Good afternoon, everyone, and welcome. We can go ahead and go to the next slide. I want to welcome everybody to the Academy pre-conference presented by Home Centered Care Institute. My name is Melissa Singleton, and I am the Chief Learning Officer for HCCI, and I have no conflicts of interest to disclose. Next slide. So thank you all for registering for this. You may be wondering how can I access, or you will wonder perhaps throughout the rest of this afternoon, how can I access the handouts that the faculty are referring to, copies of the slides, and so forth, and I want to assure you, you can access those through the HCCI Learning Hub. I'm sharing some instructions here for you. They also should have been emailed to you, but you can go to education.hccinstitute.org, and if you have an account, log in using your username and password. If you do not have an account, it's a pretty quick process to go ahead and create one, and then once you are logged in, you can click the My Resources tab on the left, and you'll look for this session, the Academy Pre-Conference, level up, and then you'll be able to click on course and be directed to the session materials. And next slide. If you have any difficulty or need assistance, please just email us at education.hccinstitute.org, and we'll be happy to help you. This session is being recorded, and we will eventually put this recording into the same place in the HCCI Learning Hub, so if you have to step away or you want to re-watch a particular session, that will be available to you here. So we'll go to the next slide, and this is my opportunity to say that HCCI is a proud sponsor of the Academy's annual meeting, and that's in part because our own mission is so closely aligned with that of the Academy. HCCI is a national nonprofit dedicated to creating universal access to best practice house call programs to ensure that medically complex patients have access to high quality care in their homes. And we assist programs across the country in building sustainable house call programs designed to care for the top 3 to 5% of those high care utilizers, and reducing costs to accountable care organizations, payers, and health systems, all while enhancing the quality of the care provided to these patients. So we assist programs of all sizes and all stages of development, and so we're very excited to bring to you this session today where we can distill some of those key strategies. Next slide. So we accomplish our mission that I just described through four main areas, and that's education, training, research, and advocacy, and you can learn more about that on our website. And if you go to the next slide, our commitment to training and developing the workforce in home-based primary care is the reason we're here with all of you today, and our centers of excellence and practice excellence partners have played an essential role in those efforts. We are proud to have partnered with these leading academic institutions to develop the nation's first comprehensive curriculum in home-based primary care, and we are honored to continue engaging COE faculty in both teaching and development of HCCI education activities. Next slide. So before I turn this over to our moderator and our presenters, I want to take this opportunity to acknowledge and thank the John A. Hartford Foundation for their tremendous support of HCCI's education activities. And so now I want to go ahead and introduce very shortly here Amanda Tufano. As chief executive officer of Genevieve, Amanda leads a team of over 180 people, including physicians, nurse practitioners, nurses, and social workers who are deployed throughout the Minneapolis, St. Paul, and greater Minnesota areas. And in addition to delivering transitional care and primary care services in long-term care facilities, Genevieve offers a unique home visit program to qualified enrollees. Amanda holds a Master of Healthcare Administration degree from the University of Minnesota, is a certified medical practice executive, and holds additional certifications in Lean, Six Sigma, and project management. She received her Bachelor of Science and Bachelor of Arts undergraduate degrees from the University of Texas at Austin. Amanda sits on the board of the Minnesota American College of Healthcare Executives and the Minnesota Association of Geriatric Inspired Clinicians. In addition, she sits on the National ACHE CEO Committee and the LGBTQ Forum Committee. She is a valued member of our faculty team, and so I'm happy to turn this over to Amanda at this time. Thanks, Melissa, I really appreciate that. I am so excited to be here with you today. We have some incredible faculty from HGCI to speak with you. So a couple of details, one, certainly we want to make this open communication. So if you could please submit questions throughout the presentation, that's my job as moderator is to help form the discussion. So throw it in the chat, feel free to unmute yourself. I'll take notes, and we're going to make sure we get to all the questions we can today, and we'll always follow up. So that's going to be a really cool opportunity is to get all those questions out, especially as soon as you think of them. We also have some breaks where we can talk through questions. If you experience any technical issues, do what you always do, try logging out and logging back in. If that doesn't work, try turning off your computer or not. But I have been told if none of these things work, leave the session and visit the VFARES help desk. And so I will not be helpful in any of that. I am a pretty face as a moderator today. And so again, try logging out and logging right back in. Let me introduce our esteemed faculty today. Dr. Paul Chang is a medical director for Home Care Physicians, a suburban Chicago house call program that's made more than 117,000 house calls to home limited patients since its founding in 1997. Personally, Dr. Chang has made over 34,000 house calls to more than 3,000 patients over his 20-year career. Just last year at this very meeting, Dr. Chang received the House Call Doctor of the Year Award from the American Academy of Home Care Medicine. In his role as senior medical and practice advisor for HCCI, Dr. Chang focuses his time on developing curriculum, teaching current and future providers, and presenting locally and nationally on the value of home-based primary care. Also, Brianna Plunsner is an HCCI very own senior consultant and manager, practice development, and brings deep knowledge and experience in house call operations and practice management. Brianna is both a certified coder, certified professional medical auditor, and prior to joining HCCI, she served as a practice manager for Home Care Physicians. Brianna excels at developing workflows and efficiencies for home-based primary care practices, and she's skilled at bringing front and back offices teams together. At this point, they have no relevant financial relationships to disclose. So we're so excited to have them, and again, throw questions in the chat as they come up. Some of the things we're going to talk about today. We're going to talk about proven strategies and recommended best practices to streamline house call programs. It doesn't matter where you are in your current operations or your growth plan. How can we streamline and boost your productivity, design and implement a plan aimed at achieving measurable results in terms of efficiency, quality of care, and practice growth? And how do we improve that patient care while enhancing the financial sustainability? So there are going to be lots of things to cover today. We're going to take a break about halfway through, and I'll be with you the whole way. Slide. Here's what it looks like. We're going to open with scheduling, route planning, and EMR optimization. We're going to talk about marketing, community relations, coding, documentation. We're going to take a 10-minute break. We're going to come back around team function and avoiding burnout, especially burnout and stress in our current world today. And then we're going to end with preparing for value-based opportunities, revenue cycle management quality. And one of my very favorite things that we always do is the last slide tells you how to get more information, other things you can do to get involved with HCCI. So I'm super excited. Next slide. So let's talk a little bit about the HCCI model for implementation. HCCI as an organization has received a number of questions at varying spots of organizations, whether they're starting a practice, they're looking into starting a practice, or they're very well-established and they have thousands of patients already. And people will ask again about these questions of efficiency and how do we operationalize and how do we think about quality and how do we become that sustainable organization? And so they've led a team of experts across the nation to come up with a multifaceted implementation strategy focused on achieving sustainability around developing the foundation, operationalizing care, and ensuring practice excellence. So this becomes the framework of how we're going to talk about today and the strategies that we're going to implement. Next slide. So we're going to take some select strategies from each of these three dimensions and walk through it. And we're going to tie this together through a secret sauce idea. So each of these ideas are ingredients to create a secret sauce of how to best run a successful home-based medical practice. So I'm going to turn it over to Brianna to kick us off. And I see a couple of notes have come in. Make sure to check the chat. That's where you'll find any tech information and you can put your questions in there. So Brianna, thanks. Thanks, Amanda. So thanks, everyone, for joining us. We're really excited to be here with you today and talk about different things that you can do and kind of evaluate in your practice. And like Amanda mentioned, I think it's important to remember that there's no sequential necessarily to the implementation model. I think we need to recognize, especially in this changing health care climate, that we need to constantly reevaluate and readapt our care models and how we're being successful. So we're going to start with the first level, which is really developing the foundation. And this is the base for your practice. And the ingredients to success that we want to highlight for you today are scheduling, route planning, and EMR optimization. So when we're thinking about scheduling, I'm going to break this down into three considerations. How are you thinking about your geography? How are you logistically accomplishing that process and that workflow within your practice? And then what technology resources are you utilizing to make your scheduling and your route planning as effective as it can be? So when we kind of start off at the base and we think about geographic scheduling and workflow development, a couple of things to keep in mind. First, you want to think about your provider territory zones. Throughout the entire service area that your program may service, where are your dedicated providers? Have you given them actual zip codes, cities, or zones? And are you thinking about where your provider lives and trying to make those in as close proximity as possible? And that's going to be important when you're assigning patients from a patient panel standpoint as well, is understanding what geographic territories and zones you're going to give providers patients in. The second that I'll offer you, and I have an example of this later on, is does your team, whoever's accomplishing the scheduling, do they actually have a scheduling guide? Do you have a tentative plan? We know that each home-based care has to be flexible and that schedules change. But do you have a plan for generally on these days of the week, we're going to see patients in these areas and any other special considerations that your team needs to be aware of in order to help build the best schedule for your providers? The other thing you might want to consider is visit units. So what I mean by that is if your schedulers know that, OK, on average, we're going to see about eight patients a day or whatever the case may be, are you considering how much longer and how much more complex those new patients or those transitional care management visits might be? So those would maybe count as two visits and that, you know, however many their max is per day. So thinking about the complexity of the visit type, again, you don't want to diminish the quality. So you're supporting your providers and recognizing the different types of visits they may be performing. And then finally, if you serve patients in facilities, whether that be assisted living, group homes, skilled nursing facilities, really making sure you keep those active patient lists. And so you understand that when whenever, you know, that day of the week that the provider is going to be at that facility or maybe a couple of days of the month, you're seeing all medically necessary patients without having to double back unnecessarily. Yeah, go ahead. Just a quick question that's super on topic. Yeah. How do you do urgent visits in geographical schedule? Yeah, that's a great question. So I'll start. And Dr. Chang, you're welcome to pop in here, too. I don't think there's any one right. There's never a one size fits all solution. But, you know, you have to make time for those urgent and acute visits. I know some programs that might have a provider of the day, someone that's on call. Again, I'll show you later some map based tools. If you know where your patients are, then it'd be a lot easier to identify what day or what provider is going to be in that territory next. Or maybe when we talked about those visit units, you keep a couple open appointment slots for the same day. Urgent or at least one provider has a lighter schedule to accommodate that. But Paul, would you add anything? Yeah. Hi, everybody. Amanda, that question comes up often as we talk with practices on how to manage kind of a challenging, thorny issue. And I think that I think that really highlights the unique aspect of home based care. Right. If if I was in an office, if there was an urgent, probably I would just say, you know, well, squeeze Mrs. Smith and just squeeze her in and I'll I'll work her into the schedule somehow. But for us who do house calls, squeezing the patient in who is 20 miles away, for example. It really presents logistical challenges. Right. So there as I talk with people, I tell them there are two ways to tackle this issue. You can tackle it from an internal. Internally, you can tackle it or you can tackle it externally. Let me explain. Internally, as Brianna has said, you can take a look at your own schedule and say, hey, I have an urgent add on. And this other patient, while she's just a routine follow up and things are stable, perhaps I can see this patient next week and then see that urgent add on instead. That's one way. The other way is to look at your other providers, take a look at their schedule and see if they're full. There's if they're there, they have an opportunity to see this patient who has an urgent need. So that's an internal way, of course, that involves a lot of logistics looking at the schedule, your front office may have to help you make phone calls and so on. The other way of doing an urgent visit is using an external using external support. By that, I mean, is there a home health agency that's involved in the care of this patient? Can a home health nurse go out and take a look and troubleshoot the problem and get back to you? That's one opportunity. The other is how about getting some x-ray imaging or lab work as a way to assess how the patient is doing and get you at least some data to help you make some decision on how to help the patient, whatever their needs may be. And the final external consider, well, two other external consideration, one would be using a remote patient monitoring or a vendor that does perhaps tell a video visits that can help see the patient on a urgent basis to at least put some eyes and if capable, some ears electronically on the patient to get you some information that you need. And finally, there are practices that does urgent calls, such as a company called Dispatch Health that will go out to the patient's homes and do visits acutely, and then they will fax the notes back to the primary care provider. So I hope that helped answer some of the questions that people may have regarding how to tackle the urgent call. Thank you. Yeah, and I think that's great. And as we're kind of thinking about the innovation that's happening right now, you know, can you use your technology right when that first urgent call comes in? Is it even triaged by your team? You know, maybe can you fit them in as a telehealth visit to determine if in-person is really needed? So I would just encourage you to all those strategies that Dr. Chang just shared with you. Think kind of out of the box about what works best for you. So this slide, just trying to give you some more practical examples, this was shared with me from a home-based primary care practice in Indiana that was kind enough to share kind of how they really break this down. So you can see they have their particular service areas or their zones in red, and they consider where the nurse practitioners that are seeing patients actually live in respect to the territories they're assigned to. They do have their visit per day goals. And you'll also notice that it's different if they're seeing patients in private homes versus if they're seeing patients in an assisted living setting or a skilled nursing facility setting. Even, you know, if you're traveling less, you're going to be able to see more patients per day than a practice that is having to travel to each individual location. So that's where those facility partnerships become really important. And then again, I'll show you an example of that scheduling guide, but don't just, you know, you can't rely on someone's just kind of uncanny ability that I think I know the area. You know, really group your provider cities by day, use some map-based tools. You never know when two zip codes or two different addresses that say they're in different towns are actually neighbors or backdoor to each other. So don't just leave it to kind of that ambiguity, excuse me if I could talk today, really put some thoughtful process into it. It's also helpful to consider the distance between locations. So again, you need that workflow to give your scheduling team. So they understand if patient A from patient B is quite a bit of travel in between that the timeframes that they're giving them are, you know, reasonable to allow for that travel time. And also they won't service any patient that's more than 50 miles outside of their office. We all know that there's a lot of patients in need and really want to be flexible. We really want to serve patients, but you need to know your geographic limit and then maybe look for some other community partners outside of your service area that you can refer patients to. And we're going to have some time for questions at the end, but I do see that someone is hand raised. So maybe Amanda, you can call on them or figure that out in a few minutes here. I will do that. And then, so the last piece that we've talked a lot about the geographic scheduling, right, the logistics of the process, but there's two pieces. And this is really where you, you should need to be using some sort of technology, but what about the route planning? So a provider has a schedule. They have their eight patients or however many, there are seven, five, however many they're seeing that day. Where are they going to start and end their day? And are you routing patients in alignment with where they're starting and ending their day. Often we'll see practices want to start with the farthest patient away. So that's scheduled first and then make their way back to the office or closest to their home. So think about that. And Dr. Chang talked about flexibility. Don't confirm your appointments super far in advance. I would really encourage you to give ranges of dates. And again, if you have that stable patient don't be afraid to make that call and say, hey, Mrs. Smith, I'm really sorry. Can we reschedule you to this day? We had a change in the schedule so you can accommodate those acute and urgents. And then we all know that many emergencies happen. Maybe you showed up and a patient was a lot more complex. Maybe you had to squeeze in that patient that was reasonable. Don't try and over-promise and say you're gonna be there at 10 a.m. Try and give them that window of time of when you're gonna be there. And again, thinking about that, not only the travel time but how are your providers answering messages throughout the day? Do they have breaks? Because if at the end of the day, number one, it's gonna be hard for them if they have to finish all their documentation and do all of these callbacks without that time. And also it's hard on your clinical staff. If their pool, their clinical message inbox blows up at three or four o'clock and they only have so much time to get back to all of those patients, that's really difficult. We've seen some practice models that use an assistant. Maybe that's a medical assistant or a community health worker or someone that's driving the provider. So they can actually be documenting in the car in between visits and doing those callbacks. That certainly helps if you have a practice model where you have an assistant. If not, there's certainly providers that travel alone but they need more time in their day to maybe see a few less patients and figure out how they can build in those breaks. So Brianna, I missed the hand. I'm sorry about that, guys. So keep trying. I figured out how to answer that one. We're getting questions both in the chat and the Q and A. I think HCCI would, or excuse me, the Academy wants to push us to kind of the Q and A, but questions around virtual visits. Now with virtual visits, how are people fitting them in their schedules? How long are they? And so you're about to talk about EHRs and tech and wanted to give you guys just where you think it's right to talk about virtual visits would be great. Yeah, I mean, I think virtual visits can definitely be a way to maybe handle that triage that was acute and urgent. Or I've seen some practices that are starting to think about every third visit is in person and maybe depending on the patient's chronic conditions, a couple of those are virtual in between. I don't think, again, there's not a one size fits all solution. You can certainly build in telehealth appointment slots in your day, in between in person and telehealth. Paul, would you add anything? Yeah, I think a couple of things. Let me get back to the mapping thing and the travel time to just a second. Brianna and I were doing consulting work with a house call practice in a urban large metropolitan area. One of the things