Good morning, everybody, and welcome to today's workshop. Before we get started, I'd like to go over a few items about today's event. We'd like to encourage your participation in today's workshop, so we will often unmute microphones. We would ask that you mute your microphone when you are not speaking. On the bottom of your screen, there is a chat button that you can use to open the chat window. You should also see the button called Reactions. Please select a reaction now, and everyone else should see it on your window. Speakers may ask you to give a thumbs up to ask if everyone understands a concept or is asking for input on a topic. We hope that you will also be active in the chat. We will grab information from the chat during the meeting to make sure all of your questions are answered by the end of this workshop. This workshop is also being recorded, so we will try to read and respond verbally to all questions so they can be captured and viewed later on demand. You will have the opportunity to submit questions to today's presenter by typing your questions into the chat box. We will also be unmuting you during some of our sessions and encourage your participation. If you have a question for the individual, please indicate that by typing their name or using the ampersand sign followed by their name. Again, we will collect these and address them before the end of the workshop. A couple of important announcements. We ask that you do not log out of Zoom during breaks and lunch, as we have set up Zoom breakouts, and it may affect your ability to join when you return. But please remember to mute your mic and turn your video off during breaks. I would now like to introduce you to Melissa Singleton, who will head us off for the day. Hi, everybody, and welcome to Advanced Applications of Home-Based Primary Care. I know we are running a few minutes early with our formal start. I just want to make sure maybe everybody can give me a thumbs up with the reactions if you are able to hear me okay, and if you are comfortable with all the Zoom controls. Thank you. Seeing lots of thumbs up, that's great. Does anybody have any immediate questions that you can either, you can unmute yourself and ask or use the chat box? No? Everybody's good. And I do want to encourage you to use the chat box throughout the day. Our faculty will be monitoring that. Send your chat to everyone, unless it's a technical issue, and then we can certainly direct you to the right person there in a few minutes. But that way, if you are putting your question or your comment out to everyone, then the faculty can respond in the chat, or we'll be able to capture that so that we can save it for a Q&A time later on. So before we get started, I do want to kind of just give you a little bit of introduction to some of your staff resources. Certainly, if you have any kind of question about your access to the workshop, the virtual workshop, or questions for, about the technology, Danielle Feinberg is going to be a great contact for you. And so you can look specifically for her name in the list. Danielle is our education coordinator. And Danielle, do you want to just say hi? Good morning, everyone. All right, great. Thank you. You can also send those to myself, Melissa Singleton. I'm chief learning officer for HCCI. And I do want to just thank you for making the time over these next two days to participate in this workshop. We hope that you find it valuable and you come away with some great ideas that you feel like you can implement immediately when you go back to your practice. So thanks for being here. I know we still got a few people popping in from the waiting room. So we will be getting started here in just a few minutes. I want to make sure everybody has a chance to get logged on. One other thing, you should have been able to retrieve in the HCCI Learning Hub your, the workbook that is a companion for the next two days. It has all of the handouts that the faculty will be referring to. And when those get referred to during the sessions, staff will be putting into the chat what page number you can find that on in your workbook. You'll also find copies of the slides in the HCCI Learning Hub. And as you see, we are recording this session. So we will make this recording as soon as possible in the Learning Hub as well. That does take a little bit of editing magic and compression and things that are outside of my scope, but I know it takes a little bit of time. So if you can just bear with us and know that if you have to miss a session, you should, you will be able to at a later date be able to go back and watch that session. But we strive to be very interactive here. And so we will be using some breakouts. We welcome lots of open discussion, not just in the chat, but at certain points. We'll invite you to unmute yourself, show your video, and engage directly with us and with the faculty here. So we've got about 10 minutes after the hour. Why don't I go ahead, and I'm going to start to go through some of these slides. And can you advance to the next slide, Danielle? All right. Well, welcome. I hope you feel welcomed. We can go on. All right. So our objectives for this workshop are numerous and diverse. But they really are meant to represent some of the more advanced level issues that you may see in your practice, not just clinically, but from a business operations standpoint, too. So and our workshop is designed for the entire team. So I know most of you here are clinical. But we do have some business operations folks as well. And so we strive to have opportunities to engage your needs throughout the workshop. But we're going to be talking about some advanced care and management strategies that we see in this patient population, including patients with dementia or where they may have acute or urgent issues in the home. We'll have a session on polypharmacy and medication management and discuss some approaches for deprescribing. And then we'll be talking about care coordination and transitions of care and how we can do that in the most optimal way for these patients and their families. We'll talk about managing difficult conversations with patients and family around advanced care planning, serious illness communication and prognostication. And you'll be treated later this afternoon to a role play with our faculty where they're going to kind of examine some of those strategies that you can use in a very difficult conversation. Can we go to the next slide? We spend a session talking about caregivers and the ways in which your team can best support caregivers in this very challenging patient population. And then there's a couple of sessions on billing opportunities and advanced coding, including using HCC scoring most effectively. And we also have a great session on looking at the various staffing models for home-based primary care and how you can improve workflows and efficiencies. And then tomorrow afternoon, we have a session with some breakouts on four different procedures that are commonly done in the home. We'll initially have an hour-long session on wound care and staging of pressure ulcers and how you can treat these wounds in the home confidently. But then we also go into some other procedures through video simulation with tracheostomy tube change, gastrostomy tube exchange, and wound care. And then we'll talk about wound care and then knee joint aspiration and injection. Next slide. All right, so we have a lot of learners on this workshop. And I know many of you participated in an earlier workshop that we had. But just in the interest of time, we wanted to get to know you a little bit through polling. So can I have—okay, thank you very much, Daniel. All right, so you should all see a poll on your screen right now. Can you please check what professional category—oh, no, now you should see it. Thank you. Just check which professional category you represent—physician, nurse practitioner, PA, and so on. I see our numbers going up, you've 17 out of 31 who voted 19. All right. Thank you. All right. I see. Yeah. Okay. Actually. So I see that we've got all three questions up. So in terms of, let's see, maybe a few more of you need to vote, 27, all right. Why don't we go ahead and at this point, can you publish that and pulling and publish? All right. So, wow, we've got a great contingent of nurse practitioners on this, on this call. So that's, that's great to see. We know that nurse practitioners have been responsible for in recent years, the greatest growth in making house calls. So we are so glad to see you here and investing time in trying to learn new strategies for, for doing this effectively. Thank you. And of course, we've got our physicians and PAs and RN, LPNs. We've got at least one practice manager administrator on the call and in an other, if you scroll through, we've got some good years of experience here. Most of you have been, have had about six to 10 years of experience in home-based medical care. And, you know, and then the next highest level is between one and five and some of you about 22% have been involved in home-based medical care just under a year. So welcome. You know, you're going to hear today about the challenges we face in the workforce shortage in this field. And so it's so essential that you are coming into a field where you are so needed and can make such a huge difference. So thank you. And then in terms of practice setting, we've got 59% of folks in independent solo or group practice and, and then value-based managed care organizations. We know there's a big contingent of you from Oak Street Health. So welcome. And all right, well, let's, we can go ahead and make the polls disappear there. And can you pull up the next part of that slide? All right. So this is the part where we want you to be interactive and I want you to everybody to pull up that chat box right now. And in the chat, I want you to think about, you know, I went over the workshop objectives. What is one thing that you absolutely need to get out of this workshop over the next two days? And put that in the chat. We are going to revisit those. We're going to make sure that our faculty keep those in mind over the next two days so that by the time we end tomorrow, you have felt like you got at least, at least that, but I really hope you get a lot more too out of it. So take that time right now and type in the chat what it is you would like to see, you would like to come away from this workshop. And I'm just going to read some of these. This is wonderful. So Barbara says time management. Dr. Shijia Kanesharel says building a successful program. Those are our friends in Florida who are starting home-based primary care at their hospice and palliative center. So that's great. Let's see. So Daniel says comfort in assessing the home, food and safety. That's right. You get such a wonderful perspective when you go into a patient's home to be able to really see what it is that they're dealing with. So thank you. Let's see. Jennifer says increased revenue with better marketing strategies and billing and claims knowledge. That's a huge part of this too. We want you to be financially sustainable. We want you to be able to grow and expand and take on more patients. We want you to be able to deliver that value-based care, you know, through having an interdisciplinary team to make sure that your patients' needs are attended to. So these are all great. Yeah, I mean, looking just for better health outcomes. Laura says optimizing visits and better understanding of telehealth opportunities. Yeah, that's telehealth, of course, has been a huge new learning curve, right, for so many of us this year, and there's been a lot of opportunities to use that effectively. We have a whole session on telemedicine that you'll be hearing tomorrow. Procedures in the home. Yes, absolutely. That's such a benefit for the patients and the families, of course. You can reduce calls to the ER by being able to take care of those challenges right there in the home, and we want you to feel very comfortable and confident in doing that. I do want to say a word about procedures in the home because this is something that HCCI has taught with, you know, in a hands-on, in-person way with some simulators, giving you an opportunity to actually touch the equipment and do it and practice those procedures over and over so that you can feel confident, and that is something that we expect to do again as soon as we get post-pandemic, but for now, we'll invite you to watch the close-up videos that our faculty filmed earlier this year. So why don't we, this has been wonderful. Thank you for sharing, and we'll make sure that we're attending to all of these objectives as we go through the next two days. Can we move on now to the next slide? All right. So I want to introduce our faculty. Next slide. All right. So we have a great treat for you over the next couple of days, and so let me just go through and let you know who we have as faculty. So first is Dr. Thomas Cornwell. He's the founder of Home Centered Care Institute and executive chairman, and Dr. Cornwell has made over 33,000 house calls to more than 4,000 patients and has mentored hundreds of medical students, residents, nurses, and physician assistants, and he brings his expertise in home-based primary care now to Village Medical as senior medical director, and Dr. Cornwell is also the founder of Home Care Physicians, which is a thriving practice in the suburbs of Chicago. Dr. Paul Chang is our senior medical and practice advisor at Home Centered Care Institute. In addition to his role at HCCI, he is the medical director at Home Care Physicians, and he has also, well, HCP, or