Jennifer: sets the other side you know Therapy doesn't always experiences es because when there's a holiday most de time de cancel Therapy o when theres a holiday.

Nursings on duty youre there for the thanksgiving celebration you're christmas morning and i have absolutely and that's a Unique aspect aspect to employment because [00:17:00] if you're in the hospital setting you know they're kind of making like fo christmas 

Kim: there yes yes. Ya 

Stephanie: may get the actual ornament on the tree setting because you're you're essentially part of the family i 

Kim: mean I'm there while they're putting up the tree so yeah I'm totally part of all that and then i also worked weekends so i got to meet everybody i so it was great yeah where the other settings es a lot more stressful people are upset so you know but i get to see every day the happy moments not just the sad moments necessarily.

Stephanie: Right so we've been talking about some of the really positives so being in a home health setting compared to some other settings but certainly there's probably some challenges as well right working in someone's home so kind of give us your Perspective on what that's like and again how you've had to adapt working in home health family 

Kim: ahm some of the negatives can be a times you do feel lonely.

[00:18:00] Ah because you've worked with so many different people you bounce the ideas off of each other so at times it feels lonely mm-hmm. Um as far as that goes other things it's just a completely different world let's face that we all have different personalities we all have different views on how to do things so you have to be really flexible.

And to kinda learn how to just go with the flow aj because like i said we all have different views we all have different personalities and you can't bring your ideas en your views on the world into somebody else's home that's not how it es how it's supposed to go. Um, another thing would probably be even lunch when you're wanting to eat lunch.

Um, in my case what i did at nap time. Even if was ten in the morning guess what i my lunch that was my little bit of downtime but you know [00:19:00] i got used to it you just kinda have to adapt that's the biggest thing private nursing is you have to be able to adapt because a completely different world i mean let's face it.

Okay, let's say. Something equipment guess what you i mean you have to be able to think of ideas right off the batch okay, what can i do en place of this you gotta be on your to pretty much qué what in Charge you thats it you don't have a crew there tobac you right so. That can be the negatives you have to have some confidence honestly.

Jennifer: Also assisting sometimes you're assisting with like [00:20:00] coordinating like the dme equipment the medical equipment and your coordinating doctor appointments while you have an infant or toddler yes is medically fragile ni your assistance needs sectioning needs all the help of just like somebody sitting there watching them you're then having to do that background part as well.

It be take incredible amount of time management multitasking which you 

Kim: definitely learn i mean it takes time obviously i did not walk in there i mean i was overwhelmed at first just not by the work the time management you gotta learn that flow but you do you totally learn it you make it work en those moments of downtime is when you figure how to do.

Okay, I'm gonna. Call doctor que theres a little bit. Hey some Charting now I'm gonna go check the supplies you have to look at those moments you just learn it it becomes your environment also you kind of learn ins and out [00:21:00] of when this is when that down moment's gonna be. Y and there's times you know you're gonna be outdoing stuff you're not gonna have time to do anything so so 

Jennifer: when you're talking about doing stuff you mean that you also would go to doctor's appointments yes and if there 

Kim: trip to the zoo schedule which there oh, yeah and let me tell you there's a lot of that that happens you do family outings there is side of it where you get to go do fun stuff like that a lot you know but you also no you have to take care of the medical aspect of it.

We're having a good time you know i gotta do a b and c. When i get back to that house so you have to figure out when you're gonna do that so that can be the negatives you make it work y just do 

Stephanie: and i hear some similarities on the nursing and Therapy side as you're talking because again home health just means.

You've got to be creative and resuelto and you've gotta manage time but in the end it's all worth it [00:22:00] because you get to make a difference in family child's life so im thinking about your busy schedule the nurse in the home sudden you get these Therapy showing up at the door 

Jennifer: wanna at the yeah por ene.

Or your 

Stephanie: Feeding time some other thing that you have set up the schedule with so i just wanna kind of go into a little bit about how nursing and the Therapy team work together what that looks like maybe some of the some of the positives of course and then some of the challenges with that and how we all work together so we can kind of just talk about how the two of you.

Have worked together with this is a case we involved Feeding Therapy what did that look like in the beginning how did you develop your relationship with the end goal of getting that patient to being able to feed 

Jennifer: i think well when it came to Scheduling I'm not for sure if we had other disciplines when you first when [00:23:00] first met.

Ah our family was really great that she had therapies on different days right so we were never like competing Therapy times and that which was good yeah but Kim was great because she was she she had the patient ready in the chair when i walked in so that like takes five minutes of my time right there which is.

I mean huge gratitude then also like she was there engaging with me like. If one patient i can tell right before she's about to throw up because her nose turns red

Kim there as the nurse Kim would've been like oh she probably had too much give her a five minute break because she knew her she watched her she studied her she knew her and she made time like when we were in Therapy like Kim was present and in Therapy mom would be in and out too mom Kim was actually present.[00:24:00] 

Sometimes it Works sometimes it doesn't right if i just made you squeeze in your nebulizer and your Feeding treatment you've gotta clean equipment and 

Kim: you can't i mean because there's times she had a tra i suction her we just kind of had that flow Jennifer knew you know just give us a second cuz obviously let me suction her and that way she gets the best Therapy possible right 

Jennifer: i mean there es a great amount of respect i confidence in the.