that you all have to keep in mind is traffic patterns, okay? Depending on which way the traffic is flowing in your morning and your afternoons, you may want to plan your visits according to the traffic pattern in your area again, you don't want to be stuck in traffic and that's just inefficient use of time. A couple of comments about virtual visits. Certainly, I think we need to keep that in our toolbox in terms of that's an opportunity for us to engage our patient. We can engage our patient if they're sick, if we are sick and we can't visit physically and then we use a virtual. We can certainly try a virtual visit in case of I think somebody had a question about can that be used for urgent visit? Definitely, I think that's an opportunity for you to explore that option as well in terms of, hey, I can't get to you but can I at least see you on the phone and get a sense of how you're doing. The challenges I see with the virtual visits are a couple. There might be more, but I'll just name two. Number one, a lot of our seniors have difficulty with technology. Broadband connection is not always available to our patients and they have vision, arthritis, hearing difficulty that makes a virtual visit a bit challenging. And the second issue, now I don't know what my second point was. Give me a minute here, but anyways. So what you can do is you can pepper your virtual visits throughout the day, but sometimes for efficiency, you may wanna bunch them at the end of your visit, meaning you do your house call, your visit visits in the field. And then when you come back to the office and then do some of your virtual visits. Oh, I remember the second point now. The second point, the challenge with using virtual visit is that our patients are so complex. And you guys know this. I'm not telling you anything that's earth shattering. When they call often is what is shortness of breath, right? We've all been there and they have a patient now who's calling in. She's got COPD, CHF, CKD, lymphedema, and they're short of breath. A virtual visit can only get you so far, I think in those scenarios. If at all possible, I think you need to have a hands-on visit with that patient. So virtual visit, definitely use it, but there are some limitations. Those are my comments. Yeah, I like the idea of it is sometimes really hard because you don't know what's gonna go on in the field of having either the start or the end of the day with the telehealth visits. I wanted to leave this slide up because I mentioned using some sort of map-based resource. Again, we're not personally endorsing any of these resources, but these are ones that the house call practices have shared with me that they're using. And I'm continuing to add to this. So I would encourage people if you're using something else, feel free to throw that in the chat. And Karen Jackson, I know, I believe you're the one that raised your hand before. So I don't know if you can unmute her, maybe, Amanda. Karen, can you hear us? Uh-huh. If not, feel free to put your question in the Q&A box or the chat, and maybe we can come back to you. It says talking permitted, but you might need to unmute your side, Karen. Oh, you know what? Oh, sorry. Okay. Well, hopefully, please throw it in the chat. Like I said, look into these resources. If you're not using technology, I mean, those pictures that I showed you earlier where you saw all of those patients that were color-coded and plotted on a map, really efficient, helps your scheduling staff spend less time doing this. BatchGeo and MyRouteOnline are the newest ones I've heard about, and they're pretty low-cost options where you can actually upload spreadsheets of your patients. Aha, Karen, I think I hear you now. Go ahead and unmute again. I thought I heard you. No, I'm having difficulties because I cannot hear. I cannot get, and I'm punching every button. It's not that I have questions. It's just that I have no audio, so I don't have questions, so I'm hitting every button just trying to figure out how to get you guys to where I can hear you. That's all. So what we can do, Karen, is- I've spent a lot of money on this. Yeah, okay, wait, I didn't mute her, but I think you muted. So, Karen, what we're gonna do is we'll put the information in the chat. We'll get the AAHCM support back, and we'll put the information on how to contact vFair. So, again, you can try logging out, logging back in, and I did put in the chat, too, to try maybe a headset, even a wired headset. But we will be doing that, and we'll keep going, Brianna. Okay, sorry about that, Karen. But yeah, log out and log back in, and then if not, go to the vFair's help desk and see if they can help you from there. This will be recorded as well, so if you miss anything, you'll still get access to all the content. But one of the resources that we've uploaded for you all in your HSCI Learning Hub, again, we have a lot throughout, it's just an example. This is very straightforward, but again, when your provider sees that patient and they say, okay, I wanna see them in one month, I wanna see them in three months, are you proactively planning that schedule on a day when, again, they're tentatively going to be in that area? That can be really beneficial. So, we've given you the sample scheduling guide, again, as a handout in the resources. And just to kind of summarize scheduling here, again, really try and make those zones in as close proximity as possible. You know, you wanna empower your team with tool. Give feedback, too. I mean, make sure that your providers are saying, hey, you know, this was a really difficult route for me, or, you know, I've crossed patients here. Talk about it in a staff meeting, and again, explore some of those technology tools if you're not already using them. And like we talked about the acute and urgent, you've gotta plan for that, and you gotta let flexibility in your schedule. Don't feel like you can't change schedules when you set them that far out. And Brianna, how many miles do people drive on average? And how many, I know we're gonna come back and talk about patients, but how far are people driving in a day? And Bri, how many are they seeing? Yeah, I mean, so what we've done is just from surveying the practices that HGCI is familiar with, I can share with you on average, the average is usually eight to 10 visits per day. But if you're seeing patients in a real rural area, or you don't have a lot of support, I would say that number gets closer to five to seven, where on the contrary, if you're seeing all skilled nursing facility patients, or, you know, not having a lot of travel, that you're gonna be able to see more patients. Travel time, I think there's just so much variance. Again, programs, I don't know that I have like a set travel time. I mean, if you can try and keep it to 10 to 15 minutes in between patients, or no more than 30, you know, Paul, you know, I don't know if you'd add it, that would be a good starting place. So the mileage is a difficult one to generalize to all house call practices, right? I'm a suburban house call practice outside of Chicago. So we try to minimize our travel times or control our travel time to about 10 or 15 minutes. That's a suburban scenario. If you're in a densely populated urban area, your travel time may be more or less. It may be more because you're trying to find parking space, right? It might be less distance wise. And then finally, as Brianna said, if you're in a rural practice, you may not be able to see eight or 10 patients a day because it's simply impossible to drive that distance. So you might be driving a lot of distance and not seeing that many patients. So geography really plays a part in terms of trying to maximize your, or minimize your travel time and maximize your efficiency. Yeah, absolutely. And so we're gonna switch gears, but again, share other strategies in the chat. We're, you know, we're here to learn from each other too. We'd love to hear from you guys in the chat about what's worked for you or lessons learned, but I'm gonna turn it over to Paul to talk about EMR optimization. Yep, well, thank you, Brianna. And good afternoon, everybody. Again, thank you so much for joining us. Our goal here at ACCI really is to try and support you. This is important work. We all know it's work that's really appreciated by our patients and we want all of you to succeed. We want you to enjoy your work and we want you to be financially successful as well. So anything that we can do to help, please reach out to us either during the session or going forward in the future. Next, I'm gonna talk about EMR optimization. A couple of points to keep in mind is to, as you are thinking about EHR, whether you're getting into EHR, switching EHR, keeping the provider in mind, and I'll talk more about that in a little bit. We wanna talk a little bit about the templates, setting them up and training that's necessary to help your providers. And then just an overall view of technology. Next slide, please. You know, I don't know about you, maybe I'm just unique. I have this kind of a love-hate thing with my EMR. Some days I think it's really helpful to me, other days I kind of shake my head and say, you know, this is so frustrating. So what's important to us as providers when we're using an EHR or considering an EHR for our practice? There are a couple of things. Obviously it needs to be portable. It needs to have really reliable connectivity. Security is on everybody's mind in terms of being hacked or a violation or ransomware that could really penetrate into your system and that could cause a whole lot of problem. And durability, right? We go to difficult places, we'll go hot to cold, we carry our equipment, we go up and downstairs and so on. So the device really needs to be durable. And finally, yes, as connected as we are, as much as we depend on all of our technology, on our laptop, on our phones and so on, do you have a backup plan in terms of how are you gonna document the visit and so forth in case you have no connectivity or your laptop decides to just, you know, take a vacation for a couple of days. Next slide, please. Template building. When I talk to my providers and I want them to, maybe this will, we'll talk more later on about team building and maybe burnout section as well. I really try to reduce the number of keystrokes and typing that we have to do. That's for a couple of reasons, not only for efficiency, but it's also for efficiency, for documentation, but also for quality in caring for our patients. Let me explain, a couple months ago, I was visiting with a patient and, you know, she sarcastically said, you know, I thought you came to see me, not to stare at your screen. You know, granted, you know, maybe she was having a bad day. Maybe I was staring at the screen too much, even though I pre-chart, I have macros and templates and so on. All that is just to remind us, you know, why are we building these smart phrases and so on? So we can document what we're doing, whether it's the history, whether we're doing screening tests, right? Towards the end of the session, we're going to talk about qualities, metrics, what screening tests are you doing, such as cognitive screening tests for your patients with dementia, or tug tests for gait disorder, or depression screening and so forth. And then physical exam, again, functional assessment and social aspects of care. And of course the plan of care that you're devising for your patient. It is really important not only to document that in an efficient way, but not to lose yourself with a face-to-face contact that we really need and our patient really cherish as we are trying to go to their homes and take great care of them and providing that connection and building that trust. So having a template building, again, work with your vendor, work with your team in terms of what is capable within your EHR to do some of these macros or smart phrases. Next slide, please. So, as I said earlier, you know, is it a friend or a foe? And depending on the day is a yes and a yes, right? EHR gives us a pathway to capture history and treatment plans and medication and look at, you know, trending their weights and their A1C. And if you wanna pull data from your EHR, it is incredibly powerful. As again, as we're talking about metrics and quality and so on, the EHR can be a huge, it's a great tool for you to get some of that information. But the EHR can have a dark side, right? Whether it's keystroke, whether it's burnout or this whole idea of cloning, where you just pull your note forward and then you can start, you know, document, you know, you think you're saving some time, but cloning can be dangerous in terms of documenting some things that maybe were not done at the visit. Next slide, please. Yeah, so- And Brianna, and you wanna take us through some of the progress notes in the domain and maybe talk just a little bit about cloning. I know that's something that you have done a lot in terms of researching and speaking on. Yeah, so to start with the cloning, so the formal definition of cloning is if I look at two progress notes, let's say for the same patient, you know, two sequential visits and your note or sections of your note look exactly the same or extremely similar as the previous entry. That is a huge audit red flag and risk that OIG and CMS is certainly looking at. And the problem is, again, you know, maybe you're just trying to save yourself some time, but if you don't remember to go back and update that information, then I've seen it where, you know, you're telling me about a wound that doesn't exist in the physical exam, you know, then your documentation starts to contradict each other and it can really threaten the integrity of the record. So again, there are times where it's appropriate to pull things forward, but we need to make sure that we're really, you know, documenting unique characteristics each time about what happened at that patient encounter. And if you don't need it, don't pull it forward. Don't overpopulate your notes. Really make sure it's what's meaningful that tells the story of what happened in each patient encounter. And kind of building on that a little bit, I stumbled across this research article and we've done a lot of research and we've downloaded it and included it in the handouts, but the link is at the end of the slide. It was called the Prescription for Notebload. And it was actually really developed by hospitalists, but I think it's just so relevant to kind of how you think about your progress note templates and how you're actually using your documentation. So it should be up to date. Again, if there's inactive problems on the problem list, you know, if there's information that's not relevant to you seeing that patient on that date, it doesn't need to be there. And if you are, you know, using certain fields, make sure you're pulling it forward so that it's accurate and that it's thorough. I will share that I'm actually not a fan of EMR matrices. That's where your EMR might be having you put in how many HPI and ROS and history and MDM elements. I think that people get so tired of all the clicks and they're used incorrectly because we don't always understand what those coding and auditing terms are. And then I get to the assessment and plan, and there's really not a lot of detail. That most meaningful part of the patient encounter isn't telling me the clinical picture and what happened because there's so many other, you know, my perception is that these providers are tired by the time they get to the end of the note because those templates are overpopulated. So make sure everything that you're putting in your notes is useful, that it's organized. You know, sometimes I'll be auditing notes and it'll be a little hard to follow. You know, they're kind of jumping around to different topics and different sections that don't always relate to each other. You want your documentation to be clear and concise and consistent. And again, spend the time in your assessment and plan, especially so it's comprehensible, but it doesn't need to be, you know, pages long of narrative either. You can give us a lot of great information and great documentation and coding principles in a succinct and synthesized way. And again, just that it's internally consistent. So you have that resource for you to refer back to. One comment, Brianna. I have seen maybe a little bit more and more of providers putting their assessment and plan at the beginning of the note rather than the end. Brianna, have you seen that? And does that affect the billing and coding in any way? Or as long as I've documented everything, it should be good. It doesn't matter what sequence I put my note in. Is that correct? Yeah. So as auditors, I mean, contrary to what most people believe, we actually are trained to be most advantageous to the provider. So I can use anything. So for example, just audited a practice where they weren't using a separate ROS section because their providers were just documenting the ROS findings within the HPI or within the history section of the progress note. That's OK to do. The other thing with ROS review of systems is just document the abnormal or the positive or the pertinent negative findings. And then say all of their systems are reviewed and are negative. That will still get you complete review of systems credit. But then you're not clicking 14 systems, negative, negative, negative that aren't really relevant to that encounter. So it should make sense. It should flow. But you don't necessarily use what works best for you as long as you understand the core history exam, medical decision making, what needs to be documented to support your work. I love this question that just came in. And I'm going to read its entirety. It just summarizes health care. I hear what you're saying. But right now, review of systems and HPI is not detailed enough. You can't meet the level of visit for charges. Isn't that the game we're playing? The fluff is required, don't you think? And I have a piece of input running a medical practice. So Brianna came out to Minneapolis and did a coding audit on us. And I had a few takeaways at the end of our two days together. And one of those takeaways was throughout all education that we have all had, we have always been graded on content of what we're doing. We've never been graded on succinctness. And I think that's where we really miss as writers of any narrative, is we actually have, again, we have not been trained in how to succinctly say what you're saying. So I think you can, and I'm hearing Brianna say that, and I'm sure she'll add more color to this. But you kind of have to go back and unpack all of our training here, again, has been make your point, reiterate your point, start the start, you know, start your opening paragraph, have all your findings and your end paragraph. And it needs to be this many words. How many courses in your educational career did you have that said you got to the point the fastest and the most clear, and that's what you were solely graded on. So just some helpfulness there is, I think that's a sync. I almost want to like triple bold it and say, I think that's where in healthcare, we have an opportunity. But Brianna, Paul, thoughts? Oh, I hear your pain, folks. I'm a clinician, I'm a full-time, pretty much a full-time provider. So every day it's like, you know, typing, clicking. So I can't agree with that comment more. So it is a lot of clicks. And yes, it is a, if you want to call it a game, we have to play. Maybe there's hope in sight though, Brianna, because there's been some documentation changes that made its way through, not all the way through us in primary care, but at least to the office setting that is trying to alleviate some of the burdens related to documentation. Is that correct? Yeah. Thanks so much for that question, by the way. And so what Paul is talking about is in 2020, we saw, or 2021, excuse me, we saw the biggest changes to the documentation and coding guidelines, but unfortunately they only apply to the office setting. So especially I was frustrated because I know a lot of home-based providers that also do office work or care for patients in multiple settings. And now you have two sets of guidelines to remember, but if you're coding in the office setting, you can use time alone without having to validate that it was truly dominated by counseling and coordination of care, or you can just code on MDM, which I'm personally, that my pet peeve in an audit, honestly, and this is coming from an auditor, is when I have to downcode a level of service or give some feedback for a new patient, just be missing HPI elements or missing history when everything else in their note was beautiful and really helpful. So there is some hope that, you know, we've actually, the academy along with HCCI has provided comment letters back to CMS, trying to advocate for documentation burden relief to reach the home and the skilled nursing facility settings as well. I don't have a crystal ball, so we'll have to see what happens, but I think it would make sense for us to all follow the same guidelines regarding, regardless of the setting of service. But a couple of things that just made me think about in that question too, so succinct too, I do a lot of work, especially when it comes to HPI, and now if it's your preference as a provider, you guys all, you know, this is your world and your patient, so if you prefer narrative form, you know, by no means I'm telling you that's wrong, but you can bullet it. You know, the status of three chronic conditions gets you a complete HPI credit. Give me the status of three chronic conditions reported by the patient and caregiver and bullet it out. How are they managing their diabetes, heart failure, and asthma, you know, in their own words, and how they think they're managing it and that presenting condition before you've really done in your exam. So there's ways around that, and to kind of hold the numbers game, you know, I think if we get so bogged down and constantly worried about counting our elements and does this meet a level 99350 or 99349, the other challenge with that is I'll challenge you that medical necessity is always the overarching criteria for the visit. So if I'm looking at a note and technically you gave me all the elements, but your assessment and plan is telling me that everything is stable, I don't see a lot of changes, I'm not going to be able to support that high level of service regardless of if you've spent all that time counting and documenting those elements because we always have to consider medical necessity when we're coding, and I know as clinicians this is not what you guys want to do and you not want to focus on, but if you use these principles, I think they'll benefit you, and it's also for a quality perspective. If the ER or a hospital physician needs to look at your note in a glance and understand what's going on with that patient and caregiver or somebody else is reading your note, we have interoperability