Home Care Physicians, has made more than 117,000 house calls to home-limited patients since its founding in 1997, and Dr. Chang has personally made over 34,000 house calls to more than 3,000 patients during his 20-year career, and I know you'll appreciate learning from him, and in October of last year, Dr. Chang was awarded the House Call Doctor of the Year from the American Academy of Home Care Medicine, so we're so thrilled to have him here. Our next faculty is Michael J. Kingan, who is a geriatric nurse practitioner at Johns Hopkins Medical House Calls Program, or J-Home for short, and Michael has been a wonderful teacher for HCCI these last few years. He's a nurse for over 20 years and has worked in acute and subacute and community care settings. He was director in the Quality, Safety, and Education Division at the largest hospital in the nation's capital, and he is currently serving as a WOC NCB certification board as the incoming president 2020, and he practices in that Baltimore region. Can we go to the next slide? Dr. Ina Lee is director of clinical geriatrics at Christiana Care, and in her role, she provides leadership for geriatrics, supportive and palliative care, home health, and other post-acute initiatives, and she's made numerous contributions to the care of patients in Delaware, including developing a home visit program that provides care to over 800 homebound patients in the community, and she also has an appointment at Thomas Jefferson University as clinical associate professor for the Department of Family and Community Medicine, so welcome Dr. Lee. Our next faculty is Brianna Plensner. She's our practice improvement manager at HCCI, and Brianna is a certified coder since 2014 and a certified professional medical auditor as of 2018, and she was previously a practice manager or the practice manager at Home Care Physicians, but she is a great asset at HCCI. In fact, we'll be talking about HCCI's hotline that we offer to our network. It's through the HCC Intelligence Program, and Brianna is often the person at the other end of that hotline to answer your questions, and then finally, we have Amanda Tufano, who is chief executive officer of Genevieve in the Minneapolis-St. Paul area, and Amanda leads a team of over 115 people, including physicians, nurse practitioners, nurses, and social workers, and so 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, and Amanda, I know you're going to enjoy hearing from her from her perspective as an administrator, and today, I know she's doing a great talk on self-care and avoiding burnout, which I think as we've endured a very difficult year is something that you will all benefit from, so thank you all so much. We can go to the next slide then, and so we also do want to thank the John A. Hartford Foundation for supporting our education activities. They've been a great partner for us. Next slide. All right, and I'm giving the group four minutes extra here, because we'll go ahead and get started. Thank you all so much. I'm going to turn it over now to Amanda Tufano for our first session. Hey, thanks, Melissa. Can everybody hear me? All right, great. Well, thanks for having me. Thanks for having all of us. Lots of things to get started on. We'll kick it off with value-based care in a video this morning. I wanted to put in a couple of plugs. When you filled out your online or a couple of comments, when you filled out your online registration, you clicked how many years in health care and home-based medicine. I calculated all of those, and there were ranges like one to five years. On the low end, this group has 350 years of experience, and on the high end has 489 years of experience. As you think about the next two days, trust me, you get as much out of us and the faculty as you get out of each other. Everybody keeps saying use the chat. About 50 percent of you are returning from Essential Elements, so you know to use the chat. You know how helpful it is. For the newcomers, certainly use it. When a question is posed either by us or by you, anybody jump in and answer. We certainly don't have all the answers. We ask a lot of questions. Like I said, jump in and help us along because we all learn from each other. I think the whole idea of this course and all the work that HCCI does and the academy does is that we all are rising in a boat here when we can learn together. It's very exciting time. One plug, too. In the last week, on Tuesday, a request for applications came out for the National Home-Based Primary Care Learning Network. If you're not on the HCCI mail list serve, certainly sign up because you get lots of great information and lots of ways to keep connected. If you don't know about the National Home-Based Primary Care Learning Network, they're doing a request for application right now for 10 new home-based practices to join the existing 18 practices in this next year to be part of a learning network around quality initiatives. I don't know if maybe some of the faculty can help put in resources or if just make sure you get connected to that. We'll make sure that goes out on the wire here probably in the next two days. Those of you who are interested at all and starting to get connected into quality initiatives. It goes right into value-based care in our conversation today. Next slide. Today, we're going to discuss a shift towards home-based primary care in the U.S. and start talking about also how we think about fee-for-service into value. Tomorrow, we also open up with another value discussion. Tom has a video here where he's going to kick us off in the next slide. Really, how do we think about home-based medical practice as a value-add to the entire healthcare systems? How do we start to put quantifiable terms for this demographic? How do we set up a framework in the 4Ms? We're going to talk more about those. Then, as I believe both Melissa and Michelle mentioned, you have an individualized learning plan. Start filling those out as we go along. Okay, good. I'm sorry. I think I said that wrong. Put a note in there. If we can't get that information out, I know I'm probably putting people on the scramble to figure out how to get it out, but I think that'll be really exciting. Slide. Tom's going to kick us off with a video. It's about 17 minutes long. It has lots of great points in there. Certainly, make notes as you go along here because at the end of this video, Tom says, think about what you want to get out of the next two days. You guys have already written some stuff down, but you're going to come up with new goals as we go through this. You want to cue the video? Slide. My name is Dr. Tom Cornwell, and I'm the Executive Chairman of the Home Center Care Institute. I would like to welcome you to our presentation on Home-Based Primary Care equals Value-Based Care. Our learning objectives are to describe home-based primary care in the U.S. and explore the socioeconomic drivers and the business case for home-based primary care. We also want to demonstrate in quantifiable terms the value of home-based primary care and assess the role of new supportive payment models. We also want to discuss the alignment of home-based primary care with the geriatric five N's, which stands for what matters most, mind, mobility, medications, and multi-complexity. Slide. So what is home-based primary care? Home-based primary care brings providers, as well as modern technology, into the homes of mostly homebound patients in order to improve their quality of life, the lives of their caregivers, while reducing healthcare costs by enabling them to stay at home and avoid hospitals and nursing homes. Slide. A perfect storm of forces is spanning the sails of the modern house call movement. Just some of these include the aging population, advancing technology, increased home and community-based services being funded by the government, the value of house calls, and payment reform. Slide. The first force is the aging of society and the cost of increased chronic disease burden. The extremes on this graph are surprising. The least expensive 50% of the population consumes only 3% of total costs, but conversely, the top 5% consume 50% of costs at over $50,000 per patient, and the top 1% consume an astounding 23% of all the costs at an average cost of over $100,000 per patient. These high costs are caused by a fragmented healthcare system that is not set up to care for the sickest patients who are often homebound. Bringing home-based primary care to these patients has been shown to dramatically improve their quality of life and, again, the lives of their caregivers while reducing these healthcare costs. Slide. Advancing technology is another force. I like to say that house calls are principally high-touch primary care in the home, but we also have the high-tech capability to provide quality care in the home. Just some examples are smartphones that can do rhythm strips in seconds. They have numerous apps now that I can do vision testing, drug databases, decision support, and much more. Portable x-rays and ultrasounds can be done in the home. Labs can be done in the home, including point-of-care testing, as well as we can draw blood in the home and spit it down in the car in a centrifuge that's plugged into the lighter. Modern technology has enabled me to do more in the home than most primary care practices can do in their offices. Slide. The third force is increased funding of home and community-based services. Government funding of long-term support and services are made up of institutional care, nursing home care, and home and community-based services. This graph shows that back in 1983, 99% of all funding went to nursing home care, so your only option if you needed help was to go to a nursing home. Over the past two decades, there has been a remarkable shift in funding, where now over half of all the dollars goes to home and community-based services, and this enables nursing home-eligible individuals to remain in the community. These individuals create an increased demand for home-based primary care. Recently, there was a study in the Journal of the American Geriatric Society showing how integrating home-based primary care and home and community-based services delayed nursing home placement by 13 months. Slide. A major force has been the data that has come out showing the value of house calls, but before getting to the data, I wanted to share a couple stories illustrating just how valuable this care is. Our first story is about Amanda, who when I met her in June of 2017, was 34 years old, suffering from type 1 diabetes that she had had since she was a child. She had kidney failure and was on renal dialysis. She also had coronary artery disease and already had had four stents. She also suffered from chronic pain. In the four months before we saw her, she had been in the hospital 30% of the days. We were able to dramatically reduce that over the following seven months of 2017. In 2018, she was so much better that she did not spend one day in the hospital and sent me this wonderful picture of her at an art festival in the fall. In 2019, she did go back to the hospital because she had gotten so much better that she now qualified for a kidney transplant and she had a kidney and pancreas transplant, which cured her of her diabetes and removed her need for dialysis. What a joy to be able to give someone their life back like this. Elsa was born in Germany in 1921 and came to the United States after World War II. I was called out to see her to fill out nursing home paperwork. When I met her, I learned she was no longer able to get out to see her doctor because of her right foot being amputated and her left leg being amputated and had been in the hospital six times over the previous four months because of multiple chronic problems, including heart failure and diabetes and pressure sores. The patient shared with me that part of the reason she lost her legs was from frostbite caused by cold winters in a concentration camp. Through quality home-based primary care, we were able to quickly get her heart failure and diabetes under control. We ordered home health that she was previously not able to get because there was no doctor to sign orders. We got her a hospital bed and enabled her pressure sores to heal. She got so much better that we were able to arrange and paid for transportation to an outpatient rehabilitation center where she got new prostheses so she could actually walk again. Over the next eight years, she only went back to the hospital twice. Besides powerful stories, we also have compelling data, such as from the VA's Home-Based Primary Care Program, which is the largest home-based primary care program in the country. The program's director, Dr. Tom Eades, about 2005, was told to cut the program because they were spending $11,000 more per veteran sending doctors and nurse practitioners and physician assistants, mental health workers, and others into the home than usual care such as home health. Dr. Eades asked to have all the cost data reviewed, and they went back to 2002, and what they found, I think, even surprised Dr. Eades. They found an 87% reduction in nursing home use, 87%. They found a 63% reduction in hospital use, an overall savings of $9,000 per veteran. And when you multiply that by the 11,000 veterans in the program, it came out to $103 million savings by giving them $11,000 more care in the home, by giving them what they wanted. As a result of this data, the VA program has grown to over 30,000 veterans, and would serve even more were it not for the shortage of providers. This data also led to significant support for home-based primary care on Capitol Hill and at CMS. The last part of home-based primary care's value equation I would like to discuss is cost-effective quality end-of-life care. The last year of life is the most medically expensive, consuming 25% of all Medicare dollars. 