In your skillset right so whenever you told me. Hey, it's time dissection or she's had too much or let's try this or or even like whenever i left and i would be like. Okay, well today we tried crumbled cookies and pure can you try just the pure without anything but we wanna get i up too right you know she did like when came back the next time it had actually pues youre like oh and i cru some cookies center i.

Oh 

Kim: my god always look forward that you [00:25:00] wanna say look what we're doing together is really working and it's having a great outcome for her 

Stephanie: how did all include the family in always 

Jennifer: in the. She would obviously Greta sometimes grandma was there que theres a lot going on in this house 

Stephanie: can siblings also running around in this house I'm aware visited this household i know that you know nursing is going on Therapy is going on you've got not only the patient but two other little ones who are also very busy how did involved the family.

It sounds like you all had a great kind of back and forth you you're working as a team but we also have to keep that family as part of that 

Jennifer: so mom would come in at the end or. Ay mom was there frequently. In a sense sometimes she had things to do in hospital visit most time she was or you know just doctor most times she would come in at the end we would kind of [00:26:00] recap Therapy definitely recap Therapy like on the way out and then i always left you Guys with homework like this is what we did this is what i think she can do and work on that just.

Couple of times if you can do i knew if miss Kim was there every day they were gonna try to work on it but i understand when it's mom and she's dealing with everything that's not gonna happen so you know we would say crumble in half of the cookie i mean we would be down to the specific like a fourth of a cookie and it has to be a vanilla away for Instagram Cracker or whatnot like we were pretty specific because this little one was very adverse to any type of change so Momma always got that.

On my way you were in the room so we would talk about it yes and then what was great was the feedback i got when i came back the next time right 

Stephanie: and i think es therapist i mean i think that helps us do our job because again we're only stepping in a couple times a week right and so we need to know from session to session and when we walk in [00:27:00] how is that patient doing today has there been some changes in there.

We to what o maybe the home program the ideas that we left you with last time maybe they didn't didn't work you didn't have time to address them y so it is that kind of back and forth that allows for that progression of. Skill o taking a step back and maybe adjusting to do something else so i know that you all had a great positive relationship and I'm wondering was there ever a time that maybe you all didn't agree on what the next step was going to be and if not in this with this case you know with miss Kim you therapist maybe that relationship wasn't as symbio this one es.

Kim: Yes first off i think i feel like Jennifer and i were always pretty much on the same page 

Jennifer: pero i think that es because of your background with your adults like you knew and you also knew the signs and [00:28:00] symptoms of aspiration and our little girl like she she had tummy issues. It doesn't take much to make her throw up so you have to be when you have a patient like that you have to be in tune absolutely yeah so Kim get about giving feedback yeah, eh, i don't no se.

Situ. 

Stephanie: I think i i want to talk a few minutes about that because there are gonna be sometimes you know we talked about different personalities different homes different value sets you know opinions about things and there could be times where the therapist is proposing something and on the nursing so they're like well you know what i can't make that work.

O maybe I'm not where you are o you know on the flip side maybe the therapist es proposing and the nurse is like no you know so it can go both ways 

Kim: i had the situation with my last job obviously it's a team situation lot de people work there [00:29:00] even you know speech Therapy there's just a lot more.

People on the group this wasn only just me some of my other fellow nurses they wanted to youtube in a patient who was eating by mouth had Forever obviously en this person would cough a lot but there never. No aspir ponia so I'm like. Okay, she's not getting aspiration pneumonia why would we put her we we fought it we were against it and guess what she didn't get one after did that so ya i mean en those situations when I'm taking care of a patient day in and day out I'm going to speak i will save my opinion.

Because i do take care of them all the time i know what's going on with them listen if they're getting pneumonia i gladly tell you [00:30:00] I'll back you but if they're not why would we do that to someone so i try to speak my opinion that's my job i there to Advocate for that person 

Jennifer: i know thinking about that i think maybe you i didn't have that es because, eh?

Just the blinds being open be the difference between them why too much sunlight too little too much 

Kim: stimulation 

Jennifer: so i think that's the thing i feel you have an opinion and i think everybody would say i definitely have opinions but we talk about it and we give our reasoning behind it and i think that that's really helpful when I'm doing Therapy.

Feeding Therapy o any type of Therapy you're thinking from that narrow my discipline Lens and then i believe that you brought to the table of okay, well she just had her breathing treatment she just [00:31:00] you know these things just occurred so maybe this is what they can expect today and then we would just absolutely.

Providing extra detailed information right 

Kim: even like she did not app let me tell you that's gonna make a huge difference and we had that discussion. She's cranky today she's tired its things like that 

Jennifer: i i don't wait to bring out the favorite until minute Twenty I'm bringing it out at minute ten the first time she's protested so that we can at least have.