now, right? Patients and caregivers has full rights to their records. You want it to make sense, and you want it to really tell the picture of complexity, and don't sell yourself short either because these patients are super complex. A lot of times when I see a note that I'm like, I'm a little concerned that this would support medical necessity for that high level of service, it's just because the provider didn't tell me what was actually done or what was actually discussed and it just comes down to those missed opportunities. All right, Paul, I'll pass it back to you. Yeah, well, thank you. A couple other comments before I move on to this slide. Think about using voice recognition as an option. Yes, it's an added cost, and yes, I know it's not 100% correct, but certainly I have used voice at the end of the day when I'm just simply tired of typing. I turn on my voice and document that way. I'm not a fast typist by any means, so voice can be helpful to you. The other is if you're on a different payment model outside of fee-for-service, for example, can some of that dollars be used for a medical scribe that your office can employ and help you with documentation burden? Just some ideas. Next slide, Brianna, please. Yeah, and Paul, one more comment you just made me think of too. I know a couple of practices that have started to use virtual medical assistants to document areas of just the past medical history, importing vitals, things that they are allowed to do as long as the provider reviews. The feedback that I've gotten from those practices is those virtual medical assistants can really help as well. More in the facility setting, does that make sense? Another thought for you all to consider. Just quickly summarizing a couple of things, and then we'll get to the questions. I'm really looking forward to engaging with everybody here on the Q&A time. We know our EHR can be very helpful. We talked about accessing records for quality data reporting. We can fax things. We can exchange information with others. We can communicate with our team members because our patients are so complex. I tell my patients, I'm just a doctor. I need other team members with more expertise to help me with this. We can communicate with our team member using EMR. Just some summarizing points. Research and investment EMR that meets your needs, that's certified, that it's not going to cost too much money, and that you can use it on a day-to-day functional basis to help better care for your patients. Take some time, spend a little time learning about your EHR, tinkering with templates, and so on. Explore functionality. Some time spent earlier can really save you a lot of time later on when you're out in the field taking care of your patients. Provide training for your providers and optimize your EHR for effective use. At our staff meeting, I have a particular bucket here. It's called the Jedi skill. Yes, I'm a Star Wars fan. In a Jedi skill, the reason behind that bucket is that we all have skills. We all have insights about, in this case, EHR. Oh, I didn't know you could do that. Not only professional training, maybe from a vendor, but also internally, what can we teach each other in terms of optimizing EHR? Then finally, we can share templates. We can share macros with each other. Again, it's team. Let's support each other. Yes, this is a lot of work. It's burdensome, but let's come up internally. Are there opportunities that we can take on and change and make documentation less stressful for all of us? That's it. Fantastic, you guys. Oh, Brianna? No, go ahead, Sam. Oh, I was going to say, we got lots of questions, so we're going to practice our succinctness in the next 10 minutes. Some super good ones. Predictions, do you think CMS will continue to pay for virtual visits into 2022? Yes, so good question. The problem is all of that is tied to the public health emergencies. HCA, we have started a blog. I just released a blog on this, but it's extended through January now. I believe it's January 22nd, but it has to be extended each 90 days. The barrier is, if we remember before the public health emergency, for Medicare telehealth, the home is not an approved originating site, and it was only for patients restricted to a rural or healthcare professional shortage area. CMX actually doesn't have the authority without legislative change to take away those barriers besides mental health. There's a ton of pushback and feedback. I think telehealth is here to stay in some capacity. We'll have to see what actually happens. We'll get the Medicare physician fee schedule final rule sometime in November, and we'll know what their final policy was. The proposed rule said that they were going to change the home only because of the support act. They can do only for the treatment of mental health or behavioral health conditions, permanent access, but there are certain codes and the telephone E&M codes you all might be using right now. If you're involved in an alternative payment model, a lot of them have telehealth waivers, so again, flexibility based on your practice model. There still are some communication technology-based services and things that we could build before. Remote patient monitoring is here to stay. That's not considered actually Medicare telehealth service, so you can continue. If you're doing RPM, that's one safe bet to say we'll continue after things go on. One more question about EMR and the scheduling piece. Any systems that work with EPIC on the geographical scheduling? One group said or someone said the IT issues with Care Link, it just didn't pass the IT standards. Do you know any that are connected to EPIC? Paul, I know you know EPIC, and I know at one time I heard that EPIC was looking into their own geographic scheduling solution, but I don't think anything has come from it, correct? Yeah, that's correct. So last time I had contact with EPIC in a work group in terms of embedding a geographic software within EPIC was talked about, but I'm not aware of anything moving on, and it's been probably a year since we last had that work group meeting. So no, I'm not aware of EPIC having an embedded software to do this. It may come, but currently I'm not aware of it. Great. As we switch to EMR optimization, an overarching couple of questions have come in. Some of the questions have come in, and I've taken myself around. Hey, shouldn't we mention all this other stuff? And I said, Breanne is really saying, talk about why you're there. And a couple of questions overarching. Do you have kind of quick tips for documentation? Do you have examples for documentation? Where can we find required billing elements for home-based codes? And so I know you guys have some resources, so maybe point us, and that'll take care of about half of them. Yeah. So there are some EMR resources. We're going to talk a little bit more about coding and documentation later on. So I'll show you an example grid that's included in your handouts. Again, quick tips are really make sure your assessment and plan. You don't need to code every problem on the patient's problem list if you're not meaningfully assessing it in the encounter. So again, yes, we want to play the game. I want you to be reimbursed at a fair and accurate level for the complexity of care that you're providing in the home. I'm the biggest advocate for that. How can I make sure you understand to get paid correctly? But also, not every visit is a level 4 or a level 5. And so really focus on what you're seeing the patient for that day and what's relevant and unique. And don't overpopulate your templates, don't you, like Dr. Cheng was talking about with all of those clicks. Or if there's a section of your template maybe used for new patients but not established, they should be different, honestly, in the framework. Or don't use it if you don't need it and it's not meaningful to you in that encounter. And then Sarah, maybe put the EMR resource link in the chat or HHCI's website for me if you don't mind. But otherwise, I'll reference the specific resources later on as well. I think one of the questions around billing is, you know, our goal in home-based medical practice is to keep people out of the hospital. And so sometimes that proactive visit is helping them keep them out. You know, how do you think of a reason for visit there? I have thoughts, but I thought you may want to do that piece. Well, I'd love to hear your thoughts, too. I can start, Amanda. But so visit frequency. If you are in a fee-for-service world where you're having to bill Medicare, again, that comes down to medical necessity. We know high touch, you know, high contact care, seeing your patients monthly to keep them out of the hospital is a good thing. Where that would become a problem is two risks to avoid is don't set all of your patients on the same visit frequency. Every patient is different. It should be based on the provider's clinical judgment and what's medically necessary for each specific patient. So if you're seeing all of your patients every month without considering, you know, maybe someone just came out of the hospital and needs a two-week follow-up and the other one could kind of stable dementia patient three months. So don't fall into that visit frequency trap, you know, trap where you're seeing all your patients in the same visit frequency. And then I think that comes down to telling me the story. Like in your assessment and plan or wherever throughout your progress note, you know, what discussions or what was, what did you have to consider? Did you change a medication or did you do something that made you want to see that patient sooner? Really tell that story of complexity based on the details that you put in your note, I would say. I, you know, and for me, I would say, if you think your patient is going to go to a hospital, it's because there's going to be like, you're envisioning a Sentinel event or a change of condition. And so you're watching that medication, you're watching a follow-up component. And so you do have a medical reason to be there. You do have, you are watching that situation. It's just the difference between I've made a change and I'm going to see them every week, or I'm going to see them in a month. And then maybe that, that will change to where I see them every other month. And so it takes a little bit more work to not just say, I'm going to see them every month and kind of set that piece out. But it certainly helps us, you know, stay in on the right side of Medicare thoughts. I want to, I'm going to put a couple of these questions around coding into our coding and billing. So I'm going to save some of them coming up. So Bree and I want you to think about telehealth and time-based billing. So those are coming for you in a future world here. What is a virtual medical assistant? Yeah. So essentially where you hire a complete remote staff. So there are certain companies, you can do your research in our local market that, you know, you can hire a virtual assistant. So maybe it's a medical assistant that, you know, think about in today's world, they can still have access to your HR and your in-basket. You could have, you know, like a ring central or a phone system where your phone is answered by different people in different locations. So that's what I mean by virtual assistant. Usually they're medical assistants. Sometimes I know some practices that are, you know, because of the challenging hiring market, you know, the company that the nurses might be not even located inside the U.S., but they have a U.S. license. So they're a nurse, but they're technically working as a medical assistant in the U.S. That's definitely becoming more common. I know people that have remote practice managers, administrative support. I mean, again, if we think about the technology that we have today, you don't need to have someone physically in the office, especially in a home-based practice. Fantastic. So, okay. Just a couple more questions. Paula asks, you know, a lot of places we're going don't have real-time internet access. So we're copying, pasting information from Epic onto our laptop and later putting it back into Epic. And are there better gas and go EMRs we should be looking at? Wow. I hear the pain. I'm on Epic. One of the beauties about Epic and our current configuration is that our laptop has built-in broadband cards. So we are connected to the internet pretty much continual, not pretty much. It is, we're connected continuously and I'm documenting in real time into Epic and I can access records. You know, when the patient's been hospitalized within the Northwestern system, I can see all of the information. So I encourage you to maybe think about either a broadband for your laptop. Some people have used like a mobile hotspot. That's another consideration. If you want to use the wifi in your laptop, connecting to a hotspot, which is connected to the internet. I certainly, I would encourage you to look into that possibility. I hate for you to, you know, copy and paste or document it asynchronously. Sounds like that's just, I think, a lot of frustration, and I hope that the technology that you investigate and invest in can help you do this in real time. Yeah, I mean I think it doesn't even necessarily come down to the EPIC or the EMR, but investing in a technology to help you be more efficient, and please if anyone wants to share in the chat, you know, maybe some other EMRs besides EPIC that they're using that they found really well, you know, encourage you all to share, but we got to have that remote connectivity as much as we can. Yeah, one more question on connectivity before we switch gears a little bit here, but Kathy says my providers use secure email via iPhones rather than EHR because the mailing message isn't as available on that, and maybe Paul, since you're on EPIC too, like what is your best way to kind of communicate outside the EHR about patient or coordination? Yeah, well two things. We use messaging, but obviously it has to be a secure messaging platform. Within the health system here, we use a product called Bosera that we message amongst providers, but there are other secure messaging systems that you can have with your staff. I think Tiger Text is another secure platform, so that's another avenue for you to communicate with your staff, do a messaging, just making sure that it is secure and HIPAA compliant rather than just, you know, the generic text and so on. I do prefer using the internal messaging way in EPIC because that way we can keep track of everything rather than, you know, having to enter what I put in a text back into EPIC from my phone into the laptop. Fantastic, well hey, thanks for your question guys. I have four questions going into getting into coding, so if you're in a Q&A or the chat and you've asked a coding question, we're going to come to that. Coding is always the hottest topic with the most questions. This is an introduction to that. I think here's how we're going to set this section up. Brianna's going to talk about our next ingredient. Do you want to move forward your slides? So these are, this is what we're covering today. I'm going to take questions in the chat and go through marketing community relations, and we'll see if we can maybe shrink that a little bit, and then before we go into coding, we're going to pause. I'm going to ask the questions all at once to Brianna so she can fit in answers as we go, and then we'll pop along pretty easily, I think. So does that sound fair? Sounds fair. Brianna, you're on. All right, so we're kind of moving along, and again, every practice, whether you're a new practice, you know, whether you're a well- established practice, how are you re-evaluating kind of the success of your, and the efficiency of your program? So as we think about the next level in the implementation model and operationalizing care, the ingredients that we're going to offer for you to think about today is marketing, community relations, and then of course coding and documentation. So, you know, really with marketing and community relations, have you identified your service area, and have you put thought into why you're serving that area? You know, do you know who the competition is? Did you know your, kind of, what gap you're trying to fill? You know, what that mileage and that travel time looks like? There's a lot of technology and resources that you can do that, too. You know, a lot of those map-based things, you can track your mileage. That's kind of the beauty of it, so you can kind of evaluate how far. We'll talk about unique value propositions, how you're locating patients, and how you're networking and looking for partnerships. Again, this is not, you can't do everything on your own, so how can you, you know, understand what other community resources are out there that you might want to partner with? So talking about the market analysis a little bit first, again, when you started your hospital practice, or maybe you're looking to grow, have you really thought about the aging population, you know, in the zip codes in the territories that you serve? You know, there's a lot of different companies and ways that you can do that, or even the Small Business Administration has some free resources, but do you understand the target population, what that geography looks like, what senior living communities? Again, that's reducing that travel time. If you can find those group homes or those facilities, are you looking for new ones as you're driving around? Do you have people out in the community, you know, networking with home health and hospice agencies, and you're considering all of those things, and then when it makes sense to partner? So this particular map, the orange was what they said, okay, this is going to be our target market, and this was what we're going to start with, and the green would maybe be a desired market for the future, but we know that we can't service all those areas right now, so just an example. So what is a unique value proposition? And I think this really comes down to knowing your why, right? I mean, when you're starting your practice, maybe you did some mission and vision work, maybe you weren't involved in that, but I think every person on the team really needs to understand the mission and vision of your practice. Why are you there? What is the problem that you're trying to, you know, solve for, and what services are, how are you benefiting the local community, you know, your local home health and hospice agencies or area and aging partners? I mean, do they know about you, and do they understand? And when you're trying to, as we're starting to see more interest of home-based care, what sets you apart? Why should someone go with you instead of another service, and what kind of market differentiator are you bringing to the table there? And finally, you know, are you knowing your audience? Based on who you're talking to, it's going to be different if it's a payer versus an assisted living community, you know, versus maybe a home health or a hospice agency. So you're understanding what they need from you as a partner as well. And Paula, kind of put you on the spot here. Any thoughts on UBP for maybe either your practice or home-based care in general? Oh, absolutely. Have an elevator speech ready. Brianna, I'll start. I'll make some comments about the last square there, and then maybe move back one square. Have an elevator speech ready for whatever audience you might be addressing, the C-suite, maybe a philanthropist if you're trying to get some dollars for a grant or something. So have something ready to tell them, you know, why you're doing this, what's the advantage, whether it's, you know, health equity or servicing the vulnerable or readmission reduction. Have something ready to go, and also have some data that you practice, that you know off the top of your head. You can say, you know, because of our involvement, the 30-day readmission has gone from this to this. Okay, so have a speech ready, have data to back up your talking points. And then the other square, why should patient trust you over another similar service? And this is where you really can sell your practice, right? What's unique about us? Hey, we get to see grandma in the house or in the apartment, whereas the other doctors say, well, you have to come in, or maybe they do a video visit. You have the advantage of really face-to-face, eyeball contact with your patients. The other is that, as I said already, our patients are complex. They're challenging, right? So let whoever you want to engage with know that you, we are accessible. This is the number you call to bypass the call tree or whatever, call this, you know, we tell them, you know, our response time is within X number of hours. When you call us, we'll respond to you within a set time. Because often we hear that, you know, we call Dr. so-and-so at 8 a.m. about her shortness of breath, and it's now three in the afternoon, and we haven't heard anything, right? We try to keep this patient out of the emergency room. What's different about us is that you call us with shortness of breath, we're going to take care of it. We'll get you with an answer with an action plan within two hours. So come up with your strength, your practice, your team members, and again, having that speech ready for whoever, say, you know, why should I pick you over the other group? One final point, I've been, I'm very blessed to have four amazing nurse practitioners working with me in the office, and they all have different skill sets. One of them came from the movement disorder clinic, the Parkinson Clinic from Northwestern. So neurologic questions or challenges, you know, hey, you know what, I have a team member who can take care of that. I have another APN, she's been with me 22 years. She has three wound certifications. So hey, you know what, you got challenging wounds, I got somebody who can help you with this. So find the strength of your team members, and then make sure that whoever you're engaged with is recognized, hey, you have something extraordinary to bring to the table to take care of these very sick and complicated patients. Yeah, I love those examples. And accessibility, right, that's what they really care about, that you're going to be there for them when they need you. I mean, these patients can't be left alone without an answer for that long, especially if we know we have to reduce ER and utilization. So how are you going to use your team and how are you going to reach these patients? I think that was a great one. So where do you find your patients? Again, maybe you're either just starting out, or you know, you're saying, hey, we really want to take our practice to the next level, we're trying to grow. So we've talked about a lot of these. But you know, often we, what I would challenge you to think about is if you know who your key referral sources are, how often are communicating with them? How much time are you actually putting into that relationship? Do you meet monthly or quarterly or, you