70% of Americans say they would like to be at home at the end of life, but in 2009, only 33% died at home. Hospice use markedly increased over the past decade from 22% to 42%, and is now up to 50%. But also over the last decade, ICU stays in the last month of life increased to 29%, and hospitalizations in the last three months of life went up to 69%. End-of-life care at the house call program I founded, Northwestern Medicine's Home Care Physicians, is much different. A quarter of our patients die yearly, and over the past five years, 76% have died at home, 77% were on hospice, and the median house call length of stay that they were on our program was 1.3 years, and so we covered them during that costly last year of life and dramatically reduced hospitalizations. One side benefit to this is because we have so many patients pass away at home and less go to the hospital, we actually were able to help reduce our hospital's mortality rate, which is another selling point to health systems. The last force we will discuss, which is helping to expand home-based primary care, is payment reform, and we're going to start with fee-for-service. We have seen an increase in fee-for-service payments to support house calls. As you can see in the slide, over the past two decades, payments have doubled for both house calls as well as assisted living facilities, where now I am getting paid over $180 for a typical house call. Medicare has also created new payments that support house call providers, such as advanced care planning, chronic care management, transitional care management, and for prolonged services before or after a visit for things like reviewing medical records. A great example of value-based payment reform is the highly successful Independence at Home Medicare house call demonstration that began in 2012. The ongoing demonstration involves 14 experienced home-based primary care programs that care annually for over 10,000 medically complex patients with functional impairments. IEH is a shared savings program where the first 5% of savings goes to Medicare. Additional savings are split with 80% going to practices if they meet the quality indicators and the remaining 20% going to Medicare. IEH has been Medicare's most successful demonstration. It improves quality and patient satisfaction while reducing hospitalization and emergency department use. This has resulted in cost savings of over $100 million in the first five years, which came out to over $2,000 savings per beneficiary. Cost savings paid for the program and qualifying practices received a share of the savings. Since its launch, the three-year demonstration has been extended twice because of its success and interest in becoming a new Medicare program. The most impactful payment reform is the new value-based models. CMS has announced new value-based programs, such as the Primary Care First program, that would pay a per-member per-month fee for complex patient visits and would provide shared savings. There's also the possibility that home-based primary care programs could come together to participate in the direct contracting program, where currently you need to have 5,000 Medicare beneficiaries. These programs are rewarded from the cost savings they generate from the wonderful care they give in the home. The last thing I want to say is we are seeing venture capital come into this space to start home-based primary care and again take risk on these patients and share in the cost savings. Successful programs have also contracted with Medicare Advantage programs for per-member per-month payments on their costliest patients, as well as participate with them in shared savings that has helped increase revenue to their programs. With these forces creating a huge demand for home-based primary care, now we need the workforce. Over 2 million patients could benefit from home-based primary care, and this number is expected to double over the next 20 years. Only 15% are currently being served. Imagine if only 15% of oncology patients were being served. Currently, there are over 1,000 home-based oncology providers that make 500 or more visits, and their distribution can be seen on this map. What you can also see is that there are 13 states that do not have even one high-volume house-call provider. We need about 10,000 providers in order to meet the need of the 2 million patients that are homebound in this country. The Geriatric 5Ms is a framework for caring for complex patients. As you'll see, these Geriatric 5Ms align perfectly with the home-based primary care model. This is what we do every day. The first M is what matters most, and it is the one that matters most. We need to understand health goals and preferences of our patients. We need to help them consider prognosis and medical decision-making, take into account risks, burdens, benefits, their functional status, and quality of life. We need to make sure a person's goals and care preferences are reflected in their treatment plans, and most importantly, that they are honored. Finally, we have to help coordinate advanced care planning. The second M is mind and mentation. We need to help them maintain mental activity, help manage their dementia. We need to help treat and, most importantly, prevent delirium and work to evaluate and to treat depression. The next one, mobility. We need to help them maintain the ability to walk and improve their balance, improve their function. We need to help prevent falls and other types of common injuries, and we need to help create home environments that facilitate mobility, and nothing better than home-based primary care can do that because we are in the home to make that happen. Medications. We need to help reduce polypharmacy through deprescribing, and we need to help optimize medication for an older person's needs. The fifth M is multi-complexity. We need to help older adults manage a variety of health conditions. We need to assess their living conditions when they are impacted by age, health conditions, and social concerns. We need to optimize therapies and care plans. We need to choose therapies that optimize benefit, minimize harm, and enhance quality of life. And again, the most important M is what matters most to our patients. So what are some of the key takeaways? We have reviewed the converging forces that are creating a tremendous demand for home-based primary care. We have also seen the great value that comes with home-based primary care and how it is being rewarded by the new payment models. In order to meet the need and realize the value, though, we must expand the workforce, because if we don't, the vast majority of those patients who need home-based primary care won't get it. This is a really powerful video, huh? I was thinking as we do this, I certainly encourage people to, when you feel like it, show your face and ask questions, too, as we go along. So the chat function and the back and forth are great. Talk to me about, and this is kind of a setup for the HCCI staff, talk to me about how we can get that video. Can they log in and see that again and again to the learning platform at HCCI? Yeah, hi. So this will be part of the recording of this entire workshop. So yes, it will be something they can go back and view. Because what I'm saying, this is the one that you probably send to your boss or the health system. This is the video that starts to connect all those pieces together and really says, you know, here's the why we do this, and here's the start of the how that we do this. So you know there's the great depth of the how, and then here are the ways that we can start being supported by our community partners. So just, you know, as you think about how do I start to get people on board, whoever your partnerships might be, this is one of those really powerful videos that I think starts to connect the things that everybody cares about, the people story and the money, right? And then there's so many really important statistics in this video, the ones that really make that impact on you. You know, for me getting into geriatrics, you know, the two statistics that popped out for me were that in the last year of life, we spend a quarter of the entire health care, Medicare budget in the last year of life, and that the top one percent spend the 23 percent of the total cost of health care. It feels to me, and sometimes you hear like people falling off the cliff, that's the falling off the cliff, right? Every 80 percent of us are fine, right? 20 percent need more support, within the 20 percent there's a special five percent, and within that there's a special one percent who need this high touch. You know, and how many of you have stories just like Amanda and Elsa, right? You have these connections, and those are the pieces that start opening people's minds. So one thing I wanted to talk about, and because I know we have just a couple more minutes, because I have a few more slides, but is would anybody be willing to unmute and talk about this? You ask the patient their goals of care, what matters most to them, and you got back something you weren't expecting. You know, maybe you expected that, I wish I could walk to the fridge, I wish I could drive to my granddaughter's house, I just want to see so-and-so get married. But just for fun, if anybody had some really good ones, and I'd send, you know, because I'm non-clinical, I'd give you an employee one. We just onboarded a new employee, and her, like, thing she wanted more than anything, I thought, wow, she's being onboarded a pandemic, she never sees anybody, like, what is, she wanted the rights on her laptop unsecured so she could put up pictures of baby kittens, and that made the difference for her work. I mean, and it was something that was really bothering her. So, you know, those are the funny things, kind of, that we hear that, like, well, if I didn't ask, I wouldn't have known that. So, anybody willing to unmute, just maybe one or two? You know, Amanda, as we're waiting, can you hear me, Amanda? It's Tom. Yeah, yeah, I can. That Amanda patient, just to let you know, one of the questions I ask all my patients is, tell me something you're proud of. And this patient had, because she was going to the hospital, it was oftentimes for pain, she wanted IV opioids, and she was kind of labeled a drug seeker. When I asked her, tell me something you're proud of, at first, she kind of said, oh, I don't like to talk about that. But her husband kind of, you know, said, oh, come on, honey, tell him. She had been a seven-time national US karate champion. She won two bronzes and a silver in the Pan Am Games and came in seventh internationally. And so I was able to treat her as a seven-time national champion representing our country, not as a drug seeker. You know, and what a difference, you know, what a difference. And so I'll just stop there, and hopefully others might have a little tidbit to let us know. Yeah, I got some shivers. I bet some of you guys did too. I mean, just to spend the time in their home and treat people as people, and you're trying to get to know them and focus on what they want. Any fun stories? Hey, Amanda, it's Paul Chang. I have a fun story. Hey, it's about a fun story about the goals of care. You know, what matters most, what Tom talked about in the video. Years ago, I was talking to a patient, an elderly patient about, you know, what his goals are. And this is, okay, you'll get it in a little bit. One of his goals, even though he was older and so on, one of his goal was to see the Cubs win the World Series. Now this is before the Cubs actually won the World Series, not in the series, not having won for like over a hundred years. So that was really important to him. So it was interesting. So how his goals changed after the Cubs did win the World Series. From a one of, you know, wanting to live, live, live, and see the Cubs win, to one that he was at peace and he was ready to go. So that's interesting. It was a fun story that I remember. Yeah, certainly fun. But any, we'll do one more maybe, if anyone has anyone want to share. I'll share my story. This is Ed Aronke. I actually just saw a patient yesterday who had been a teacher's assistant for many years in the elementary school. And she just moved to Alaska about five years ago. And one of the things that she's been wanting to do is going back to helping those children. And right now with the pandemic, and she was pretty sick for some time, she hasn't been able to go out and do that. So the family and I were trying to see what we can do with technology to see if there's anything that she can do to help some of those students online. So we'll see how that goes. Oh, that's awesome. Thanks for sharing Ed Aronke. Cool, super cool. Well, you know, I'm sure you all have stories like that and we could spend all day, you know, swimming in them. So that's really fun too. So thanks for indulging me there. As we look at this slide here, Tom outlined it in the video, the four M's in the care of older adults. This is a collaboration between the John A. Hartford Foundation and the IHI. And he did a great job of really talking about mind, mobility, medications, and the most important of what matters most. They added the fifth M of multi-complexity. And sometimes you hear it used and sometimes you don't. Does anybody use this framework as you think about your patient population? Today, you can put in the chat or jump in. People using this? The formal kind of more structure