A good session 

Kim: im basically giving her the insider information run down so she knows how this day is gonna go cause I've been there all day you know and she's coming in and that's good to have 

Jennifer: but even down to I've had today there has been a lot of secret yes and I'm like. Okay let's not Peter product we're gonna increase secretions and it's gonna you know not be to advantage 

Kim: we understood.[00:32:00] 

Listen you're not gonna have the best outcome exhausted there's so many factors y you have to always think about that 

Stephanie: right and that kind of leads me to another question so you know clearly all you know we're able to start a a great foot you you know working together as a team. Um, but you know therapies coming in and they're very focused on.

Therapy goals you know what we're going to do today and so forth but you know kind of bes the question you know what can the therapist do to help support nursing in the home like when we when we come in to that setting and you're already established with this family what do you want therapists to know would asist that en coordination of care.

Kim: Eh to know to basically that we can work together obviously. Um, we've gotta have [00:33:00] good communication for sure. Ah and realistic goals definitely i think is the biggest thing. Um, i think sometimes people lose s. What realistically is gonna happen. Mm-hmm. So when you're on the same page and you work together as a good team you know kind of how this is gonna play out.

Jennifer: Ah, i think seeing the tiny little goals that need to happen because with the spoon in your hand by yourself yes. Doesnt just happen day one the bowl in the room and gotta have the bowl in the person hand one it was a dry spoon just near her mouth for Forever and that was almost longer than it took us to change textures was just tolerating the spoon beside her mouth 

Kim: you Guys had play 

Jennifer: when i wasn't 

Kim: there [00:34:00] we were so excited.

You think

en her and i understood that i feel we were so excited so en sometimes you kinda you know people in this profession don't always understand.

Understand es es pro i always know she's gonna be ok, you know mean shes gonna reach that why at the end of the gonna. Yeah 

Stephanie: and we talked a little bit about in this podcast and previous one about how isolating home health could be that when you work as a team even if it's therapist coming in or maybe your teammate the next nurse is taking the next shift it really is important to share not only just.

De the day to day going on the successes know the steps that have been taken and so it does give [00:35:00] you that sense un part of something know not only with the medical staff but also with the family and just making sure you know they're always hearing those. They may not understand that those steps are important if youre helping them see that end goal in that big picture then they're going to feel that excitement that success 

Jennifer: as well and i know with this little one like she would make gains and then it was almost like she would get sick yes and then we would go back yeah so we would have to you know and always feel like.

Im like push push push and then I'm like no Jennifer you're gonna go sit in time out and you're gonna let this child catch up to where you to to be right so I'm constantly feel like I'm having put myself in Feeding Therapy time out mm-hmm. I will say with this one it was helpful because we can kind play.

Play it back and be like well six months ago we were dry spoon right and today we're pure stage too you know like that's progress remember that [00:36:00] progress it may not be in the timeframe that everybody in the world 11 it done but that's huge progress in 

Kim: absolutely. Absolutely 

Stephanie: well really appreciate you Guys like sharing this particular case and just how you work together how you coordinate care what it's like to be in that home health setting just wondering Kim do you have anything else to share just anything just that might be helpful to know about nursing nursing in the home o your general experience.

Ah, well 

Kim: nursing. Quién es hard it es what its very fulfilling at the same time there are days i feel like every nurse will be like i anymore when you have these great days where he reach these goals and you can see how much you have helped someone improve even just your patient a. Es huge and i feel like [00:37:00] how can you not be proud of that profession yes just don't ever get don't give up don't get frustrated que sino know what you are so important to somebody out there you're taking care of them you care about 'em and you definitely needed.

Absolutely 

Stephanie: those are great 

Jennifer: words they are 

Stephanie: we appreciate our nurses let me tell you just you know coming from a therapist per ah it is less scary to have a nurse on staff you know automatically that you're going to have some camaraderie some support Teamwork working with that family and so we really appreciate you sharing.

Today just your progression of home health is your experience with that and is there anything else you would like to add Jennifer before we close down our podcast today no i 

Jennifer: mean i just really enjoyed working with miss km [00:38:00] and i think having a good partnership can make or break your progress in Therapy absolutely from a Therapy Perspective that's great because we all have the same common goal yes our goal is all.

The this will get back to their midline medium state normal and we're just here to facilitate i just love that you said everybody has value everybody your the wisdom that so 

Kim: true you know i mean know

es ya, eh? I mean its' so huge it really even we important we are. Ya so i feel like every nurse especially in the setting because it can be lonely just remember that kiddo is looking forward to you walking in that door and that family also you become part of the family ya so just remember 

Jennifer: that wrap it up with that again.

If you have any [00:39:00] questions or you want more information please go review the website send us an email let us know what you think and we will hear we'll talk to you next time 

Stephanie: yep and I'll give you that website it's www viva vps peds do com and we look forward to talking to you again on let's talk Therapy thank you.