know, whatever the case may be to actually talk about how things are going? And, you know, especially senior living communities, yes, it can be that push pull relationship, right? You have to meet their needs, but you are, they also have to understand yours, you want them to call you and not just send your patients out. But again, that can really reduce the travel time, especially if you kind of, you know, understand new facilities or new opportunities, they have to give patient choice. So understand who those senior communities are in your area, and try and network with them or start serving a patient. And then by word of mouth by how great the service that you're providing is, generally, that tends to generate new patients, your local area on aging and senior services, if you're not connected with them, they are phenomenal resource number one, they have some really challenging patients that might come to them and not even know about home based primary care, and or palliative community palliative care. So really connect with them and make sure they understand how to use you. And especially if you're part of a health system, you know, do you have a transitional care management program? Are you thinking about the ER and the hospital discharge planners and those care coordination teams who know who those frequent flyers are, who know keeps who's come back into the hospital and didn't follow up with their clinic PCP, there's probably a barrier reason why so have you talked to them. And when we think about, you know, Amanda and I sometimes talk a lot about kind of stable revenue and what kind of different revenue streams you have coming in, you know, skilled nursing facilities are taking on some medical directorships, you know, that might be a good opportunity. Again, you're seeing a lot of patients in one place. And for your clinic PCPs, you're a partner, explain to them, hey, I only want your sickest of sickest patients as their patient that's coming in here, you know, and the family's telling you how many hours it took them, they're barely getting a wheelchair in the door, you're a resource for them to help improve their quality and not have risky patients on their panel that's not getting into the clinic that they might still be refilling medications for. So think about that, think about how you can get the word out in your community, can you talk at, you know, grand rounds, or maybe a local Parkinson's meeting or dementia support group, things like that about the resources that are available. And then certainly your home health and hospice agencies, often those are the biggest referral sources for home based practices, because they need those face to faces, they need people that can see patients in the home and can communicate with them and really be a true partner. So that and then your payers, you know, Medicare Advantage in particular, and we'll talk more about value based care later in the session. But are you, you know, we know we're in this time where we're transforming to value based care, it's going to happen eventually, I don't think fee for service will go away completely, but we're going to transform to value based care. And so how are you thinking about, again, you have to have that data to get in the get your foot in the door with these payers or look for state based innovation models, alternative payment models that you might be able to get in on. So when you're maybe approaching a new partnership conversation, whether it's a new senior community, or, you know, home health and hospice agency, you want to be succinct, but can you tell them the mission goals and outcomes of your program? Can you explain to them what what are appropriate patients? What is the actual kind of eligibility or criteria of who it makes sense for you to serve in the home? What are the benefits to them do your research on your partner? What are their pain points? And what are you bringing to the table, and then flexible referral options, lots of options on how they can refer patients to you and get what you need. And then you know, what's going to make that talk about what's going to make that partnership successful? And what kind of information are you going to collect to maybe evaluate how things are going down the road? Paul, I'll turn it over to you. Thank you, Brian. I think just a couple of comments. When you're engaging in conversation, whether it's a payer, whether it's a value based care, excuse me, or an assisted living, I'm so sorry. One second. Whether it's an assisted living or, or other entity, take some time to get to know them. Brianna said, you know, get to know what, what is what are the pressure points for them. And, again, we as house call providers, we have a unique set of skills, we have unique solutions to some of the challenges that they face. Take some time, find out what, where they're hurting, and, and how, how can we help them through our home-based medical care? Right. Right. Next slide. Yep. So some models regarding clinical and practice considerations. Just, there's some things, some bullet points for us to consider. Again, there, there might be more, but we can get started with some of these. How quickly can you see a new patient referral? Right. Some of these referrals might be non-urgent, but looking at my practice, a lot of my referrals are urgent or semi-urgent. There's an acute issue, they're post-hospital, post-ER, they need follow-up. Do you have a wait list? Is there a way, and we can talk about this later on in a conversation about metrics and so on. Is there a way to reduce the wait time that you have for your patients? Okay. How easy is it to meet your team by telephone? Again, you know, we've all called our bank or, or whatever, and we go through the phone tree. And that's pretty frustrating, especially if you're older, hearing problem, and you get the idea. What's, what is easy? Is there an easy button to borrow a commercial? Is there an easy button for your family members, for your patients to get to you? How quickly do patients and caregivers get a response from you and your team? Again, we talked about some of these patients may not have acute issues, but a lot of them are calling in with fever, shortness of breath, right? And they need to hear from us pretty quickly. This gets into some of the scheduling thing that Brianna talked about, right? Do you have some time building to your schedule where your providers can just maybe take a break, pull over and respond to these messages in a timely fashion? Again, we want to keep them at home, want to be home, want to go to the emergency room. So quick response is, is really important. Does the provider take time doing home visits and build patient and caregiver trust and respect? Again, we are at their home. We have such a unique opportunity. A lot of these patients are sick, they're vulnerable, meant medically and emotionally and so on. We can really come alongside of not only the patients and the family members and the caregivers and support them through this difficult time. Do you take the time to look them in the eye and say, you know, and put the, you know, close the laptop. And I've gotten more and more used to doing this. Now, when I walk in, the first thing is not opening the laptop, it's actually closing it and say, you know, how are you? Tell me what's going on and just don't touch the laptop for a fixed period of time. And also do that at the end. Close the laptop and say, you know, how are you guys doing? And particularly, maybe also not particularly, also turning to the caregiver and say, it's been rough, hasn't it? How are you? And often at that moment, it's, you know, the tears, the Kleenex, because we've touched a nerve, right? And they need help. When I give talks, one of the things I see, you know, there's a unique part of what we do is because of our proximity to the pain, our patients are suffering. And then we're at the home of our patient. And, you know, just don't ever underestimate the power of your presence. I don't operate, I'm not a brain surgeon and so on. But being in the living room with a patient close to the pain and suffering, it's incredibly powerful. Don't ever underestimate that. And the final thing is, do you explain your services at the end of the visit? Or is it just you just give them a whole bunch of paperwork in a nice little folder, but they have no idea what your policies are, or what your after hour triage looks like? What about refills? What about if there's an urgent need? Take time to explain who's available, how to get a hold of you during business hours and after business hours, and so forth. So again, empower them, give them hope, right? So that they feel like, you know, I can do this and take care of their loved ones at home. Next slide, please. Some networking strategy. Some points here, foster relationships, right? Or we are here to take care of our patients and building relationships, whether that's with family members, whether it is with a facility, it is so important to stay connected. Now I was going to say, you know, before COVID, you know, we would periodically visit facilities and so on. But, you know, COVID has changed all of that. Hopefully, maybe things will change in the future. We can get away from Zoom meetings and emails and so on. And again, having that across the table conversation, hopefully that can come back to us soon. Having a marketing tool or having a website presentation, when opportunity presents itself, you can go and, again, having a five-minute website presentation or elevator speech ready to talk about your practice and your unique value proposition. If you have facilities in the area, you may want to go and introduce yourself and your practice and, again, developing that relationship, building that referral base for your practice, if strategically that's something that's available to you in your area. Don't forget discharge planners and care coordinators, whether you're in the hospital, emergency room, and so on. A lot of them are working with sick and complex patients. They may not know about you, okay? There might be staff turnover and so on, and the next care coordinator may not know about home-based care. So periodically make a phone call, go visit them in the hallways of the hospital and so on and just introduce yourself, again, having that elevator speech ready. I already talked about data. It's great to tell patient stories. It's very touching and emotional, but also have data to back up, you know, this is what we can do. Not only do we do great work and the patients love us and the data tells us that we are doing incredible work, whether it's meeting certain metrics, flu shot, vaccines, and whatnot, or cost-saving, stays at home, readmission reduction, and so on. And the final two points, maybe I'll group them together, either internally or externally, having analytics, it is so important, especially as we go into value-based care, identifying those high-need, high-cost, frequent ER, hospitalized patients, and finding them early, right? And responding to them proactively so that they are not going through the revolving door. So you can break the cycle of this kind of fragmented care so that you can reduce costs, again, improve quality, and just bring the kind of care your patient really want and they deserve. So just to summarize, know your referral sources and your areas for potential growth. Again, if it's assisted living, you might want to go that direction, or a particular home health agency, perhaps that's an area that you need to explore as well. Coordinated communication, again, you can do that through the EMR or a secure text messaging that you might want to explore and consider. And again, finding out where they're hurting and how you can help so that you can grow your practice, the assisted living can have their needs met, and most importantly, the patients will be well cared for. Thanks, Paul. Something that you were saying earlier that I kind of just wanted to tag onto, too, about building that trust with the patients and caregivers, too, is a lot of times that comes down to just being present. I remember hearing a story from a practice where they said, you know, we really appreciate everything that you guys do, but it would be great if Dr. So-and-so would take that coat off when he came and saw me. Maybe you're having a bad day and you have a lot of patients to see and there's a lot of pressures that patients and caregivers don't understand as you as a provider, but just being present in the conversation with patients and caregivers was the only thing I'll add. All right. Amanda, did we have a question before we move on to the next section here? Yep. Just a quick time check, too. So we have 15 minutes before we go to break. I'm going to introduce a couple of things that, as you can talk through in optimization, this is super high level. There's so many more HCCI resources related to billing. Lots of questions. Feel free to ask them. If you could talk a little bit about how you bill for telehealth, telehealth versus office code. So I'm giving you a quick list. So if you quick jot this down, time-based billing and how time-based billing works in home-based medical practice. Can you charge for traveling fees and can you charge and how do you think about billing and productivity time for all the completed signed facts back and forth, et cetera? So I know, you know, all the answers to those and thanks for kicking us off. Okay. Thank you. So let's dive into the coding and documentation section then. So we're going to talk about variables that really make a difference, accurate E&M services and optimized billing. I think I'll kind of save the questions for the end or if they tie in, I'll kind of mix it in here and I'll watch the time to make sure we get to those. Otherwise I can always follow up or put some information in the chat. But again, and a lot of this comes down to if you're in fee-for-service rate, a lot of us are still, maybe you are fully value-based care or mostly value-based care and you've been fortunate to get there or you're, you know, primary care first or direct contracting practice. But we do have to understand from a financial sustainability, you know, consideration, how are we going to be here to continue to care for our patients? So the productivity standard should be a partnership between your clinical team and your, you know, administrative or your leadership team. I mean, you're not going to sacrifice quality, but we do know that, especially if you're in fee-for-service to have a positive bottom line, I would expect visit averages closer to eight to 10 visits per day, four to six is going to hurt you a little bit. If you are at that four to six, because of your geography, can you do some telehealth? You know, are you making sure you're utilizing those advanced coding opportunities? You know, which we'll talk more about later. Again, less drive time, grouping patients together, having more facilities, part of your model, and then using that interdisciplinary team, right? Nurse practitioners, physician assistants are great assets to the team. How do you really use your physicians and your nurse practitioners to the top of their licensure and use them smartly to care for patients that fit with the unique skill sets each of them have? You've got to spend some time on strong documentation and coding and billing. I know it's not everyone's favorite subject, we're here to help you with that, but you have to be billing for time outside of your visits. So that question about kind of, you know, faxes, all of that, are you billing for some sort of care management, whether that's chronic care management, you know, or if you're reviewing past medical records, maybe prolonged services, non-face-to-face, all of those things are going to help kind of capture that complexity of work that you're doing. And then start preparing for the future now, if you are still 100% fee-for-service, you know, what are you, you know, at least preparing with that data, looking at your local area and what kind of models are coming out of CMMI and searching for those opportunities or Medicare Advantage plan partnerships, things like that. You have to have access, as I would say, especially from the community palliative and hospice organizations that I'm seeing get into kind of that continuum of care, that's our biggest concern, right, is not being available, is being available 24-7. And how do they make that culture shift in their organization? That doesn't mean that you're going to drop everything and make a house call at 10 p.m. or on the weekends, but do they have a clinical person that can give them medical advice in real time to help them understand if they really do need to go to the ER or the hospital? And what does that response time look like? And when we start thinking about documentation, especially if you're in a value-based care arrangement, you know, yes, you might have some flexibility in coding and documentation, but that HCC, that hierarchical condition category coding, that's looking at your ICD-10 diagnosis codes, and I need you to support that through the acronym we use in the auditing world is MEAT, which stands for monitor, evaluate, assess and address, and treat. I need to see that you meaningfully assess that condition. The simpler way that I like to think about that is condition, status, plan. What is the condition? What was the status? You know, what are you doing to evaluate it or what changes are you making? And then what's the treatment and the care plan? You know, if you're lacking detail or it's just saying on metformin, that's not condition, status, plan, right? So think about that in your assessment and plans. And then uncovered services, you know, you can't be the end-all, be-all. So understanding where to partner and kind of how to make the most of that and minimize those uncovered services and those other kind of more steady revenue streams, maybe from a medical directorship or a contract or something like that, that you can, you know, drive up some additional financial support from. All right. So someone asked for E&M resources. So we do have them for all settings of service, home assisted living, which is down in the solar area, as well as the skilled nursing for new and established. There's a link here, but again, they're in your HCCI learning hub as a handout. This is what it means when I say a comprehensive versus a detailed history. A detailed or a comprehensive both either need four individual HPI elements, or don't forget the status of three chronic conditions when you're caring for complex patients will get you complete HPI credit every single time. Review of systems, yes, this is somewhat that counting that, you know, that 10 point, but again, that all of their systems are reviewed and negative. I still credit that as a complete review of systems, as long as you've given me some positive and abnormal findings for new patients, don't forget the past family and social history. I do have to downcode the entire level of service if I don't have past family and social history for a new patient or an initial visit encounter. And then also your exam templates. I'm a fan of organ systems rather than the body areas and organ systems, because if we're thinking about the 95 exam, it is eight or more systems. And so we do have typical time here. I think I'll take a minute to talk about the time question. You should only be billing on time if the visit is truly dominated by counseling and coordination of care. Or if it was a really long visit, you probably had some counseling and coordination of care. So are you billing that time and maybe prolonged services to get paid for all that extra time in the home? But your time statement needs to have three things. It needs to tell me the total amount of time that you spent, the exact, not greater than or less than, approximately above 30 minutes, the total amount of time. You need to use that exact language that greater than 50% of it was dominated by counseling or coordination of care. And then there's a third piece that's often missing. I need you to personalize that time statement. What was the nature or the context of the counseling and coordination of care? Again, it doesn't need to be a long narrative. Give me a sentence or two that says, I'm dedicated to discussing goals of care and evaluating the patient's safety at home, or whatever the conversation was. Give me a little bit of detail to why it was dominated by time. And the other thing is, if you're a practice that bills 100% or almost all of your providers bill on time, you're probably leaving revenue on the table, because again, looking at these elements, you're caring for a really sick population that can be supported by documentation and complexity. And it's not always time. It shouldn't always be time. That's a compliance concern that would come up in an audit finding. All right. So how do you optimize your billing model? I've sat here and told you a lot about why you need to do that. So I'm going to touch on these things. There's a resource that goes into a lot more detail. And again, we're here to help if you know, follow up questions after the fact, but transitional care management. Yes, that means that within 48 hours after the patient is discharged, you have to have that interactive contact or that licensed clinical staff member that's calling the patient to check in with them. And then your provider has to see that patient within seven to 14 calendar days and document some certain things in that post discharge visit. But again, all of this ties back to quality. CMS has increased the reimbursement for TCM by 30% in the past two years, we might see another increase in 2022 with that. And also even just the clinical framework, you know, if you are a value based care, a lot of people kind of forget, but CMS does try to build these billing opportunities based on quality. So, you know, contacting that patient really soon after discharge, getting there, doing all those things are for the quality of your patients too. So think of it as the extra work is worth it from a quality perspective, you absolutely should be doing some kind of care management. So what I mean by that is how are you getting paid for your non face-to-face work? So usually your two options are chronic care management, which is CCM, or care plan oversight, which is CPO. Chronic care management, you need that certified electronic health record technology, you need to, you know, start it, you know, talk to the patient about CCM during that initiating face-to-face visit if they're a new patient or not seen within the past 12 months. You have to develop an electronic comprehensive care plan. That's really a one-time thing on enrollment, and then it just has to have a schedule for periodic review. So maybe once annually as part of your annual wellness visit process. And then you're counting and documenting your time throughout the month and it's billable. But I will say, you know, I