of this, and you've heard of this, or is this kind of a new idea? Hi, this is Odessa. So I do use this framework, especially I think it's very helpful actually to introduce people to the concept of geriatric and home-based care. When I work with students or I train UNPs who may be new to it, I think it simplifies it, but in a very meaningful way. So I do think it's a very useful concept. Yeah, I completely agree. I think, and for me, for those who haven't used it, so Odessa, thanks for jumping in, because for those who haven't used it, what it does is it takes what you're already doing and it just kind of puts it in buckets. And then it gives you a framework to think about, did I make sure I kind of checked everything? And did I, you know, what does that look like? And the way I think of the fifth M, if you click to the next slide, please, I think of it really as, you know, almost a header, if you will, a title to the four M's is multi-complexity, right? Because how many times are you thinking, you know, this is a PDSA or PDSC if you, PD, you know, plan, do, check, adjust, and you just kind of keep going in that. And with these patients, there's never the one thing. There's the many things. And we try this, we try that. And this multi-complexity, again, it allows a framework, again, as a title framework to try things within our four M's. So we'll keep talking about this. I know HCCI is doing a lot of work on the four M's to continue to bring it to us as a framework. It's certainly in geriatrics, something that I think is making a big splash and will continue to. And I love your example, Odessa, as using it a way to train people in. You know, because we haven't thought of, you know, a lot of people coming out of residency or even, you know, long-time clinicians who haven't done this type of multi-complex, even in home-based work, really haven't thought about tying all these things all together all the time. So my final slide here is key takeaways. So as we set the stage for the next two days, due to the number of all of these industry forces coming together, we are positioning it to you. You're here because you believe it. Is home-based, you know, primary care is the future. It's poised in the perfect spot to grow. It connects the high quality care, the high touch patient experience with the most, you know, expensive patients who are getting not the kind of care that they really need. And it creates that value there. And that value adds tremendous value to not just an individual patient's life, but to the total cost of healthcare for what we're trying to do and for our community that we live in. And I think, you know, in closing, it really create like these new payment models, and we'll talk more about them tomorrow. And I'd love to jump in. So as you start thinking about it, you know, what are some of the value-based things you guys are doing? They start to create the sustainability. So Tom points out in the video, the fee for service has gone up, but the second slide to that was, and now we're starting to see more and more things, not just fee for service that are starting to put more money into this. So that's an exciting time too. Final slide. You know, we keep talking about it. Fill out your individualized HCCI learning plan. And then I think we're going on to the next one with three minutes to spare. So I'm not doing too bad on timing today, which is a huge feat for me. Okay, great. Let me pull up my slides too. I'm turning it over to my colleague, Brianna, to open us up and I'll talk to you in a few minutes. Is that fair, Brianna, are you on? That sounds good to me. Good morning, everyone. Thanks for being here. So, and many of you mentioned this in the chat too. I mean, there's so much that you do, but it's also really important to be efficient. So we're going to talk a little bit about workflow efficiencies and how you can really maximize using different roles on your team. So if we start out really just kind of framing this conversation on the next slide, you have to think about the different roles and functions that you're going to need. Oh, I'm sorry, I got ahead of myself. So I like to put these in buckets. Let's think about your front office. And what I mean by front office is that non-clinical, maybe your administrative support staff, your practice management team, those that are going to be helping you with revenue cycle billing, but also just maybe even answering phones, processing all of the paperwork and, you know, getting that communications out when they're needed, you know, medical record requests, all of those types of things, processing their intake paperwork. And I refer to back office for this talk. What I mean by back office is generally that clinical support staff. So who's helping reduce provider burden, who's, you know, doing refill requests, prior authorizations, patient and caregiver education, and really supporting those providers. So front office, think of administrative, those kind of non-clinical folks. When we refer to back office, let's think of our clinical support team. You also want to think about the different types of professionals. One thing that, you know, we've learned from home-based care is there's no one size fits all, and you can really utilize a lot of different types of relationships and team members to accomplish your goals. But it's important to identify the right people and the right processes and roles, and then consider how technology can improve your operational workflow. Next slide, please. So this triangle really just kind of, you know, starting from the bottom up and not necessarily in the order, but what roles and functions do you need to be successful? And this is going to look different if you're a small practice that's just starting out. That's generally where you're going to have fewer staff that's going to have to wear many hats. So you need to think strategically when you're hiring, right? Medical assistants, for example, can be a great, maybe initial hire if you're newer or smaller, because they still have some clinical skill and can support you, but they also can be utilized to do things like scheduling and, you know, maybe answering phones and some of those administrative things and working that into their role. But if we start at the bottom, let's think about your clinical staff. First and foremost, you all on this call, many of you are clinical and providers, there would be no care without you, but you have to, you know, realize that taking your time when you're onboarding, especially new people to your team, really making sure it's the right fit because it's very expensive to hire and then have people not work out, especially with the credentialing fees and things like that, this isn't for everyone. You know, I was just talking to someone the other day that, you know, after their first ride along with someone that was interested in their training, you know, they were like, you know, this isn't for me. You know, these patients, they're just a little too much, it wasn't what I was expecting. So really make sure you're setting expectations, even with your providers and telling them what they're getting into, especially if they are showing interest that they're new to this space. And then also don't try and do this alone. A lot of the times when I hear people just starting out, you know, you may be doing everything at once, but, you know, could you afford even part-time help or someone to reduce that burden on you or contract out when you can or outsource functions? So really think about that and what your clinical team looks like, whether it's gonna be, you know, nurse practitioners, physicians, are you gonna hire an MA, an LPN or an LVN, depending on your state? Do you have that ability to hire an RN that can have that higher scope of practice? Think about those things. We move on to practice management. I'm gonna open this up to that broader front office term too. Who's gonna be your nine to five person or whatever your hours of operations? You know, who's gonna answer that phone and make sure messages are directed appropriately? We're gonna talk more about intake, but who's processing all that new patient paperwork and getting those visits scheduled and helping you plan your day? Thinking about appointment confirmation, all of those types of functions. And then social services, the top of this triangle, don't let the smaller kind of display of it fool you. We know that these patients have just as many complex non-medical, psychosocial related issues that you have to address that are just as important as their medical. So you don't necessarily have to employ, you know, if you're just starting out, you probably can't afford a social worker right away, but can you work with your local area on aging or senior services, or, you know, if they're active with home health or other areas where you can refer out to get that help? There's a lot of opportunity for innovation and partnerships that you can do in your community. But I would encourage you to, if you are able to hire, you know, depending on your state, I mean, if you hire a licensed clinical social worker, there are some, you know, psychotherapy billable codes and these even newer online digital E&M and services that they're letting licensed professional, licensed clinical social workers bill and things like that. So hire strategically and think about how you're gonna use them. And then not to forget that little left-hand box, you need other specialists and other providers that can care for your patients. Home podiatry is a big one. You know, do you have that in your area? Can you find out, you know, what reliable home health and hospice agencies you have, not just one, you know, who are you gonna work with? Who are your partners? Those could be great referral services too to help you build your practice. Sometimes you can find home optometrists or dental providers. Again, this is gonna be really region specific. So you really have to take that time to do that resource inventory and figure out where you're gonna need to be successful. So before we move on, again, I think just the power of learning from each other, I'd encourage you to use the chat. If there's a role or a type of kind of professional or function that you found really successful for your practice, I'd love for people to be able to learn from each other and just hear what your experiences are. So go ahead and put that in the chat if you'd like to share. Next slide, please. So intake, you know, it might seem kind of funny that we're bringing it down to this point, but this is really kind of, you know, start your practice and make it, break it with what kind of processes you have. You know, first and foremost, talking about from a revenue cycle standpoint, if you're not getting active and correct insurance information, when you first enroll a patient, that should be verified before you ever go to the home. And I would push it even further and say it should be verified before every time you see the patient. Almost every EHR has what's called a real-time eligibility function where you can actually verify insurance within the EHR. You can also, you know, use online paid subscriptions like OneSource or things like that. You know, Medicare Advantage is very confusing to seniors and their families. They're, you know, not gonna understand their plans or if they happen to have one that's an HMO that has to be assigned and things like that. So really think about that. But taking it even further than that, whatever information do you need to know on intake? If you go to HCCI's website, we have our HCC Intelligence Resource Center and tools and tip sheets with various sample forms that you can utilize and modify for your own purposes. And we'll make sure we put that link in the chat for you all too. But, you know, what kind of medical history do you want? What kind of questions do you need to know in advance? And then if you're gonna kind of, that formal questionnaire, what are you asking whoever's making that first phone call when you get that referral back to that patient? Think about clinical information. Think about clinical information too. You know, when was the last time they were hospital? Do you have at least the last visit note or an up-to-date medication list for your patients? You know, do they have DME needs? Sometimes even just asking too when you're confirming that appointment, you know, what's the primary concern or reason for your visit that you want us to be aware of? You usually get two ends of the spectrum. People that will tell you anything and everything right off the bat, or sometimes it takes that prompting when you're asking on intake. And then all of a sudden you learn that a patient's had recent falls lately and all of a sudden this visit needs to be prioritized and moved up. So think about that intake process. I'd encourage you to build that into your EHR if you can. Even, you know, macro or smart phrase, or if you're using kind of a form, you can do it that way too. But use your technology if you have it. And then also think about, you know, things you need to know when scheduling. You know, we'll talk a little bit more about scheduling later, but there's things you need to know in advance, right? If they have special requests, if their daughter needs to be there if they're not, you know, bed bound and needs to stay in through the door, all of those things should be recorded, whether it's a flag you build in your EHR or somewhere central in a record that you're able to find that information. So it's really important to get all the information up front, make sure it's recorded in your EHR so you have it to go back to. And then finally, I would say the last part of intake that you really wanna make sure you're spending time on is explanation of services. This is your opportunity to set expectations. You know, these patients, especially if they're transferring from an outpatient PCP they may have been with from 20 years, tell them, you know, this is how after hours work. This is how I'm gonna come see you. This is how, you know, we'll notify you about your appointments and times. This is how our services works. You know, here's who our team is. Here's how you reach us. You know, we're gonna partner with you, but really take that time explaining if you do have that staff to do it for you, because it's gonna save your providers times when they're in the home. Not that they're not gonna, you know, go over things with the patient when they're face to face as well, but really, you know, use that opportunity to explain services, answer their questions. It can be really unsettling for some of these patients switching to a new provider. So just recognizing that and taking the time. And we can move on to the next slide. So triage, and this is, you know, if you have clinical support staff, the goal is always gonna be to remove the, or to reduce, excuse me, the number of touches, if you will, that your providers have to do for an encounter. And so what I mean by that is, it's every question or message that comes into your office does always have to go to a provider without someone else getting information or doing some sort of action that's gonna slow down clinical care. If you do have RNs, you can build out really helpful triage protocols. I think sometimes when people hear your triage protocols, depending on your experience too, these don't have to be the really extensive, disease-specific, hospital-based protocols. Thinking about things like, if you have an RN, you know, when a patient calls in with urinary symptoms, you know, do you want them to go ahead and start placing those orders and then send it to a provider to review and sign off on for UA and culture? Or what about simple wound care orders or continuation of home health and hospice? You know, things that you can, within their scope and their license and state considerations, really act on, you know, even medication refills. Are you gonna ask your staff to, non-controlled substances are always 12-month refills or six-month refills? But thinking about those things and documenting those processes is really gonna help, again, reduce that provider burden and just let your team work to the top of their license and help your patients get what they need quicker and more efficient. Amanda, jump in too, if you have anything to add here at any time. You know what, I was just writing an email to Ada. She asked a question about, you know, will the social worker build for his or her services or does he or she need to be on the payroll and what are some of the codes? And so you can fill in some of this too because I don't have the full answer, but I was, you know, my typing answer that I was doing is you can certainly have a contracted provider, social worker, nurse, that if there is some collections piece that you can put through your own collections, your own NPI and tax ID numbers. So you can certainly have that arrangement where you do the collections, again, contractually and they're not an employee. When you think about employees, so this, again, is backing up just a little bit, but when you think about employees, you need to check with your labor laws because they're starting to crack down on how people use contractors. So if you're like, I'm just using someone severely part-time, but otherwise they would do what any normal employee would do, you probably need to employ them. You know, just at a very, very part-time basis. And so there's just that contractor, you know, how you use contractors, where you use contractors, are they coming in for a specialty period of time and how you're gonna use them? And then from, can you bill for social worker? You know, we've been doing some research on billing for some behavioral health. And I think there's a licensure in which you could do some of that, but we don't do it. So I defer to Brianne and others on social work billing. And maybe that's something you'll get into coding or we could punt to your coding, talk to if you want, so. Yeah, no, we can talk a little bit tonight. So the tricky part with it is it's really state by state. So from a federal standpoint, Medicare licensed clinical social workers can bill for certain services. Very select, you know, psycho, sorry, not psychosocial, the psychotherapy codes. Also some of the non-physician practitioner codes for like online digital E&M or virtual check-ins, which could be phone calls, things like that. So it is limited, but you know, think about what kind of social worker you wanna hire. Are you gonna be asking them if you're employing them to go out and do home visits, then you need to make sure they have the right licensure. So I can't give you all of our answer federally, yes, but it depends on the state. Like, I think it's New York, that's pretty limited still with social workers, but like Chicago, they can bill, you know, in other areas. So it really is state specific, but that's a great point. And, you know, whether you employ them or you partner with them, they're still an important part of the team. If you're part of a larger organization too, you know, do you have other departments that their social workers have bandwidth to support some of your patients? You know, you could think about those workflows and what you might be able to do there. So thanks, Amanda. Feel free to jump into, I'm not really monitoring the chat all that well. So thank you, nice question. So kind of thinking on, you've done all that intake, right? You've got the information that you've needed. You've got those new patient forms. You've thought about their communication choices and things like that. What do you do before the visit? If you're caring for patients in an assisted living or even a group home or kind of a senior building, there's a lot of coordination that should go on because you don't want them to be at lunch or suddenly change rooms and your provider shows up and, you know, then they have to spend time finding the patient. So we always stress the importance of calling ahead for appointment confirmations, but with facilities, you should really be, you know, connecting with the DLN. I would give you two strategies. You could either, you know, send a fax the day before with here's all the patients we're seeing, what times we'll be there, you know, ask them to respond and just confirm receipt or if you can trust them and build that relationship, that's one way. Or you could make a call and just go over and just go over with the, you know, nurse on duty or someone that you have a relationship with. What that might help too is the last minute add-ons. It's generally helpful if you say, oh, you know what? I know Mrs. Smith isn't scheduled today or we just got this new admit that we'd really like you to see. It gives you a little bit more time to adjust schedules and not throw off your provider's day on the day of. And they do move around a lot. I used to always stress to our staff, verify room numbers. I want that every single appointment. I don't care if they laugh at you. Even private residents, we would confirm the patient's home address because we were part of a larger health system where our addresses would be changed sometimes. So addresses and room numbers, you're confirming that ahead of time. And then you want to make sure you're keeping track of what patients you have at what facilities, who's active at what. Some EHRs you can use patient list features to do that or you might, you know, have some sort of a manual spreadsheet if you really have to go that route to start, but use your technology. There's usually always a solution. You just have to be pesky enough to bother those EHR folks and those customer service reps and what you need. And when you're calling for the home visits, I know some providers that prefer to, you know, call on their way even, but again, you can have your staff doing this the day before or the day prior to, you know, ask them to have all their medication bottles out. Again, efficiency in the home. Do they need to have someone there? Some practices ask to have a family member or primary caregiver there during the first visit. So what are those things that you need to ask? And then again, just confirming their primary needs, you know, all of a sudden, we're going to talk about procedures later on tomorrow, but if, you know, if their G-tube is having an issue, do they have a replacement at home if they're asking you to change that? You know, are there extra wound care supplies that you need to bring? Because the patient has a bed sore that you're going to be treating. So thinking about those things ahead of time, both from your administrative, those front office staff, and then also for your clinical providers reviewing their schedules and their patient needs in advance. So you make sure you show up prepared. We can go on. So scheduling. If you attend the essential elements, you heard me talk a little bit about this too, but you really just can't stress the importance enough. Your providers need to be face-to-face with patients, or you as the provider, providing clinical care and doing what they need best. Not spending hours and hours there and driving or having to backtrack to accommodate a, you know, an acute visit or things like that. So know your zones. What I mean by zones is if you're just starting out, what zip codes or what territories or mileage or radius are you going to travel to and where are you not going to travel to? And, you know, furthermore, plan all of your future visits. So know generally what areas you're going to be on and what days, and always have a tentative future appointment scheduled so things are already kind of being set up and grouped for you ahead of time. And know your ideal kind of drive radius that you want to consider. You know, how much is really reasonable, especially if you're in like a city area, in downtown Chicago, for instance, you might have to take into account traffic or different kind of construction, even on routes and things like that, that you might not have to in more of a rural area. If you are in more of a rural area, you know, that's going to affect how many patients you can see per day. Are you going to mix some telehealth in there to try and be efficient? Think about strategies that you can use. And when we say scheduling guides, and that's that plan. So what providers, what areas, what are some of their personal preferences and things like that that you need to keep in mind. And again, just monitor and review from effectiveness. We can go on. The other piece of scheduling is route planning. So try and never tell your patient you're going to be there at a set exact time. Give them a window of time. Think about where providers you're starting and ending your day. How much travel time do you need? Amanda mentioned, if you have an employee, thinking about labor laws too, do they need breaks? You know, are you building that into your schedule and making sure you have time to address messages to your employees? And then finally, you know, and making sure you have time to address messages throughout the day. Next slide. So use staff if you have them, otherwise just at least create a general scheduling plan. You know, what's an approximate timeframe, either AM or PM or two hour windows typically work well. You know, how far in advance are you going to notify them? I wouldn't recommend calling patients or telling them an appointment date at the least amount of time a week in advance. So you have flexibility to change your schedule and add on and adjust from there. And also for memory's sake with these patients, define how many visits per day is your target. So your staff knows if there's cancellations to add on or if there's open slots for acute visits, things like that. But make sure you're, you know, it's sometimes like Tetris and realizing how much time that takes too. I used to say our staff had to be good negotiators. If somebody has to be seen at eight or nine in the morning and they're not going to like it, but are there really barriers to what time they can be seen allowing time for those conversations and just explaining that, you know, in order to come to your home and see you geographically, this is our process and this is why. And then making sure you have those kind of special considerations saved in your EHR when you can accommodate them. And then Brianna, a question in the chat is, you know, how many patients a day do people generally see? So maybe, I know we had a slide at essential, maybe you could kind of walk through that a couple of- Yeah, so that's definitely one of those kind of hot button questions. I think it depends on a lot of factors. So if you have a rural geography, you know, what type of visits, you know, new patients are you going to consider that kind of queue or if you're doing a lot of transitional care visits. On average, what we've seen nationally is eight to 10 visits per day is pretty high performing productivity that may be more reasonable too if you have a medical assistant or somebody traveling with you. You know, rural geographies are people that are really doing everything theirself. They usually see closer to five to seven. But if you're under fee for service, I would say you should at least be striving for five visits a day. Moving on, sorry. So here's some