know a practice, they had about 700 active patient census and when they first rolled out CCM in their fiscal year, it was almost $50,000 just from CCM revenue alone. So think about that. Care plan oversight, if you're an independent practice that doesn't have a lot of clinical support and you're doing a lot of coordination with home health and hospice patients, that might be an option for you. But there's very, it has to be 30 minutes of all billing practitioners time. You can't count your clinical staff and it has to be tied to those home health or hospice episodes and there's very specific billable activities and non-billable activities. So again, think about compliance. I had to help a practice, you know, give some feedback that was in a bad place after an audit with CPO services. Make sure you know the requirements. You can get paid for signing those 485s, those home health initial certifications and recertifications once for the initial and then once every 60 days if it's that recertification. The other documentation that CMS expects to see is really just ongoing communication within your EHR. So again, so your EHR should be that source of truth. Make sure that you're keeping records of the communication and the review of status reports and all those things you're doing. Compliance care planning, from a billing perspective, it has to be 16 minutes, a minimum of 16 minutes dedicated to an ACP conversation and you can bill for it. We've, you know, given you some resources on that. That can be billed in addition to an E&M visit with a modifier 25. It's also an optional element of an AWV that if you used modifier 33 would have no co-pay to the patient. And then again, if you're spending 90 minutes or more with the patient, that's usually just the easiest way I think about it, then you should be tacking on prolonged services if it's an established patient, if you've exceeded that typical time threshold by 31 minutes. That's where time comes into play. The cognitive assessment and care plan, CMS actually has a new web page all dedicated to resource on that. That's for a patient with dementia or cognitive impairment. When you're doing a comprehensive assessment and care planning visit that's face-to-face, it's really focused on that condition, you know, staging their dementia or evaluating it and then connecting the patient and caregiver with appropriate resources, there's a very high reimbursement for that face-to-face service. And then certainly remote patient monitoring is another one, you know, doing annual wellness visits from a quality perspective. Don't forget about the little things like, you know, four minutes for smoking sensation is a billable service. So no, I do not expect you to remember everything I just said, that would be terrible of me. I've summarized all of these guidelines in this resource that's called HCCI's Advanced Coding Opportunities, and you can find it in the handouts that we've provided with you for today. It's also on our website and our free HCC Intelligence Resource Center. So before I move on, I think the other two coding questions I didn't get to was, let's see, time-based billing, or I'm sorry, not time-based billing, travel fees. So that's actually a huge topic, right? So I do know some programs, and actually I have the privilege of sitting on the American Academy of Home Care Medicine's regulatory work group, and we're actually working on a resource right now to summarize travel guidelines and what's out there. So some practices have patients sign an ABN and have a self-paid travel fee. There's some concern from a compliance level, because the home visit codes used to pay a little bit more than the office visit codes, if a MAC would consider that bundled into the E&M visit. So my response to this is you should always check with your local Medicare administrative contractor to see what their policy is and get something in writing, so you know you don't have any risk that the travel is not considered Medicare benefit, and it's not considered part of the billable service that they're paying you for, so that you can choose if you want to, to choose a self-pay fee for patients. Think about your patients, though, especially if you have like a Medicaid population that's not going to work or, you know, patients that can't afford that. You know, a lot of these patients don't have a lot of financial resources. So think about that when you're setting up those costs and those reimbursement models. But the Academy should have a new resource coming out within the next six months to a year that kind of summarizes what we're seeing in the field with that. Brianna, would you take a question from the group? Okay, Maria, if you unmute yourself, you should be able to talk. Here she comes. Can you hear us, Maria? Yeah, I see you're unmuted. Okay, Brianna, a couple of final thoughts as we head into break here, you got a couple of minutes. Yeah. So again, just think about your billing model. The way that I like to think about this is it comes down to your clinical model first. Like look at this handout, look at all of these opportunities and say, okay, what are we already doing? You know, do I have some way that I'm getting paid for all that care coordination and that non-face-to-face work or what kind of services for the population that we really serve? It should always come back to your clinical model. And then how do you get paid for it? And we'll talk later on about kind of this transformation to value-based care. These are all fee-for-service coding reimbursement opportunities, but there's a lot of education and resources out there. Again, think about your clinical model and then bring it back to how you're going to get reimbursed at the accurate way for really all of the complex services that you're providing. And I think I will end with that. As we talk about payment reform, again, these are kind of your opportunities. I just put some large buckets out there, right? Like know who your Medicare Advantage plans is. We've seen a huge increase in Medicare Advantage penetration. Are you following the new alternative payment models and things that are coming out of CMMI? That stands for the Centers for Medicare and Medicaid Innovation. Maybe someone can put that link in the chat for me too. There's some state-based innovation models, so know what's happening in your local geography. The Medicare Shared Savings Program, that gets into more ACOs. If you have 5,000 lives, you might not be there yet. But know that you can contract directly with payers, you can negotiate these things, and you can also maybe partner with a larger entity that is at risk, and how can you help them be successful in that arrangement? So kind of that next step, and as we're kind of tying things together, you have to optimize your billing model, do it in a compliant way, do it in a thoughtful way, but get paid for the work that you're doing. Master Revenue Cycle Management, we'll talk more about that later. You should be doing internal auditing, at least annual internal audits, so you understand how things are going, and you're identifying those growth opportunities, and then you're preparing for the future, right? Like value-based care is the future, we're here, how can you get ready for it? And I think with that, I don't want to take away from the break, I believe, right, Amanda? Yep, that's right. So we'll take 10 minutes. So it's, let's see, it's 2.45, we'll come back at 2.55 Eastern Time, and you don't have to log out, you can just mute or stop your video, and I'll see you in 10 minutes. So thanks. Welcome back, everybody. If you can hear the sound of my voice, it's your warning that we're gonna get started here in just a minute or less. I wanted to, the slide that you've been looking at here just shares some upcoming HCCI events with you. We really, in this half day session, we only have time to kind of scratch the surface of some of these issues, but in our essential elements workshop or advanced applications workshop, we really drill down into a lot of these issues and more. So you may wanna check that out on our website. In addition, we have a webinar that's offered in December that will focus on some of the changes for 2022 in coding. Brianna, can you go to the next slide, please? Sure thing. Thanks. So some of you have been asking about how do I get access to the handouts the presenters are talking about? I want a copy of the slides. All of that is available for you in the HCCI Learning Hub. If you've registered for this event, of course, you've gotten an email from us so that we've directed you to go to the HCCI Learning Hub. You can log in if you have an account already using your username and password. If you don't have an account yet, it's real quick to set one up. Go ahead and do that. It's a one-time creation process. And then once you're logged in, just click on My Resources on the left-hand side, and then look for the Academy Pre-conference level up with the course title. Just click on that. And once you are there, there's a tab that says Course. Click there and all of the resource materials will be available for you. And if you go to the next slide, this is your phone-a-friend, your help. Contact us at education at hccinstitute.org, and we'll be happy to help you if you are still not able to access the materials. So at this time, I wanna go ahead and turn it back over to our moderator, Amanda Tufano, and we will get started with the second half. Great, thanks for coming back. We're gonna move into our next operations around, or our next ingredients around improving team functions and avoiding burnout. We have a Q&A period after that to kind of wrap up marketing, fee-for-service coding, and burnout. So we will have time for that, and I am aggregating those questions. So thank you. Paul? Thank you, Amanda, and welcome back, everybody. Next slide, please. In this section, we're gonna talk about team function and avoiding burnout. We're gonna talk about the quality of an optimal IDT. We're gonna talk about an effective IDT meetings and communications. We're gonna have a brief overview about process and workflow, ways to avoid inefficiency, focus on some data-driven decision-making, and also just touch a little bit about avoiding burnout. Obviously, burnout is a huge topic, and that's a talk that could be its own session. So we're just going to scratch the surface on a lot of these issues. As I was reflecting on this slide, our work is very rewarding. It's meaningful. It's so appreciated by our patients and our family members, but it can also be very complex, can be very demanding, and it can be a very lonely road for us. I've been doing this for 21 years, and sometimes I, as much as I've got some success, street smarts, and sometimes I still feel like I'm a Lone Ranger out there. You're standing in the living room of a patient and family member, and they're looking to you to kind of fix everything, right? And there's some of that existential distress that you feel because we went into this business to help people. We want to assist them and help them best as we can, and sometimes it's just so, there's a lot of burden that I carry. So I need to remember that I'm never as smart, I'm never as strong as all of my team members here in the office pulling together. I can't do this on my own. So it is really important to have a great team that helps support the work that we're doing so that the patient will get great care, and that providers, whether it's nurse or clinicians or whatnot, we don't get burned out. Next slide, please. So what are some optimal qualities of a interdisciplinary team? Well, here are some. It is patient-focused. Each member plays a direct role in the care of the patient. Each clinician understand the patient's needs and challenges from their own professional perspective or discipline, and more importantly, that clinician brings back that information and connect with other team members on the team in order to improve the quality of life for our patients. I'm pretty much in focus on my physical side of things. So if you have a social worker on your team, they might be focusing on other aspects of the patient's crisis. No less important, maybe in some ways more important than the physical part that I'm trying to tackle. The team needs to be lean, obviously because of cost considerations, but also it would eliminate redundancies. If you have a whole bunch of particular discipline, that might bog down some of the communication or the workflow that's necessary to streamline the care that you're trying to deliver. A lean team also enable you to have more efficient problem solving, and a lean team can promote innovation faster rather than having a large team, having repeated meetings or having to come to some group consensus and so on. The lean team, however, cannot be just lean. I recommend that you all consider the diversity within your team. The reason for that, I think having different perspective, different disciplines represented gives us a much more rich and a much varied perspective on the patient's care needs and issues. I remember when I was a medical director for our hospice here with the organization, I remember sitting at it, I don't recall all of the details, but I do recall being kind of struck by the chaplain brought up a particular conversation that she had with the patient and the family member. And I just said to myself, Paul, you never even thought about that. It was not even on my radar at all. And yet it was so important in the emotional wellbeing of the patient and the family. So allowing diversity, I think it is a critical part of a quality interdisciplinary team. So what are some bullet points or highlights of an effective IDT meeting? Well, first I think we need to determine the frequency of the meeting, whether it's weekly or monthly or some other combination in between. Set a time where all the team members are available to participate and all of your discipline can be there, whether it's a pharmacist, social worker, as well as a medical director that's the structure of the team. And follow an agenda, which we'll talk about. We'll give you a sample agenda in a couple of slides later. And appoint a leader to organize and run the team. I think it's also important to set some ground rules as you are meeting. Example is, allowing others to speak, cutting off others during the middle of a presentation and so on. And have a spirit of learning and the willingness to teach from each other. Build on a consensus-based decision-making if at all possible. Again, I think it is so important to have team members support me because again, I've said this before, I'm just a doctor. I only have a particular skillset and perspective and it is so welcoming and helpful for me to get additional input from other team members that help me make decisions. We need to address conflicts. We are a people and we don't always agree on things, but we need to set some ground rules about addressing conflicts in an open fashion, in a respectable fashion. We live in a very toxic culture and we don't need to bring that kind of toxicity into the team. It's not good for morale. It's not good for providers. It's certainly, ultimately, it's probably not gonna end up very well for the patient if there's such distrust and discord within your team. Make sure that you consider all the opinions that's around the table from your team members and make sure you share responsibility. I've said this again and again, I need help from all of you because I have limited knowledge base and our patients are complex and sick and I need help from all of us to take great care of our patients. Next slide, please. This is a sample IDT agenda. You don't have to subscribe to this particular order or all the bullet points on there and so on, but just some points to consider. What are your metrics that you are tracking or need to review? Think about your hospitalizations. Who's in the hospital? Who came out of the hospital? What was the diagnoses and what were the root causes if you can find that landed this particular patient in the hospital? For example, did you not respond to a call soon enough so that the patient did end up in the ER and having to be hospitalized? So take a look at your hospitalization. And care management. It's an opportunity to discuss complex cases as a team or for clinical support staff to bring forward cases for discussion. Again, all of us have different backgrounds, different strengths. I might come at this particular dilemma in this way and my APM may come at a different way and it's an opportunity for us to dialogue and explore and say, hey, I like your approach. It is certainly better than what I was thinking. So having that opportunity to discuss, I think it's important. It is also a time to bring up announcements and update. What does the entire team need to know about what's going on, maybe from a system perspective? I work with a very large health system and also on what I call my little happy planet model. I'm the team leader here for my team. As I look at what's going on across the landscape, healthcare-wise of our country, what does it mean for a hospital practice like mine? What can I share with my team members? Are there things that we can do to eliminate or reduce waste? I'm not talking maybe like literal waste, but maybe waste of time, waste of phone calls. What can we do to improve our process to reduce time on the phone, messaging back and forth and so forth? And also, what can we do to help improve breakdowns in communications or duplications? For example, right now, my practice, without going into all the details we're working on, on reducing the number of messages back and forth and clicks in Epic regarding ordering a particular lab test and so on. Again, it's a process in eliminating waste, eliminating front office, my time and a nursing time in trying to get the order, just a simple order placed into Epic, right? And then recognition. Now, I talked about one of my jars, the three jars here at my office. The first jar is a thankful jar. Again, this is hard work. Often, it's a thankless work. We, a lot of people take us for granted, maybe the health system take us for granted because we've been around doing great work for such a long time. Take a moment to write something you're thankful for. It could be personal, it could be professional, it could be recognizing each other that I thank you for going the extra mile to help patient XYZ when you were at the patient's home. So having a thankful jar. I think when our tank is running low, it's important to take out some of that thankful jar or something from the thankful jar and read it to your team and say, hey, we're doing great work, keep going. The other jar I talked about is the Jedi skill jar. We all have skills, share that with others. There are things about my laptop and PC. Somebody just taught me something I think is really simple that's saving me a lot of time. And after I learned that, am I going, you're such an idiot. That was so simple and it was so helpful. So having a Jedi jar, I think it's important. And the final jar is the wish jar. What do I wish things could be different here? And as the leader, I can take that wish jar. There are things that I can do and improve, but there are other things I have to take up to the health system because that's simply beyond my pay grade to address. So that's a sample IDT agenda. And Paul, we have about two more minutes for this section and then we're going to go to questions. Okay. If there were some highlights, let's do that for sure. Thank you. Sure, no problem. Thank you for that. Real quickly, team huddle, some of the practice that we have learned or when we've done some onsite meetings or assessment for, they have a quick touch base. It's a brief, it could be in-person or virtual. Anybody on the team can lead. And we recommend that you maybe rotate the schedule to allow all the staff to engage and follow a standard agenda or flow about how the quick team huddle can happen for your practice. Give an opportunity to share information, to solve problems, to organize and to prioritize. And then what's important for you and your team for today. Next slide, please. Here's just, I won't go through all of the squares here, but some process development in terms of having your team help you with, say, triage protocols, having urgent visit protocols that we talked about earlier in our session today. Even, yes, the unpleasant topic about dismissal policy and so on. Having a team engage in some of the conversation and developing some of these process that's really important for the health of your practice. Next slide, please. And what are some ways to avoid inefficiencies? There's some staffing inefficiencies, and then it could be some workflow inefficiencies. When you have lack of role clarity or duplication of tasks, sometimes it can lead to staff conflict and inefficiency. And then I talked about before already when there's a workflow inefficiency, about not putting in the order for the blood test correctly and epic and so on. That can bog down the work of everybody here in the practice. And when you have, real quickly, when you have inefficient work plans and so on, clinician can be burdened with a lot of administrative tasks that, no, we're not, we're clinicians. We want to see patients and so on. And communication can break down and certainly the care of our patients can be delayed. Next slide, please. And when you find there's a problem with your practice, have your team talked about, do you need data, more information? When we say, oh, our patient waits such a long time. I feel like the patient waits such a long time. Is it a true phenomenon or is it just a feeling? I tell my providers here, let's find fact. Let's find out if it's fact or feelings. So do you need to collect more data? For example, what is your wait time for a new patient to be seen? Once you have that data, do you need to do a deeper dive into root cause analysis? Why is there such a long wait? Because are we not efficient? As Brianna said, maybe a routine patient doesn't need to be scheduled to be seen every month. Maybe it's every three months. Maybe that can free up for me to see a more urgent patient instead of having them wait. Next slide, please. Again, you can take some time later to look through some of the strategies to avoid burnout. We talked about defining roles, obviously being competent in what you do and willing to change and to be flexible and having that spirit of learning among others here that's on this slide. We all want to enjoy our work. And these are just some strategies that we can employ on a day-to-day basis to help us enjoy our work a little bit more. Next slide. Now, about a month or so ago, I took a I'm taking a look at the data here of our practice because I was getting the sense that my providers are getting worn. I'm including myself in that feeling. So I looked at how many calls, how many in-basket messages am I getting and so