technology resources. If you were at essentials, you know, I talked a little bit about these too. You know, if you have less staff, sometimes having a software like CareLink that has practice management and scheduling and route planning and visit frequency alerts and things like that could save time. Road Warrior, if you're by yourself, is a free app. You can download it. It's just for route planning. You could also sign a Google BAA, that's HIPAA certified with your Google business accounts to create your own custom map and color code visits. Or you could simply, you know, be asking your staff to use Bing Maps. You know, two addresses that are technically in different towns could be next door to each other. So that's when using technology and really thinking about driving routes is gonna be important. Next slide. I'm gonna turn it back to Amanda. Okay, thanks. I'll take the next slide too here. So EHR maximization, right? Now, you know, I think actually someone just put in the chat that, you know, the charting is killing me. So we have a couple of thoughts on that. You know, really, so if you're an independent practice or check in on you on how you're using your EHR, spend some time, put aside some time just to say, am I being the most efficient that I could be? If you're in a practice, then the sentence really comes into play. Evaluate how your providers are using your EHR. So what we often do is we are like, here's how you're gonna use it. Here's your regular workflow. You train it once, maybe you train it twice and you feel like you're good to go. But what happens is over time, we develop these bad habits and shortcuts that make us inefficient. Or new things come out and we don't roll it out in a timely way to make sure we can kind of keep up with all the things that they're trying to fix on the backend, you know? So include, you know, coding tips, templates, examples, new software updates, you know, go elbow to elbow with someone. Any software or hardware bugs that may appear or any future product launches, make sure you and your providers are up to speed on that. That can really save you a lot of time. From, slide. Now, from an EHR template standpoint, many of us have developed templates within this. Even if there's a basic level of new, you know, established patient, you know, maybe an injection or procedure template that you might do. There's certainly an acceptable form of documentation. This is a way you should think about it. You know, really think about creating, you know, any phrases for documentation, any time and counseling statements, med rec statements. As you think about some of the templates you might want, an annual wellness visit, you know, that is a little bit different than just an established patient. A new patient visit. As you think about pulse or advanced care planning, that might be a separate template. Chronic care management consents, that's going to be another piece. All of these, you don't have to make up yourself. You know, now you have a cohort of 45 where we can bounce ideas off of each other. And you could contact HCCI for more examples. DME requirements. You know, how are you going to build your note? Now, what we then do is we sometimes take templates a little bit too far. And Brianna would definitely speak to this. We don't want to do cloning. So as we think about, we're going to build a template. Great. We're going to use the template. Great. It's super efficient. We don't want to then take that template and every time when we go see Bob, we use the exact, we just copy the note forward and we change one or two words. That really is from a Medicare fraud standpoint, not what we want to see. So how do you create the template that allows for ease, but allows for personalization of each situation and patient visit as you can? So is that fair to say, Brianna, did I misstate anything on cloning or our risks here? No, absolutely. Yeah. So cloning, the formal definition is anything that looks exactly the same or very similar to previous entries. So really focusing on what was unique with that patient on that date of service, not, you know, the problem with cloning that I've seen too is you won't accidentally realize that you're carrying things over and then your notes starts to conflict each other. For example, I was auditing a note the other day where they generally clone their HPI. Well, their HPI started telling me there was no bed sores or anything, but the whole visit was focused on wounds and sores. So you really do have to watch that. Absolutely. You know, and again, one more comment on just EHRs is you think about templates and who you're going to use and how you got it set up. You know, many of you may use big systems, McKesson, Epic, you know, even Athena. You know, if you're going with a smaller, a mid-sized group, you have some more ability. And even at the bigger side, you know, to start getting involved in what they're rolling out. You know, are there ways you can partner on the front end, even if it's just, can I join a group chat lister that they post online? And so I can see other people's problems and then other people's solutions to those. And often, you know, the squeaky wheel gets the grease. So if you're part of the person putting in the complaint ticket of this is not working well, you know, don't stop doing that because of the, oh, it never changes with an EHR. Do do those things because then you can get some good, you know, it may take time, but you can get some good results back. Slide. Oh boy. So to be efficient, I mean, really the supply ordering, this is one of those that is, you know, I have really, Brianna asked me this week, you know, what are other ideas you have? You know, I really think about it a couple of different ways. You either go direct to a supply ordering group. You know, if you are, you know, a small or medium-sized practice, you can join together to order, you know, maybe in an informal way, you can join together. If you're a large organization, you can maybe kind of bump out or siphon off some of the materials for yourself, or you can join a group purchasing organization, a GPL, just to get smaller quantities. Because really the challenge here is to make sure you get smaller quantities so things don't expire, things are still relevant. You're not stuck with, you know, a million Band-Aids, you know, when you only need a thousand. So how do you think about that? Does anybody else have any ideas on supply ordering kind of outside of those four areas? Yeah, we share supplies with our visiting nursing department. That's, Michael, that's great, that's very helpful. Yep, yeah, I mean, and if there is some sort of way you can kind of compensate, but sometimes, and I always say this, I'm a big negotiator, and you'll hear me talk more about value contracting stuff next, you know, go, you don't have to go in with, say, I'll pay you anything for stuff. You can go in and say, you know, are there kind of some exchanges we can do? And so I've certainly taught this class where people are like, oh, I get, you know, I get the Band-Aids and the little stuff. I get all that from the nursing home because I also do XYZ, right, when they need me. I do this, and it's just kind of a quick pro quo there. So, you know, think about those things before you're trying to, you know, give up, sell the house for things. All right, slide. Okay, from an inventory, right? How do we then optimize? We get the supplies, and how do we optimize it? So really, you know, from a supply inventory and calibration of equipment, you know, create a system that allows providers to stop by a home base, and even if it's your own house, but, you know, like, you know, functionally, what are the orders in which we need things? How do we restock supplies and know when something is lower? And so who's the point person for monitoring the inventory and understanding regular intervals? I can say during COVID times, we've had a challenge to try to say how, like, and understand how much do we have? Usually that's a pretty easy fixed point, but then how quickly are we utilizing it? How quickly are we utilizing surgical masks in 95 so we can understand when we need to get ahead of ordering? So it can kind of be a challenge, but even if you just start marking it down on a piece of paper, you know, I really say, just put a sign up and say, you know, when I'm checking stuff out and at what quantity, and then do that for a week, a month, and take really that experience and try to put it into an inventory experience of when you're going to order so things don't get too low, really as you, you know, adjust our PAR levels here. You know, and then, you know, make sure you set up a process that has the staff and the provider both remaining really productive. You hate for when, oh, I'm out, I'm in the middle of my day and I'm out of some supply. So how do we, is it we refill every week, every, you know, day, what does that look like to make sure that you have all the right pulled supplies together and you have your bag filled out as you head out into Saving Lives? So any other things? I'll try to look at the, maybe Breanne, if you could check the chat on any of the inventory things, if people are bumping in there. Yeah, just to share, there are PPE calculators that's available as well, excuse me, that can calculate your burn rate. Yeah, that's great. You know, I'll tell you, I'll tell you the funniest story. We got, I know I have one minute here, so I know I can do it, but from a PPE usage standpoint, everybody's been trying to get those N95s. We have not been able to get a ton. We were one of the groups going to the hardware stores in all these little towns in outstate Minnesota trying to get them. And no lie, like We have been begging and borrowing and stealing these N95s. And no lie, we got 900 duck-billed N95s in the last week. And I was like, are we even going to use them all? How is this going to work? And it was like, yes, we're going to use them. But we just you know, like there's some of those pieces too when you're like, I don't know how much I can get. So I'm going to order everything and then you find yourself with 900. So you know, what do you do? I also I've been told I can't share them. I'm just kidding. But I wanted to share that too is you know, where is your inventory partner, your supplier and how what kind of quantity they have and what they can give you and when how far backordered are they? Next slide. Okay, on community partnerships. So really, as we think about community partnerships, are there things in your practice that can be outsourced? And this is where I get to kind of this idea of negotiation. Are you spending time chasing down resources? Are there are you doing, you know, drawing your own blood contact, contact outside vendors, you know, figure out what the value is, if we're going to exchange services, if you're contacting the same vendor twice a week for every week for half the year, there's some new partnership that maybe we can do, we can make things more efficient, we can partner in a new way, maybe there's a gain that we can both benefit from. And what we recommend you doing is create a community comprehensive resource cheat sheet. So you always know who to go to. And we do this the most successfully in our care management department, we have a long list of here's who to go to. And for what the phone numbers, the NPIs, the information of what you can get, and any changing information, hey, they no longer do x, y, z, hey, they only do this. You can contact the Division of Aging in your city to see if there's any other, you know, potential for partnership grants, personnel, people that we can blend together to try to, to, again, if we can do some of those things for free, but how do we kind of blend our general missions together and our work together to move an idea forward? Would you add anything else, Sabrina, about the drawing of your blood and the phlebotomist? Certainly, I know this is a big area for home based primary care. Yeah, I mean, just know your resources, mobile phlebotomy, if they're active with home health, you know, are you going to do it yourself, you know, thinking about if you have that, you know, how often that has to be spun down in the car and how travel it is. So is it really reasonable for you to draw your own blood or not? Or do you need to partner? Yeah, that's great. Slide. So you've heard lots of ideas. And what's cool is you've heard lots of things in the chat, and people are talking there. So really, an efficient workflow is critical for creating a solid foundation for your practice, leverage technology in this leverage community partnerships, leverage community organizations that are already working in areas that you are or you contact a lot, really define what everybody's going to do and work people to the top of their license. Really, that's your biggest bang for your buck on employee resources, and define the work that they're going to do well. And if that needs to be redefined, continue to redefine it, and then empower people at a local level to avoid waste, work together, figure out how to get rid of that red tape. And so it's the efficiency goal is never ending. It's just a constant refinement of what we're doing. And so a lot of these things, again, none of these are clinical, their back office to support the effectiveness of a clinical and that's what you want to see is that that process is constantly learning and adapting to what you need in the field. So I'm excited to turn it over to Paul for our next session. Well, actually, thank you, Amanda and Brianna, we have a break. Oh, sorry. And thank you so much for kicking off our