forth, comparing my panel size of about 320 patients to a PCP of about 2,000 patients. And you can see my 300 patients generate about as many in-basket messages as a 2,000-panel PCP. And more acutely, I think, from this is that most of my messages are patient phone calls. And I think that gives me, again, the feeling and the fact thing. So now I have some facts to back up our feelings. Like these are calls. Our patients are high need and so on. And now I have a better understanding about why we're feeling the way we are feeling. And what can we do to help each other regarding reducing the phone calls from having maybe better processes that the nurse can follow to macros or other templates so that I don't have to type as much when I'm having these phone calls. Again, having this data is really important. And you can bring this information to your IDT meeting and invite kind of a team approach to solving this problem. Next slide, please. So to summarize, in terms of avoiding burnout and improving team function, I want us to really embrace the model of teamwork and having good coordination with your team members and good communication and make responsiveness. We talked about being responsive to our patients and so on. We need to be responsive to each other. Again, I won't go into all the details. We're working on a particular issue here in the office. And it is my job to say, you know, I hear you. We're working on it. And then at the next team meeting, I say, you know, this is the progress we're making. I've not forgotten about the pressure point that we're facing here. And this is what has happened since our last team meeting. And don't feel like, you know, just because I don't feel this way that others should not feel this way. You know, everybody's unique. Everybody's got different needs and different challenges, both as a professional and also as a person. You know, we have lives outside of our work, right? And finally, you know, think about having an efficient, effective, and well-documented process. You know, we're all in this together. We're all in this together. And I think that's the last slide for this section. Fantastic. Thanks so much, Paul. I just love the experience that you bring when we talk about the efficiencies and how do you engage teams. It's not just a day-to-day, it's a long, ongoing engagement. And so when something like COVID-19 happens, you can keep people engaged and you can keep their spirits up as best you can. So thank you for that, for sure. We're going to move to the next ingredient. Brianna is going to talk us through value-based care and revenue cycle and our quality work. I do have a list of questions that I have kind of right now in three sections around coding, value-based care, and operations. We are going to have Q&A at the end of this section as well, so I've not forgotten about them. Continue to throw them in the chat. Michelle, at the beginning of this section, you raised your hand. So I'm going to unmute you. Was there a question you had regarding this, Michelle Reisner? Can you hear us? Okay. Well, we can hear some background, but we can't hear you. I'm so sorry about that. Put in the chat your question and we'll certainly get to it. So, okay. Brianna, you want to take it away? Sure. Yeah. Thanks, everyone. Keep hanging in with us this afternoon. We're going to make it engaging as we can. We promise. I know virtual work can be a little, but so we're now moving on to the next level of the implementation model. So when you're thinking about ensuring practice excellence, some of the ingredients that we would offer to you to think about is obviously preparing for value-based care. It's a huge hot topic right now, but how are you also managing your revenue cycle management? And then we're going to invite Paul to talk a little bit about quality and performance. How are you really measuring the success of your practice? It's no longer enough to say, I do great quality work and we reduce total costs of care and reduce screen admissions. But if you can't prove that, that's going to be a problem as we move forward. So when we think about contracting with payers, we're going to talk about a lot of details, building those relationships and don't forget about the patient stories. That's why we're all here. And those can be really impactful. People have feelings like pull it, those emotional ties. So, and Amanda, I'm going to kind of invite you to jump in and participate in this. I know it's one of your favorite topics and do as much as you want, but let's like start with the basics. When we think about how you're saying I'm doing great work, I'm in fee for service. I have no idea how to even approach a payer. You know, what do I think about? And I think you have, you have to think about your product, which we're, you know, we're not talking about a best buyer on Amazon. Your product is your care model. If you do not master that clinical care model, then you're, you know, you're not ready to go to that payer strategy. So understand your population. Who specifically do you take care of? You know, what is, what is the clinical elements that make you successful and how do you measure that? And how can you tell that story through a mix of data and those kinds of stories? And the second, and I think this is what people have a hard time with this cost, right? You really need to start thinking about if you're going to take risk for a population, or if you're going to accept a PMPM, a per member per month, you need to understand that it's going to be fair and it's going to be adequately reimbursed. So do, are you starting to look into with your financial team, your cost per patient in understanding those, those kinds of steps that you have. And then as you're preparing for that, you know, potential conversation, really who is your audience? Have you done your research on that health plan or the provider organization that you're planning to meet with? Or that's in your area, you know, what are they focusing on? What are their initiatives and how do you kind of mesh into that? And then you need allies, right? You know, you can be a solution, but you also need, you know, it can be more difficult in a larger organization to have clinical leaders that kind of understand where you stand. And it's up to you as, as the kind of boots on the ground, practice person to, to make them understand that because a lot of people don't understand home-based care and why it's important and contracting arms that make sense for the care that you're actually providing. So that when you go finally to make that pitch, they understand your clinical model, you're making a smart pitch, like, yes, you want to be flexible, but really take the time to look at those contracts or look at what they're proposing and understand that it's something you can actually perform well in, because what you wouldn't want to do is get into a situation where you're underperforming, and then you have penalties or you're taking on risk too fast, right? You're not going to go from fee for service to fully global at risk. So how do you incrementally think about how you want to get there? Amanda, I'll pause if you want to add anything. I might just say one thing. I think that's all very well said. In geriatrics, we're very blessed that doing the right thing is also lowering the cost of care. When you do that, when you do the right thing, someone is making money on that transaction, as horrible as that sounds, right? And so who is the person that is making money? Is it the payer? Is it the ACO? You know, because they're part of a local health system, understanding that base thing and understanding what their needs are, and really doing that background, starts off all these other pieces. And so I just can't reiterate enough, you know, trying to find that good partner really starts with what are the incentives and disincentives and focuses and strategies of the people who are making money when you do the right thing, and how do you get your foot in the door there? So yeah. Thank you. All right. So I really like this slide, too. And again, we kind of talked about that clinical model being the foundation. But as you're starting to prepare, thinking about organizational change readiness, what needs to change, right? If you're going to start looking at more data or trying to close the gap on readmissions and really make a difference for a certain targeted population, what has to change? And what kind of kind of change management approaches are you preparing your team with to find that right partner as you gradually start to take risk and build meaningful relationships, right? Like it shouldn't be a one-time conversation once a year when that contract is up. How are you building meaningful relationships and keeping them into, you know, here's how I'm doing on my progress, or hey, we're really struggling with this measure. You know, maybe there's something that they can help with to ultimately in the end help you deliver on the expected results so that it's a mutually beneficial where, you know, you're receiving cost savings, they're doing well, and it's that kind of two-way street. Would you add anything, Amanda? I know you love this slide. So I sound a little bit like a broken record, I realize, by now. But again, like, have you actually sat down and thought what your clinical model is? Like, one of the questions I feel like comes up time and time again, and again, it's going to be different. I don't have a magic answer for you is, well, what should my panel size look like? Or what should those interventions from my other team members on that IDT look like? So one kind of more practical way to think about it is, are you risk stratifying? Are you making sure that patients, you know, it's, you're not being unfair, but the patients that really need more resources and more touches or more contact with you are getting it? And do you understand what gaps you have? What are your strengths and resources? And what do you need to work on before you would be able to perform well in quality metrics and receive shared savings? So again, you know, the definition of insanity, doing the same thing and expecting a different result, really honing in on that clinical model and seeing what changes need to take place. And I would just say this is, this is by far the most interesting part. I get talk, I talk all the time about how to get into value-based contracting, how to think about it, how to work with local payers. And the number one thing that you need is to make sure the clinical foundation is steady and that your team is really ready to take on this work. It doesn't mean that you have every quality measure figured out, or you have every workflow figured out. It doesn't have to be perfect. But when Paul was talking about, you know, how do you quantify and talk about the successes of your business, tie those into how that then helps someone else and make sure that you can be really nimble if you need to change or move something. You know, if you're paying people on work RVUs and you're going to get, you know, jump into a big Medicare Advantage contract where you need to take a lot of time, you're going to struggle with that pull, that incentive disincentive between each provider, who's like, I want to, I want to make sure I keep my bills, you know, my lights on and my bills paid versus, hey, you know, sometimes I only do three visits a day, four visits a day because I'm spending, you know, they're prolonged visits and I'm keeping someone out of the hospital. And that's, those are just different components. And so you have to make sure your entire clinical team is ready. Not just the business office is pushing you into doing it. Absolutely. So the devil is in the details, right? So what does that really mean? What is your value proposition? Do you know your why? And do you know what your brain to the table with that partner? And don't get yourself into a situation where you feel like you're over-promising. If you realize you get a partnership opportunity, but you're like, you know what, we really need to kind of go back to the drawing board and do some more work before I feel like we're the right partner to be successful in this, you know, make sure you're kind of being honest and having that conversation. And if you are an independent practice, I mean, you know, TCM is probably the best example, but is there a larger healthcare system that you could be a solution for? Hey, if you don't have a really good transitional care management, or you don't have, all you have is office PCPs in your network, I can be a solution for those patients that keep coming into the hospital and they can't get, they don't have an option to get to that office. So what can you leverage? Who can you partner with? You don't have to do this alone. Like even, you know, the CMMI's website published who the DCEs are, the direct contracting entities, you know, know if there's some in your area, think about how you can form those relationships to kind of build a mutually beneficial partnership down the road. So how do you build that relationship, right? So I think it comes down to two, you have to have a really clinical champion. I think sometimes when I've seen teams, usually when they have multiple settings and they have a lot of part-time kind of positions where maybe they're doing only doing house calls certain days a week, that's not a bad thing, but you do need a clinical champion that's bought into the program and somebody that's really dedicated to it and is going to put that time and effort in. So they can help you figure out, you know, what those potential partner's values are, you know, what are those goals? And they may not be the exact same goals as you, but are there some that kind of have, that have some alignment or that would, you know, be for kind of the greater of the community that you think your clinical model fits well into? And don't give up. This isn't, again, someone tells you no, great, you know, keep trying to build that relationship, keep trying to find somebody else with that pair that you can talk to, whether it be, you know, the medical director, you know, their websites, you can cyber stalk, you know, that's okay, you know, figure out who you need to try and talk to to get in the door. And, you know, the first person that's going to tell you no is just your contracting, you know, representative. And so they're going to have some sort of delegated provider rep who's, who really is just negotiating basic details and does not have approval to do that work. Sometimes you get a really good one who's like, I see a diamond in a rough here and I want to move them forward. But you want to figure out multiple ways into payer conversations. It's not just through kind of the prefabbed line coming in. So I just wanted to reiterate that of, you know, reaching out to Humana and the account rep telling you no, we're not interested doesn't actually mean no at all. It means that's not really in the pay grade of that individual. But there are other ways in and how do you think about that? How do you leverage your partners and your skill sets and your hospitals and your hospital leaders and, you know, community leaders and your value that you've already done? How do you leverage that to get in the door? And then when you do, and this is why I love this next slide, right? What are you going to say to them? That's my favorite part. Yeah. And Paul, I invite you a little bit if you want to chime in on kind of the power of patient stories and maybe how you went about kind of capturing these kinds of stories in your practice. Yeah. It's important. Again, data is important, but I think they want to hear patient stories as well. The two halves of our brain, right? We got the analytical and then we got the emotional side. So I think it's important for you to have some analytics either, again, either within, or if you contract with somebody who can help you look at this particular patient, right? 65, 16 meds, 12 chronic medical problems. Let's be honest, this is the kind of patient that we take care of, right? She gets frozen, delivered meals, kids that are really not involved. She's never married and she kind of lives on her own. So having some analytics that looks at, you know, looks at how many hospitalizations this patient has had. Again, these patients came to us from the hospital discharge planner or the hospitalist and whatnot, because they're kind of like, they're not quite sure what to do with Mrs. Jones here. They see, you know, Paul Chang, can you bring whatever clever resources that you have and do what you can to take care of this patient. So having some data from the time of intake, I'm looking back and say, well, in the past year, before we came into the picture, the patient had this many ER visits and this many hospitalizations. And then you go down and then having the ability to ask analytics and say, hey, can you look at the data a year after we came and had these interventions and compare, you know, what do you see in terms of before and after? And again, Amanda said, you know, be persistent, go after these conversations and then be ready with patient stories like this and say, before, after. We do amazing work. You know, we cut down her hospitalization by 80%. ER visits to almost nothing, okay? So as you go throughout your practice, your day-to-day taking care of patients, which is so important, also keep these stories in the back of your mind because it's gonna be important as you engage. And we'll talk more about, you know, metrics and stuff later on as you engage in the conversation with your payers. Thanks, Paul. So kind of wrapping up, you know, we know we need to prepare for value-based care opportunities. How can we still think about our business model, think about our financials, optimize the billing for our fee-for-service population, but develop the right quality metrics? And we're gonna have a resource for you. That's a pretty exhaustive list. You know, you're not gonna, don't try and do too much because then the quality is gonna suffer. You know, pick two, pick five, you know, start small in something that's really meaningful that you think fits really well. And I would encourage you to start doing some work on trying to think about understanding your costs as you tie that to your clinical model. But Amanda, were you gonna say something? Well, we got a couple of questions that kind of intersected with value-based care over the last couple of sections. And I just thought I'd throw them out there for all of us here, but before we move on to revenue cycle. But how should home-based primary care programs work with contracted MA programs such as Landmark? So, you know, how do organizations working with MA programs and can you bill CCM or maybe any of the other kind of fee-for-service plus type codes under Medicare Advantage contracts? And so how do those kind of intersect those pieces? So I don't know if you have a order in which you would like to take those, but. Yeah, so I'll start with the latter maybe. So the chronic care management, I think it depends on your contract. So if you're being paid a fully capitated contract, often that PMPM is factoring in care management time and chronic care management would be considered bundled. Like for example, in the primary care first model, you know, chronic care management is bundled, is considered a bundled service, but there's still some that aren't. Like cognitive assessments and visits, for example, are not bundled. Remote patient monitoring might not be bundled. So kind of understand what's built in and what's not and what kind of fringe you might have flexibility with. And, you know, I don't know if I have a perfect answer to the other one. I think it's every partnership is gonna be different. And Amanda, if you have, you know, thoughts on kind of how you would partner with a landmark or someone like that, but, you know, they're only so big, they can only serve so much. Do you have, you know, for example, maybe you have community palliative care service line or some sort of other skillset that you can bring to the table. You know, like I said, I know that a lot of practices that have been partnering with dispatch, so they don't have to do those same day acute urgents. So think innovatively, but, you know, Amanda, your thoughts on that. Yeah, I think, you know, home-based primary care practices can be expensive for Medicare Advantage programs and for them to, you know, pay out and they're also high claimants and they're expensive patients. And so really, again, understanding and, you know, it seems kind of business folky, I get, and that's my background, but keep coming back to who are you? What's your differentiator in the market? And then who are you actually solving that problem for? So if you're working with an organization like Landmark and you want to get in with their Medicare Advantage population, you know that you're caring for some of those patients. Now you need to pull some data, get some patient stories, but say, hey, we have 300 patients of yours today. We'd love to grow the program. We think we can do that in this geographical area. And maybe you can really help us in that. When you start dipping your toes into other MA programs or even I would say maybe generally a payer you've never worked with, really figure out how you set your contract up for success. How do we think about and make sure we have a dedicated account rep? How do we think about what kind of quality metrics, financial metrics we're going to get on a quarterly basis, maybe even monthly basis? So set those things up without necessarily going all in on a full capitated component. They may not pay attention to you enough if you don't have a sizable population, but again, everybody's looking to grab patients. So you can be their solution. You can say of all the patients that exist in the world, we manage these really well. There's an opportunity for you. So yeah, that's my answer there. Yeah, and while we were on the break, I was trying to catch up a little bit on the chat and I really love all the knowledge sharing that's going on too. I mean, definitely learn from your colleagues, but Amanda, I think this tied into kind of a previous section, but here too, that I was curious, I can ask, I have some thoughts, but I wanted to get your perspective on too. There was someone that said that they're struggling to figure out, they have 15% Medicare Advantage and 85% fee for service. And how do you think about, you know, between the service lines, which I know is something we've talked about a lot. So I thought I'd get your perspective first and then I can add any extra thoughts. What's the exact question? How do I think about what? So how do they think about like contracting and billing between the two? So they've got 15% MA and 85% fee for service. You know, how do they think about services and kind of billing between the two different populations? Okay, maybe, well, okay. I don't know if I'll have