workshop this morning. As a reminder, please submit questions through the chat. And we'd also like to encourage you to complete your learning plan. As we go along. We will collect those at the end of the day and tomorrow. Let's see, we will take a 15 minute break and we'll start promptly at 1050 Central Time. Please remember to stay logged into zoom during breaks and during lunch. Don't forget to mute your mic and turn off your video while you're on break. And when we come back, we will be revisiting we will be meeting Minerva. We did send out her case note to you yesterday via email. So you might want to have that available when you come back. We'll see you soon. Let's get started. As a reminder, please submit questions through the chat. Questions will be answered throughout the workshop so they can be captured on the recording. We'd also like to remind you to complete your learning plan as we go along today. We'd like to welcome our next speakers, Paul Chang and Amanda, who will be introducing us to Minerva and discussing care coordination and transitions of care. Thank you, Michelle. Hi, everybody. It's great to be with you and have such a lively group. And I really have enjoyed the chats and the comments and the engagement and keep them coming. We love to help out and where we can as and as Amanda said, not only can you learn from us, I think there's a lot of a lot of cross pollination learning from each other. I think this is a huge opportunity for us to to build that team and and learn from one another. Next slide, please. So we're going to talk about care coordination and and care transition, which we do a lot in our practice, just because the nature of what we do and the kind of patients that we see. So the objectives are we're going to apply recommended practice, practices and transitions of care in homebound patients, we're going to describe the responsibility, responsibilities of a care coordinator and site appropriate behind the scenes function to ensure that the patient get quality transitions in their care. We're going to talk about the roles of educating and empowering patients and family in the care. And as I said before, in essential elements, in a home based medical HPPC is it's always it's often always a dyad, we take care of the patient and also the family member, or the care provider. And finally, we're going to explore resources and strategies for identifying and connecting with community services beyond HPPC practice to provide more comprehensive care for a patient who's who has a lot of of complex needs as beyond simply a medical issue. Next slide, please. So this is our chance, this we're going to meet Minerva for the first time and throughout the next today and tomorrow, we're going to be talking about Minerva. And, and I think it's on page 38. Is that correct? ACCI staff? Minerva's case? Paul, it looks like it's on posted in the chat. Thank you. Page 20 in the workbook. Thank you. All right. I'm going to give you a couple minutes just to take a look at Minerva's case. I'll just highlight a couple of things that we're we're seeing for the first time post discharge. She was hospitalized in the hospital for congestive heart failure, exacerbation and leg swelling, and cellulitis. She was discharged two days ago. She has history multiple other admissions for similar episodes. Her past, her past history is complicated. Like many of our patients. She's older. She's homebound. She's got a lot of conditions, such as heart failure, dementia, heart disease, CKD, macular degeneration, osteoarthritis, recurring UTIs. And her medications are extensive. I think a count of 13. And later on today, we are going to spend more time talking about medication management, and specifically about deep de-escalating or de-prescribing medication for our senior patients who are often on too many pills. So as you take a look at Minerva, and just get a feel for who she is, and you know, the complexity, and as she transits back and forth from the hospital to home, and you're stepping into the home, visiting her, what are some strategies in your mind and in your practice that you can implement to make sure that she receives really high quality care during this transition? And I want you to keep that that question in the back of your mind as we talk as Amanda and I talk about transition in care, and how we can really, really come through in HBPC, making a huge difference in the in the care of these patients. Next slide, please. So as I said, you know, before she's older, lots of medical complexity, multiple hospitalizations, and we are seeing her at home, two days post-hospital stay. Next slide, please. So what are some of the challenges for Minerva and patients like her in transitional care? You know, it's many of us who've been doing this for a long time, one of the immediate challenge that we noticed is that she's got multiple conditions. She's got heart failure, COPD, dementia, neuropsychiatric disorder, right. And the next bullet point, which is is kind of a teaser for the next slide. So we'll just go to the next slide. So what are some of the reasons for repeated admissions for patients like Minerva? There are a couple here. One is lack of timely follow up. You can see the references down below. I'll just highlight Miski, his study showed that the patient lacking a timely PCP follow up were 10 times more likely to be readmitted to the hospital than those who had PCP follow up. So it just highlights the importance of timely follow up for patients like Minerva so that we can provide them with great care and keep them out of the hospital. Polypharmacy, it's as you can imagine, it's a risk for readmission. More than six medical conditions, and also specific medical conditions such as renal failure, cancer, CHF, weight loss, also increase your risk of being readmitted to the hospital. Paul, a question from the chat is what is considered timely in the context for timely follow up? Sure. In our practice, we try to have at least a phone call engagement within 48 hours, and a follow up with our patients post discharge within a week. Great question. Low health literacy. That is a challenge for many of our patients. Whether it could be simply a language barrier, or educational challenge that they have had in the past, that we give them a lot of printed out material about their condition and after visit summary, but it is just hard for them to understand and navigate through pages and pages of records and information about their follow up about their medication, and so forth. And lastly, another risk factor for readmission is reduced social network, and other social determinants of health, which I think for many of us, that's self explanatory. Next slide, please. Now, there's some other barriers in transitional care. And it can be broken down to three levels. One is on a on a medical level. And by that, I mean, a clinician workload, whether it's an office clinician or hospitalist, we are facing a lot of demands on our time, especially during COVID. Now, some of the hospitalists are really a challenge in in, in getting the patients out, making sure the medications reconciliation is done, appropriate follow up is being ordered, and so on. So there's a clinician workload challenge. And there could be a last minute change in the discharge plan or discharge recommendation from either the hospitalist or, or specialist based on the most recent data or the patient's condition. There could be errors in medication, resting reconciliation process, especially if there are a lot of specialists involved in the care of the patient, one may recommend one thing, and somebody may recommend something else. And for the nursing staff to pull that all together, and give it in a way that's without error to the patients and family members can be difficult. And as I said before, lack of a timely discharge summary, especially if you go back to the first comment is the clinician workload. discharge summary is very important for for providers out in the community to understand you know what what happened in the hospital, what follow up needs to be done, whether it's a lab work or, or a specialist. So not having a timely discharge summary can be a barrier in transitional, good transitional care medicine. Now, there could be also a systemic level or systemic challenge, the complexity and the discharge process, whether it's paperwork, or setting up for follow up lab work or setting up follow up, follow up appointment with a specialist. There could be insurance barriers. And as I said, you know, follow up, telling the patient and family, you know, you need to do this, you need to have this visit with a specialist, you need to have this lab done, or you need to have this scan done, can be complex for, for, for clinician and family members to understand and navigate. And lastly, there could be a knowledge deficit. The knowledge deficit can be divided into the patient provider and the caregiver patient may be unaware of the diagnosis that they were treated for in the hospital. They may not be aware of some of some of the medication changes that were made, and what follow ups are necessary for them when when they get home. There could be a provider knowledge deficit, especially as I'm thinking about, like, if I'm a PCP out in the community, I may not be aware that the patient was even admitted to the hospital, let alone what was done in the hospital, what, what discharge instructions or follow ups are recommended from the hospital. So there could be a knowledge deficit on a provider side. And finally, there could be a caregiver deficit, in a sense that they may not understand when they get grandma home, what kind of support is needed, whether it's medication or oxygen or to feeding, or tracheostomy tube and whatnot, what is required of them when they bring the patient home after a hospital stay. So those are some challenges that that we face in taking care of somebody like Minerva, or patients like her with complex medical condition, and multiple hospital stay. I think I'll just pause here. Before I turn it over to Amanda, I just want to put a plug in for just the beauty of HPPC. You know, people, you know, I really love what I do. This is, and I've, people have heard me talk. This is just, I really believe HPPC is just an amazing place to practice medicine. And as it relates to transitional care, and you saw the video from Tom about, you know, the value, the story, and so on. And I encourage you, as I did before, to have a three minute elevator speech, you know, what is special, what is unique about HPPC in transitional care, and I have the mnemonic G-O-L-D, it's gold, what we do really is gold. The first G stands for go, you know, we go to patients homes, we, we, we really seek them out and following up with them. Remember one of the reason for readmission is lack of timely follow up. What's unique about what we do is we don't depend on them to come to us, we go out and see them in their homes, trying to overcome some of the barriers that they may face in coming into the physician's office. So the fact that we deliver care in the in the comforts of our patients home, that is one unique feature of what we do. The other, so that's the G, the O is what we observe. When we get to the home, we get to see what's what's transpiring, what's going on, from a safety standpoint, from a literacy standpoint, from medication management, and compliance, we get to see or even, even cultural or religious context that the care needs to be delivered. And we get to observe things that a regular office doctor may not or provider may not have the ability to see. The L is what we learn, learn from again, from observing, from talking with patients about whether it's a family dynamic issue, or a literacy issue, or learn about the fact that, hey, you know, the you're really not using the medication in a correct way. You know, whether it's, for example, it's an inhaler, you learn that from the show me how you use an inhaler, they're not using it correctly, they may that might be a reason enough for the patient's frequent COPD exacerbation, because they are not using the medications accordingly. So you can learn a lot from being at the home. And finally, the D is what we do. You know, what we do is so unique at home. You know, whether you can talk about the brown bag going over every medication, you know, one by one, rather than depending on a list, you know, what we do for them in terms of, you know, the four Ms finding out what matters most mobility, medication, and mind. That's what we can do for them at home. And we're going to talk about procedures that we do at home for them to save them a trip to the hospital or the emergency room for trach change or g tube and whatnot. And we can do a lot of end of life care and finding out what matters to our patients, thereby avoiding unnecessary medical interventions or ER or hospital stay. So I really think what we do in HPPC is gold for our patients, for the health system, and for our society as a whole as we try to find ways to take care of these complex patients at home inequality in a cost effective way. Amanda, now with that, I'll turn it over to you. Oh, that's great gold. I absolutely love that. Actually, if you wouldn't mind just kind of putting a couple of notes in the chat around the you know, the because I think many people are going to take that away from this. So as we talk about the barriers, we talk about the reasons for readmissions, you know, we've really defined what's not working well, what are the important aspects of a quality transition? So I'll open it up to the chat or jump in about like, what are the things