the most- It might not be re-articulating. This is from memory, you're the best. No, no, no, no. No, I saw it come through too. Yeah. So fee for service patients might be a feeder to your other programs. So you can certainly think about them as a feeder, as a loss leader, if that's the case. If that is not the case, it might be the cost of doing business. You know, sometimes one program subsidizes the other. You can shrink that population and just say we will no longer accept X fee for service because we don't have a value-based contract on that population. I think it depends what you're trying to grow. So if you have 15% and you're hoping to get, you know, and it's in a tight fee for service, again, maybe it's original Medicare, you're hoping to get into a direct contract or maybe you're, you know, or something like that, and that's maybe an opportunity for you if you're like, we just take these patients. For us, when we think about assisted living, I would say we generally, we have contracts for duals. So we generally think about our fee for service patients as kind of waiting to be in a dual program as they spend down. And so it's a kind of a cost of doing business. So it's not really motivating in any way. It's not a motivating answer, but that's what I have. Yeah. And that's why I say, you know, I think the question made me think about where I've seen some pitfalls is people trying to do, you know, really putting the burden on their clinicians and that front-end team to be like, okay, you're doing, you know, maybe CCM for this people and not for this. So like build the framework of quality and then have, you know, back-end, use your technology, back-end billing things where you say, okay, my fee for service patients, we're billing this for, but don't put that burden on the provider. You know, if you have a good technology and way to track your time and are documenting care management, do it for all your patients because it's the right thing to do and it's quality. And then let billing figure out on the back-end or try and have some resources. And we'll get into a kind of rev cycle later on how you make the most from the different revenue streams. But I would just, the only thing that that made me think of is trying not to over-complicate it based on payer population. Great point. And then I wondered if maybe Sarah could put in the chat, Melissa asked, looking for good education or resources on HCCs. And HCCI has great resources for HCC coding and what that work is. And so I'm gonna call that answered and we'll get a link out to that. So thanks. Thanks, Amanda. So, yeah. So again, just thinking about all of these things, again, this is a process, right? You're not gonna transform to value-based care tomorrow or do any of these things. You need your team. You need that clinical model. Think about proactive care management. We need to stop being reactive to when problems occur. How do we, Dr. Chainlake-Sutala, what's that? Now I'm forgetting the term you call it, but that backup plan or that plan B in that emergency situation, do your patients and caregivers know what to do? And then, yes, obviously HCC scoring, especially if you're working with Medicare Advantage plans, that comes down to that ICD-10 diagnosis coding, but it also has to be supported. And you have to show patient and caregiver engagement and really find the right partners. So with that, we're gonna switch gears a little bit. We're still thinking about ensuring practice excellence when we're kind of at that hole here. But what are some factors to consider when you're thinking about revenue cycle management, compliance, and practical strategies? Maybe you're not part of a health system or a big organization. How do I, as an independent organization, think about this in a tangible way? So I'm gonna start with revenue cycle. So this really comes down to intake, honestly. And I think a lot of people don't realize the impact of gathering correct active insurance information and verifying it before you see the patient, before you go to that first patient visit, and then continuing to make sure that it's active. A lot of patients that have Medicare Advantage can't tell you that they even have Medicare Advantage. So are you using some sort of real-time eligibility and are you training your intake staff and engaging the entire team? Like if a patient's at a home visit and says to the medical assistant or the provider, hey, I have a new insurance card, can I give that to you? And they feel uncomfortable and they're like, oh, can you just call the office? That's a delay and then a potential you not getting that information. So train your team on the importance of, hey, this is a good thing for the practice as a whole. This isn't just the business office or the front office or your practice manager or your biller. We need to understand that intake process and we need to make sure that our team is doing it correctly the first time and getting that information before you just jump and run out and see that patient. So what I mean by timely and clean claims, do you even know your denial rate? There's a lot of billing reports you can use and EMRs or different billing systems. How much of your claims are coming back? And then once you have that data, is it a missing modifier? Is it something that you can correct to help the appropriate charge come through next time? And are you using the appropriate codes? And the example that I'll give you here is telehealth is a huge one. So right now we have telephone E&M codes for audio only. We have billing our video visits as normal E&M services with the modifier 95. We have all these different virtual options. Do your providers really understand the correct code use or have you done an audit, an internal audit even of all of your virtual services? And you're really making sure that the appropriate codes are being used in the appropriate time because when we throw all of these things at our providers, it's really hard to keep track of. So build your billing guides, reference sheets, do some internal auditing and think about all of those things. And then you do have to have some sort of set productivity standards. And I know I've mentioned this a lot and I'm not saying push your providers to the end and just see more patients, right? That's what we're moving away from in fee-for-service. But also based on your panel size and the frequency, think about your panel size, think about the average visit frequency for your patients. How many patients a day do you have to see to just make sure the care is provided? And that is gonna be positively impacting your bottom line. Or if it's not maybe a visited hour, is it a billable service an hour? What other non face-to-face work or to hire that social worker, they need to be billing for psychotherapy services and things like that. So you can think creatively about those productivity standards, but you do need to understand how that ultimately is letting you provide the care that you need and grow your services. And then denial management and follow-up. As frustrating as it sounds, I will tell you sometimes payers deny things in air or it's in air on their side. And if you don't follow up on that claim, they're not gonna go back and pay you for it. So you need to have someone, whether it's in-house or outdoors, you can certainly look into some external billing companies or you could hire a certified coder. The American Academy of Professional Coders, the AAPC has job postings that you can find on their website and other resources, or maybe it's just someone that's through experience and working in offices has gotten pretty good with that, that you could empower and send a training to really help your team. And then you have an in-house person to help you make sense all of that and not put that burden on your clinicians. And of course, we know that patient collections can be difficult for our patient population, but it's also, you can't write off everything just because you feel like it. That's a huge compliance concern. So making sure that you understand that and you have a policy or someone that's looking at that, that you're doing education when there's a problem or when something's being done incorrectly and that you're correctly credentialing all your providers with all your payers upfront. Don't get into an incident to mass when you hire a new provider and they're not credentialed yet. So all of these things are gonna be impacting your bottom line. Got a lot of questions about compliance plans and what that means. So OIG actually, and I have some resources on the next slide, as a response to the Affordable Care Act, it really is required to actually have a formal compliance program if you're accepting Medicare and Medicaid. And what that means is they have seven elements. So they consider a compliance plan to be having written policies and procedures. Who are you designating as that compliance or security office? Do you do effective training and communication? So if there was a potential error identified, what documentation do you have of what you did to rectify that? And are you doing at least annual internal audits? Small sample sizes, doesn't have to be a ton. What's that corrective action plan if there really is something fraudulent going on and how do you show kind of that prompt response and that little abstract risk assessment is a HIPAA thing that's required with that. So understand it, if you don't know what it is, there's some really great resources out there that are all free. There's also a compliance risk analysis that's for free that we'll look at some that I've just kind of stumbled across that I thought I'd share. But again, if you're like compliance plans way over my head, I'm an independent practice, I don't have a compliance department, how do I think about this? I think you can kind of break it down into some of these simple steps. Do some ongoing auditing and internal monitoring, understand what your risk areas are for your home-based practice, what services are you billing for that's on OIG's work plan or things like that. So know your risk and know your trends. Like if you have a lot of, we talked about time-based billing earlier, if you have a lot of providers that are billing 100% on time, I have a hard time believing that every visit is 35 minutes. If I see that exact 35 minutes in every single visit time statement, I'm gonna have questions and I'm gonna think about how much time in the day there was. So understand and monitor trends across your team. Is there an outlier? Is someone really under-coding actually because they're scared, they don't feel like they're coding at that higher level, but all of your other team is, then maybe spend some support and resources educating that particular provider. Understand denials, feedback, education, can't stress that enough, and then invest in your team and they'll ultimately be successful for you. So think about that as we're moving on here. So just kind of summarizing this all up, again, I think it's important to kind of engage that entire team in that, offer flexible payment options as patient portals and things don't just say, oh, call a different department or call a billing department or the practice manager isn't available right now. Do you have like a general cheat sheet that anyone on your team could give some information and can't stress that intake process enough? So revenue in, identify those outlier problems and put some effort into it. Brianna, a quick question as you're going through revenue, any tips on how to financially survive deductible season? Oh, yes, you know, this is an interesting question that's come up too. And so it was interesting, the practice that I was talking about, what they were talking about is what we try and do is towards the end of the year, the beginning of the year is when we bill our annual wellness visits. Like that's where we really dedicate that time because it's a Medicare preventative service. And so when you have that deductible hiatus where you don't have that revenue coming in, can you focus on those annual wellness visits or something like that? It's not a perfect solution. You have to prepare for that, have money in the bank. But I thought that was a pretty cool solution in practice that I worked with was like, hey, we just prioritize our AWVs. We get those done at the end of the year, we know that's a preventable service that will at least get paid for. Paul, you have anything to add before I move on? That is really creative. Yeah, so I think as health call providers, I've learned that we are very creative and people of perseverance. We are, you know, whether we're talking about COVID or billing and whatnot, we have found a way to keep marching on and keep going, facing the headwind of fee-for-service and with you helping us with all this billing and coding thing, and with knowledge from all of us, you know, sharing this, you know, annual wellness visit. Just like, I never even thought about that. How cool is that? So, yeah, I don't have anything to add, but other than just being encouraged, like, wow, really smart and innovative people. All right, with that, we're going to move on to our last section, and I just want to take a moment here and thank everybody for your time. Thank you for trusting us with your time, which I know is very precious, and I hope the information that we have provided for you is, information is helpful in your day-to-day operation, also, as you plan for the future. So, the last section, we're going to talk about quality and performance. I'm going to talk about quality improvement in home-based primary care, just highlight some quality metrics under MIPS and quality metrics under SIPP and primary care first. We'll talk about end-of-life data, consider what are some of the barriers in implementing quality into your practice, and just some logistical considerations. Next slide, please. So, first, I think Brianna, I think it was Brianna who said, you know, there are a lot of metrics out there. Under MIPS, I think there are over 200 metrics. So, take some time to take a look at what are the standards out there in terms of metrics that you can monitor and you can assess. More importantly, you know, what metrics are important for you for a house call practice? What are meaningful metrics? For example, there are some metrics that may not be, that's under MIPS, that's not terribly, I shouldn't say, it's not as significant, perhaps, for my practice, such as, you know, follow-up thyroid nodules, follow-up lung nodule, although that could be arguably maybe a little important. But maybe things like, you know, screening for depression, screening for fall risk, and so on. Cognitive assessment, as Brianna talked about, maybe those metrics are more important for my practice other than some of the other ones. Again, as a team, if you're a leader of your team, maintain a culture of continuous improvement, whether it's through team building, meetings, or getting data to, for you to share with your team about your performance, not only financially, but improving clinical outcome. You know, I'll say it now, I forgot to say it with the first slide, and I'll say it at the end too. Quality, it might sound a little dry about quality and metrics and so on, but it is so important for patient care. It really is. It matters to our patients. So don't, I hope you embrace that in terms of measuring quality. So it's important for patient care. And also, it helps you tell your story about the great work you and your team are doing. We could go around and say, oh, I'm great, I'm great. But having some data to back that up, very important. Next slide, please. And Paul, before we move on, I just wanted to mention the website that's linked on this, improvehousecalls.org. The National Home-Based Primary Care Learning Network is a great resource if you're struggling with quality improvement. They do different quality improvement learning collaboratives that you can potentially apply to participate in. Dr. Bruce Leff and Christine Ritchie, who I know are very well known in the academy, have done some great work around meaningful quality metrics for home-based care. So definitely check this resource out. Thank you for that. Again, these are just some examples of MIPS-eligible metrics. MIPS is a merit-based incentive payment program, is a way for us to participate in quality payment program, and that's under the Medicare Access and CHIP Authorization Act, which is the MACRA. All that is to say, these are some metrics that's under MIPS that I talked about may be more relevant to our kind of work, such as cognitive assessment, such as functional assessment in terms of activities and daily living for the kind of patients that we see. Again, these are just examples. Next. This is a primary care first and SIP quality metrics, and specifically this is for group three and four. Risk group one and two, they have different metrics, such as patient experience, A1C, under nine, blood pressure control, advanced care planning, colon cancer screening. As you continue on, if you're involved in primary care first or under SIP, and if you continue on, as you move on into group three and four, these are some of the other measures they're monitoring, total per capita cost, patient experience, and days at home. Next. Again, there are many metrics out there. What's important for your patient care? What will help you tell your story? What information do you need to understand, you know, to improve your performance under value-based care? There are some bullet points here that are listed for you to consider in terms of, you know, what can your practice do regarding, you know, patient care, tell your story, financial performance, and so on. Take a moment to take a look at this. Also, when you are done with our session today, take a look at some of the other metrics that are out there. I think it was Brianna or Amanda talked about, you know, you don't feel like you have to tackle everything. It's impossible. Tackle a few things, and then build on your experience from there. Next slide. And this is, again, can we maybe send a link to, send a link in the chat about where learners can get some of the metrics that we're talking about here? And they also have it in their handouts too, Paul. So, we've downloaded these, and it'll be in that My Resources tab for you all. Thank you. So, you can take a look at that as well at a later time. Next. And this is a data that we've been collecting or we've collected on our practice. Now, we know that end-of-life care regarding hospitalization and ICU stays is really costly, but more importantly, beyond cost, is not where a patient wants to spend the last days of their lives. Not in a hospital, and many of whom I have told in surveys and studies and so on, ICU stay is just not the place where they want to pass away. So, you can see some of the national data that's out there regarding hospitalization 90 days prior to death, and then ICU stays 30 days prior to death, and then looking at the practice and the performance of home care physicians here. You can see we, again, we do remarkable work, and we get patients on the hospice. We keep them out of the hospital. We keep them out of the ICU, and this is an indirect way, if you want, as a way to show that you're reducing cost, because we know the final days are costly, and many of our, majority of our patients spend their final days at home. Again, having metrics that you can measure that's relevant to you, that's important for you, that you can, again, for that elevator speech, whether you're talking to payer or whether you're talking about maybe a hospice organization and so on, so that you can share the great work that you're doing from a statistical way, but also know that we are making incredible impact in the lives of our patients. Next slide, please. Yeah, be ready to address some of the barriers, provider engagement, limited resources. Yeah, you know, Enterprise Data Warehouse, as much as they're helping me, they have other projects that they're working on in Northwestern. I can't have them for every single thing I want them to do for me. Staff satisfaction, and then also being able to sustain your ideas. If you have different service lines within your practice, you know, a palliative line, a primary care line, you know, what can you do with the limited resource that you have to sustain all of your good intentions, good initiatives, right? For example, even in our practice here, a couple of meetings ago, we devoted a good chunk of our time talking about value-based care, talking about ACC score. It could be that they, you know, what is this? You know, why are you doing this busy work, if you want to call it? Why do you want me to change the way I chart and code my diagnosis? You know, why is ACC so important? So maybe they're not engaged because they simply don't understand. So help them understand the why. Get your team involved. That could be from your providers, but also from say the healthcare. For me, from the healthcare side, I had them build a dashboard for me looking at all the ACC scores of myself and my providers, and potential ACC score in terms of what can I do to document better to improve my ACC scores on our patients, and why is that important? Okay. Next slide, please. And just something to consider. I already talked about, you know, finding some metrics that you can measure. Getting support from IT is really important. They have been so helpful for me. Again, the most recent work for me has been on the ACC, and I say, hey, I can do a whole lot better once you have that data. What process needs to change? Maybe, like I said, maybe education. It may be having the providers look through the diagnoses and pick the one that's most representative of their patient's condition, rather than just a less nonspecific one. For example, you know, chronic respiratory failure with hypoxemia, hypercapnia, rather than just, you know, other COPD. And that could be important. Documentation is key. Again, training, education, taking some time, like I did with my practice, to give them information, have them handouts about, you know, why we're doing this, why is this important, and then having ongoing monitoring and feedback. And this is our ACC score for this quarter, and next quarter, hey, look, or next year, say, you know, we've improved upon our score, great work, and having, again, IT support, having extractable data, so you can continue to provide the action plan and monitoring and feedback that's needed for you and your team. So, to wrap up, improving quality and closing performance gap, support and validate your practice value through meaningful data and outcome metrics. Continue to set goals and challenge yourself with new metrics. You know, what is it, Star Trek, to boldly go, right, to no person has gone, but whatever. Don't just settle and say, you know, we're great, we're awesome. You know, look for that opportunity to improve your work, and share and engage the team with data and to help you buy in and understand their role in success. I can have great ideas about what I want to do for my practice, and it's very important for me to share that idea and say, you know, this is why we need to go from here to there, and ultimately, the clinic is going to benefit from this, and our patients are going to benefit from this as well. So, I think everybody can chime in here. They're the secret sauce. I hope this is a very tasty stew that, as you take some of the information away from this afternoon, if you go back to your practice, that it will be a flavorful, fragrant part of the healthcare in your community. Yeah, I don't know if we can be more descriptive on the secret sauce. That's fantastic. I kind of like that. The only thing I'll say is, you know, there's so much information that's always shared anytime you attend a virtual meeting or a conference, too, so I think, you know, take some time to think that these ingredients and these levels and where you think your practice is at or what you think, you know, where's a starting place. So, sometimes, this was our creative way to try and present this information to you, but, you know, what ingredient is lacking in your secret sauce, maybe, is the takeaway I would add. So, I want to make sure that nobody actually logs off thinking that we're ending. We are not. We have left time for questions. We are going to go until 430. I have kind of grouped some of the questions together, and so I want to make sure we do that, and we spend just, you know, a few minutes wrapping up at the end. So, we, yeah, we have kind of almost 20 minutes for questions. So, this is the really fun part. I've already gotten a couple. Feel free to throw them into the chat. Yeah, 430 Eastern Time for those of you on the West Coast. We're not going to keep hearing that long. Okay, coding is always a big area. Is it okay if we come back to coding, Brianna? So, I'm going to throw them at you. Can you do an annual wellness visit at the same time you're doing a routine visit? Okay, so the word routine, I'm not crazy about in that statement, but yes, you can do an annual wellness visit with an E&M visit for a separate and distinct problem. So, keep in mind with AWVs, I mean, the way that I like to think about it is it's not really practical in most instances for a house call clinician to go to a patient's home who has chronic medical conditions and just have a preventative discussion because that's really what an AWV is, right? It doesn't even include exam. It's vitals and that planning. So, you know, they're a great tool if you make them meaningful and don't just make it a box checking or maybe even have a nurse kind of set up the visit for you. But yes, you can build an annual wellness visit with an E&M service. You do need a modifier 25 as long as you can show the separate and distinct documentation that both services occurred. So, just maybe don't use that routine word, but you had a medically necessary visit addressing their other chronic conditions or a acute problem or exacerbation of their visit while you performed an annual wellness visit. Patricia asks us, does it matter who bills an MD, NP, or PA for various high-yield HCC diagnoses? The answer is no. You just want to get the diagnoses down and attributed to your patient and attributed to your NPI. It does not matter who the biller is. So, I know that the APPs receive a little bit of a haircut on reimbursement that does not extend to HCC. You're just trying to get the diagnosis in annually, every year starting January 1 for that patient. So, I wanted to make sure we leave that and not just answer that one in the question or in the chat box. So, any other, anybody would add anything on that? The only thing I'd add is it doesn't also have to be every visit, right? Like you have 12 months to capture HCC scores for your patients. So, I like to see prioritizing, you know, the first listed diagnosis that's on the claim with what really you focused on during the visit and then coding those acute exacerbations so there's more severe episodes as they happen. But don't think you have to put all of the codes in one visit. I mean, it's over a year for that patient. Okay, we got questions from the group. Namara, I've unmuted you. If you unmute you, we should be able to hear you in theory, right guys? Thank you. I just wanted to follow up that question about the annual wellness exam and E&M. So, maybe a city question, but could you also add on advanced care planning to that or that would, do you just add another modifier with that? I mean, how does this work? Yeah. If that's what you're doing. That's a great question. So, tackle that in a couple pieces. In theory, yes, if you have an E&M and advanced care planning, that would get really tricky if you were billing on time though, because you would need to separate out the two. The other way that you could do it is advanced care planning is always an optional element actually in the annual wellness visit. So if you were doing an AWV with advanced care planning, and those were the two services you focused on that day, in that instance, you would use modifier 33 to negate the copay for the patient because it's an optional element of the AWV. If you were going to do all of them, you really just need to make sure you have that separate area in your progress note that shows that 16 minutes is truly dedicated to the advanced care planning, and that doesn't include the other E&M work for very distinct conditions or an acute problem that was exacerbated, plus all of your annual wellness visit work. So it kind of depends on, logistically, I would say what's reasonable to implement in one visit. But if it occurs, then technically, yes, you can bill for it. The modifier 25 would just stay on the E&M visit. You might, I'd have to double check, you might need that on the advanced care planning code as well. But usually there's only one modifier 25 on the claim. So it'd be like on the E&M visit is where you would put that modifier 25. Okay. Thank you very much. Yeah. I'm going to, so, you know, in our 20 minutes, I'm going to split the first half with coding and then some ops questions. So we'll go a few more minutes on coding. Can you talk about TCM versus CCM? Any advantages to using the TCM codes over CCM? Yeah. I mean, so they're very distinct services and they were unbundled for, you know, Medicare purposes too. So transitional care management, that's a really a face-to-face visit. That's your post-discharge visit. There are non-face-to-face elements that have to occur. So as a reminder, TCM is technically a 30-day service period, but it requires that face-to-face element. So if the patient has an eligible discharge, so if they were discharged from inpatient or observation hospital, if it was a skilled nursing facility stay at home or to an assisted living setting or rehab stay at home, all of those qualify for TCM. What you would do is you would have to have a licensed clinical staff member contact that patient within 48 hours, 48 business hours, to have what's called an interactive contact call that has to be medical in nature. And we have some TCM resources with template recommendations for that at HCCI. And then, and this is all still one service, your provider makes that face-to-face post-discharge visit. When they see the patient face-to-face for that transitional care management visit, that's when you bill the code. That is their face-to-face visit. So you wouldn't also be billing an E&M. Your TCM is your E&M for that day. So that's TCM. The reimbursement was increased 30% the past two years. It is also a great clinical framework. You know, you can look at, you know, if you're billing a high levels of service with the prolonged services, technically that might still pay more. So kind of, you can look at your cost options, but it is a great model and framework. Whereas chronic care management is all about non-face-to-face time. So that's that clinical staff and your providers talking with patients and caregivers, talking with home health aides, refilling medications, sending orders, all of that is billable time. I love that because it's getting paid for the work you're already doing. And often that's how you afford, if you're under fee-for-service, other staff members like a nurse or a social worker or things like that. So that's the difference with chronic care management. It's non-face-to-face work and it's all your time throughout the calendar month. And again, look at that advanced coding resource. I really break down CCM in more detail in that as well. It goes along that same lines with CCM. Catherine asked a while back, I've been saving it. How are people getting the copy of the personalized care plans to patients in their home? Because a lot of patients aren't tech savvy and the providers aren't carrying printers. So best practices with getting those in their hands. Yeah. So it does, Medicare does require it to be electronically provided to the patient and caregiver. So best practice would be if maybe it's not the patient, but it's their caregiver signed up for a patient portal and you can send that to them on the patient portal, that counts as you delivering a copy of that care plan. It could also be secure email, if worst case, it had to be that way. If you have to go to, the mailing aspect is a last resort, but really the Medicare's requirement is that it's electronically transmitted. You could document that it was offered the other way. So I was just working with a practice on this the other day, and they were like, you know what? We thought it wasn't possible, but we on intake and after that first visit put some work into signing people up for the patient portals and their caregivers, they have about 70, I think they said 75 or 85% uses, and this is a home-based primary care practice of their patient portal now. Wow. Great. Maria, I've unmuted you. Can you hear us? Yes. Hi. I was the one that asked the question about TCM. I think it was misunderstood, but I just want to clarify, I have not built TCM because my understanding was that chronic care management cannot be built with TCM, but I have a lot of phone calls and a lot of coordination of care with like say home care, like a child nurse or PT or OT, when they go in that same month that they've just come out of the hospital. So initially I was thinking that it wasn't worth it to use TCM, was just bill high complexity and CCM rather than TCM. I was just wondering if there's an advantage to billing TCM rather than like 99350 and CCM, or maybe TCM can be billed together with CCM in the same month. Yeah. Thank you for clarifying that question. That helps a lot. TCM used to be bundled, but for Medicare purposes, commercial payers and Medicare Advantage should be following Medicare policies, TCM and CCM were unbundled, I believe it was 2019 or 2020. I think it was actually 2019. So yes, those technically, again, they're separate and distinct services. When you make that post-discharge visit, it would be a TCM essentially, whereas all of your time throughout the month, like you were describing, those are your CCM minutes. You just have to make sure you're not double dipping, right? Your TCM time, that interactive contact that you're having that phone call with, don't count that as CCM minutes, because that's TCM. So you just have to separate the two services. I will double check when we get to some of the other questions. I believe it would still pay more potentially than 99350 with a prolonged services might pay slightly more than the TCM. So you would want to just look at that. I have all the prices for those codes on that handout too. So just take a look at the codes and just make sure it makes sense. Yeah, but I was just wondering, is it to my advantage for quality that I have to include TCM? Yeah, there has been some research that shows that programs that have formal transitional care management programs reduce your admissions by 30%. If you're one thing you could Google is like the Naylor TCM model. I know there's a lot of research on kind of the quality that a TCM program could have. So I do think it would be an advantage. Whether you're billing for it or not, I think you would want to have some sort of structured approach to post-discharge visits would be my recommendation. OK, thank you. Thank you. OK, one of the questions was, is there a good EHR that helps with the HCC capture? I'm going to I'll take a stab at that one. I would say a lot of them have moved to trying to make them very visible when you go to make the diagnoses. You know, it might be bold. It might have the RAF score after it. They are going to vary. It's certainly worth looking at. And again, I would encourage you to reach out to HCCI and talk more with Brianna about some of the experience on maybe which system would be would be helpful. I would say from an organization that in the last five years has purchased an EHR and works with the vendor. It's not the most important thing, but it certainly is on the list of how of how that works. So I want to quick switch to some operational questions. We have a couple of pieces in here that have been sitting around for a while. Any tips for managing non-urgent after hours call in a patient friendly way, but also preserving your sanity? All you want to I feel like that's a great question for you to start. It's interesting that this question is raised. We again, as part of our burnout conversation or mitigation, I should say here at the practice, I actually have been able to pull all of our answering service in terms of the volume of calls and so on. And also what the messages are referring to a couple of things. So if you have the capability of doing that, I think it would be good for you to know for your practice and your clinicians on average, how many calls are you getting per night, per weekend and so on? Again, we want to separate feelings, not separate. We need to consider feelings and facts and not just go on either one alone. The other. So getting data. The other is encourage your patient, encourage your providers to have talking points, to have scripting. By that, I mean, you know, thank you for your call. But we, for example, scripting, you know, we do encourage you to be filled with medication during normal business hours and so on. So having set scripting for your providers so that we'll be all talking the same way, even though there are five different clinicians here. The third is repeated education. You know, hopefully with handouts, which we have printed now, every visit we give them. This is the policy about, you know, refills, appointments and so on. So through phone calls, through handouts, hopefully we can reduce some of the phone calls after our calls to my practice and so forth. And the final thing I encourage my providers is to have boundaries and say, you know, I'm so sorry. I'm so sorry. But, you know, can we talk about this tomorrow and then we can pick up the conversation? I know this is very important for you to discuss. But can we do this tomorrow when there is more time for us to get into more detailed conversation about this? So having some boundaries related to these calls hopefully will be helpful in terms of maintaining your sanity. I hope my comments are helpful. That's great. How do you handle phlebotomy needs? So, well, for our practice, you know, I've been drawing blood forever since I, you know, since for a long time. And I have medical assistants that travel with me and they draw blood as well. When they're really difficult blood draws or if I need an INR next week and there's no reason for me to go there just for an INR, we do contract with a, well, we don't contract. We use a phlebotomy service that that goes out and draw the blood and then pass the results to us. Fantastic. When we were talking about quality measures and kind of proving yourself and following it up with data, two good questions came in here around how do you get a place of death data? And I'm not sure if it means how do you individually capture it or how is it comparative, but maybe both those sides of that coin. And then how do you prove a PRN visit to prevent an ED? Right. So when you don't have the cost for it, how do you prove it? Tough ones. Yep. So I think so the advantage of the EHR and being part of a large health system, the majority of our patients that we take care of, the great majority of our patient is part of Northwestern. And when they go to the hospital, they go to a Northwestern hospital in the area. So anytime they're there, I get notified and I have access to the data. So we've been collecting death data here in terms of our practice when we're notified either by hospice or hospital or whatnot of their passing. We manually track the numbers in terms of where they are hospice, when did they go into hospice and what was the place of death. All that is to say it's labor intensive and it's not financially directly financially reimbursed. So, again, think about your practice. How much resource can resource can you devote to this particular set of data gathering? The same goes for ER visits, right? A tracking, like say, you know, I have to go make three ER visits or not ER visits, urgent visits this week. And I'm able to track within the health system of like, you know, did they end up going to the emergency room and so on. So, again, a little bit labor intensive in terms of tracking. But information can be very valuable to you, whether we're talking about ER diversion or aversion or whatever reduction or a place of death. So tracking data, get some staff to help you with that. That's great. Sean asked a question a long time ago and he's asked it in a couple of forums. I definitely want to get to it. Incredibly operational here. Is there an appetite for Bluetooth 12 lead ECGs in the home? He believes there's a need for this and found that not a lot of tech exists in this space, no disposables. Is there a perceived need or an actual need? If not, what Bluetooth devices is needed and not readily available? So support there would be great. Sure. Getting EKGs at home, very difficult, mainly because of very poor reimbursement from Medicare. Doesn't pay for gas, as one of the vendors said to me. So unless you bundled a, say, an echocardiogram with the EKG, he will not go out just to do the EKG alone. In my practice, I don't have a 12 lead. I use a Kardia, K-A-R-D-I-A 6L. It will give me a 6 lead EKG and you can visit the website and get that device. And there is a small reimbursement for that rhythm strip. But in terms of a Bluetooth 12 lead EKG, I'm not aware of that. But technology is always changing. As you know, POCUS is certainly has been talked about and that's point of care ultrasound. Sorry. So that could be a useful tool for us clinicians going to the home trying to address very complex and challenging patients. And POCUS may be an additional tool in the future for house call providers. But there is a learning curve related to its use and interpretation. Well, thank you very much. We have just a few minutes here. I want to just cover a couple of things we didn't cover. So there were a lot of very specific questions around codes that came in, around can we use this, how much do I bill for this, time specific. So we put a lot of those resources and they'll be on the education hub. And Brianna's email also went out on the chat. And so a great resource to continue to talk about coding and very specific coding questions you may have. There was a really good question that came in around staffing ratios and how we think about administrative and front end to back end staffing ratios. That's a much longer answer. And I think there are lots of different ways to do it. So we kind of didn't have time for that one. So I just wanted to throw a couple of those questions out there. They're not hanging chip pads in my mind. Certainly we've answered all of these questions before at HCCI and have the resources. So reach out to Brianna. I would also say that all of us will be teaching a basics and advanced course in December and we will be covering a lot of these things in detail. So I'm going to turn it over to Melissa to kind of talk about other resources here. But I wanted to mention those pieces before I wrap up. And I'm actually going to turn it over to Brianna. Oh, sorry, guys. So all these resources and saying how to contact us. So one of the great things about HCCI being a mission driven nonprofit and having some very dedicated grant funding is we're able to offer a lot of free resources. We're not a membership organization. You don't have to pay to access these. Our HCCI Intelligence Resource Center, you can find it on our website. It's completely free. The hotline is if you have questions, if you have specific questions we didn't get to today or if you're struggling with something in your practice, we learn from working with you and hearing from you and are here to provide resources and support. So you can call or you can email us. We do free bi-monthly webinars. We call them our HCCI Intelligence webinars. They're on both clinical and practice management or practice operations and leadership topics. And we always make the recordings and the handouts for those available on our website. You can see the whole library of the past webinars we've done as long as what's upcoming. We always dedicate time for what we call our virtual office hours. That's just so we can continue to engage with you and answer your questions at the end of each of those webinars. Whether their question is related to the topic or not, we always welcome those questions. And then we have a plethora and we continue to add more each year of what we call our tools and tip sheets. Those are some of those handouts you're going to be receiving for today's on the key metrics and the advanced coding. And we've also recently started doing blog posts, too, so you can find all that information on our website. And, you know, we're here to help you not reinvent the wheel and make things easier for you in your practice. So we thank you for being here with us today. And thank you to Paul and Brianna for speaking today and answering so many of our questions. Thank you to HCCI for holding this. Thank you definitely to the Academy for offering this as a pre-conference resource. I would say this in summary. This pre-conference is the start of finding your people. So welcome. We're happy you're home. HCCI is happy to be with you in your journey. We hope everyone has a wonderful two days and enjoys the Academy annual meeting. And we look forward to a lot more discussion in the coming two days and years. So thank you. Thank you, everyone. Bye.

EMR systems

value-based contracts

revenue cycle management

quality and performance measurement

patient engagement

burnout

efficient templates

voice recognition

billing and coding processes

regulations

care outcomes

shared decision-making

patient satisfaction

social determinants of health

continuous improvement