that we absolutely have to have to say it's a quality transition, it would be the thing that we want for our mom or dad if that was happening. Clear plan going forward with the appropriate follow up that's already been scheduled, ideally. Yeah, yeah, absolutely. A clear plan, you know, that the, you know, someone has reached out to you a care coordinator, someone has touched base with you probably within 24 hours, and they've started to, to put that together. And now we're going to go see you and we're going to create a plan for you. So absolutely, a clear plan, you know, that the, you know, someone has reached out to you a care coordinator, someone has started to put that together, and now we're going to go see you and we're going to create a plan in writing, we're gonna put it down, and it's going to be very clear, and it's gonna be well communicated. Okay, let's see chat here, med rec, make sure they were able to get all their med changes, and they know why, and that they can show you how, right, and we'll talk more about that. But they have the supplies, they have the meds that they need. Timely contact, I'm seeing med rec, review of admissions, how many people have left with the 15 page stack of all of the things that they have to do, right? So yeah, we go through that, we understand what that is, lots of meds, safe place to be discharged. Absolutely. You know, there is a safe place and they have all the DME, the functional utilities they need. They know, they know if home health is coming out, right. Yep. Okay, I think, I think we've covered it. Any other? Yeah. Great. Patient engagement. Yep. I just want to put a quick shout out for med rec, especially in assisted livings, boarding care homes where they use fax for meds, they may not be on the EMR, like other, you know, places are. So just put a shout out for that. Oh, for sure. And how many times do you, you have them on something, they go to the hospital, and they come back with all the things you just deprescribed from them and took them off. And now they're coming back. And you're like, oh, we got to go back through it again and talk about why we're getting rid of it. You know, x, y, z. Absolutely. And also a couple other things I was trying to catch up, you guys were so fast here, you know, review hospital records. Absolutely. You know, make sure everything's accurate. I can certainly speak from my own experience to say, when my mother was in the hospital before she passed, I didn't, she was probably there two weeks before I realized that her advanced care plan was right. They said she's full code. And they did it in a nurse transition. They were just transitioning. It was a nurse handoff. And they sell full code. And I said, Well, shoot, nobody's asked, I guess, but she's not full code, you know. And so just making sure everything they captured is true. It's accurate. And we and often, the opportunity to review the records going in and the records coming out. If you need another hospitalization, it's all value added time. So you can start to fix it until the hospital the next time if it were to happen again. Hey, let's look for this. Hey, you didn't get the post. Hey, you know, you keep putting her on this, please stop doing that, you know. So let's talk about some strategies for improving transition slide. So I actually have two slides on this. But as you guys go through, I'm certain marking down because I'm going to ask what are we missing here? You know, an outreach phone calls, we talked about that home based primary care provider, whether that's your care coordinator, they check in, are you home? Do you have everything you need? You know, when can we're going to come out and see when can we see it? Let's schedule that right now. Make sure you have all the relevant med rec or the medical records before you go out there. And you have reviewed them. And if you don't have them, then we make sure we need to really try to capture them. And again, try to improve that process of capturing them earlier in the process. Sometimes with our practice, we can be delayed in getting that information. And so if that's a delay, you know, we, you know, we'll still go out and see you. But ideally, this is the strategy, you get it before you go out. A visit by a provider and Paul said this is their strategy as you get that that call within that first 2448 hours from an RN, and then you get the seven day post discharge visit. At that time, you review those medical records, you do the med reconciliation, and any optimization any changes, of course, you have to, to make and now you have to say what's their functional status? Did they have everything they needed from a functional status before they went into the hospital? Now that they've been in the hospital, what are they coming back with that they need? Was there something in their home that maybe caused that that we need to look at DME functional status and supports to make sure that patient can still move around their home and live the way they need to live? Or do we need to talk about other things? place the order for, you know, home health care, and if necessary, ask barriers about compliance, medication, diets, any impairment, and again, these things change, you got to kind of go through everything one more time. Slide. Okay, and as Paul mentioned, you're treating the family and the patient, right? So address and discuss the caregiver concerns, what's new that's changed? What did you like or didn't like about the hospital experience? And let's talk about how that can be different, if this were to happen again, review those patient and caregiver goals and advanced directives, you know, and it gets down here to discuss the emergency plan. I like to say, we create these goals of care, we create these emergency plans, because we want your mom or dad to experience the same thing at two in the morning that they would have happened at two in the afternoon, we want their wishes to be met, no matter what time of day it is, or if it's convenient for anybody. To be able to do that, we have to have a high level of communication, we all have to be on the same page, we have to make sure that all the onsite caregivers, the offsite caregivers, right? The brother in San Francisco, you know, every healthcare worker that may be around this person, whether it's home health, whether it's, you know, potentially hospice, assisted living, whatever that support structure, again, that health care support structure that we know, and we have defined the goals of care and advanced directives. And if we need to revisit them, coming back from the hospital is a good time to do that. Identify and address any knowledge deficits. Hey, I don't know what I got put on for this. I don't know what happened here. I now have this new, you know, piece of medical equipment, we need to start talking about how to use it. And then we provide the written instructions and the teach back method on conditions, medications, follow-up appointments, any DME, any functional new needs, and how do we reach that provider if needed? So, and then as you leave, it's again, this assessing the and understanding the care plan. So Tom shared in the chat, and I think we're going to try to combine the links, but shared a tool that we can be used to assess the patient's comprehension of all the healthcare terms you're using and how we can optimize that. And finally, we see, you know, how many times have we done, I'm certainly guilty of this, we've laid out this great plan, and it's not fully communicated. So we lay it all out with the patient, the family, we understand the healthcare workers. And now we need to coordinate with the team, the other healthcare workers that we, you know, employ, and the ones we don't employ to make sure again, that we're delivering that high quality care at all times. Anything I forgot? Anything that was not on there? This is Michael, I just like to highlight Tom's comment in the chat about having remote access to EMR for healthcare systems or hospitals that you patients that you might see regularly. Is anyone familiar with the process you you request that access? So you have real time access to your patient's records on transition. Yeah, that's great. Do you want to, Jennifer says, can you elaborate a little bit on the process and it may vary by state. I mean, it may depend if you state as an HIE, if you have, you know, if you're tapping into Epic, you could get kind of Epic care everywhere, or some, you know, facility functions of their EHRs there. But are there other ideas you're thinking about, Michael? In Maryland, we have an HIE where it attempts to collect all of the EMR information for healthcare providers on kind of one platform. And we can get alerts by inputting our census. So it tells us if and when our patients are admitted to a hospital or transferred to a subacute rehab or discharged to home. It doesn't work 100% of the time, but it's, it's pretty good. We can also access a lot of the major EMRs through that exchange. But an alternative is to ask if you were, if you see patients that go to a large health system regularly, you can ask for remote view only access to their EMR. I'm not familiar with the process because usually our front office team does that. But I think I think it's, it's fairly regularly done. And Michael, I'm familiar with it. It's called, you know, for Epic, Epic Care Link, Cerner also has a product. And for Epic Care Link, you have to get permission from the health system. All their independent doctors that aren't on Epic, get it. And you can actually do ordering. You can, you can do things even with it. In addition to just getting read-only, you can message specialists. Our nursing homes in our area are given Epic Care Link. So when patients are transferred to the nursing home, they have complete access to every test, every lab. I mean, anything that's in the chart they have access to. And you can do the same thing. You just have to give permission from the health system. I will find a link, Amanda, to Epic Care Link and put it on the chat. Yeah, I think that's great. I'm seeing in the chat a little bit really mixed bag on how much access we have to the EHR that they need. So, you know, it, you know, Tom's going to put the link to the chat and also it doesn't hurt to ask, especially with the big system. Sometimes it could take a little bit of time, but keep pushing, keep pushing and figure out how you show the value of being able to be a provider in the field, getting that information. It's, it's really, you know, I don't think anybody's saying it's not valuable in the chat, right? So we all are in agreement. It's how do we get it every time. And part of that is, you know, people going into other charts they shouldn't go into. And so that's just their kind of dilemma. You know, do you do enough work with them to make it worth that risk? Yeah, absolutely. Slide. So successful transitions, you know, what is a successful transition overall? And we talked about so many of the pieces already, but at the core, it's really the access to providers. You guys address the symptoms, the crisis, the hospitalizations, you know, any transitions, if they need to go to a different level of care, you're the ones on site and you do all that managing of that med medications of the reconciliation. And, you know, sometimes that, again, that deprescribing needed after the hospital and then changing everything on you. That key piece around advanced care planning and supporting the patient and family giver, you know, it, this works because of a targeted population, a team care model and a positive outcome. Otherwise home-based primary care is not successful. So tying those things together is really key. The, you, you are all great clinicians. I certainly very rarely run into, I never, of course, I've run into one here, but I very rarely run into a not great clinician. Everybody knows how to do the science of it more than many. I'm trying to think of any other specialty that requires such a high level of home-based primary care, because you have so few healthcare resources on site. So again, that access point for the patient and family for their outcomes, for the health systems, that's really key to a successful transition slide. And it's made up of a lot of people, right? It takes a village. They're providers, nurses, therapists, right? There are so many other people we could put on here for a successful transition. So, you know, I, I think as you guys think about who I'm going to build the team and how I'm going to keep that high level of communication, you keep thinking about, you know, where are my problem points? Where am I seeing continual issues? Is it out of the hospital for a transition? Is it with a service of, you know, a home care or DME service? What is my problem points, you know, my headaches and how do I attack those? Slide. So has anybody used the Naylor Transitional Care Model, the TCM? It's been utilized for over 20 years. Throw, throw a yes or no in the chat. It, it really, it's really interesting. It's on page 29 of your workbook. We're going to, yeah, I'm seeing a lot of nos. It's, it's, so it's really starts at the hospital level. And so Dr. Naylor goes in and he says, if, you know, if you're eligible and we have a kind of a flow chart here, but if you're eligible, you, when you hit the door at the hospital, we ask if you're eligible and we start evaluating and send a nurse in to start your transition within hours of being in the hospital admission. And the goal of starting in the hospital and continuing into the community is really to, to improve. And they showed, I guess, improvement in patient safety outcomes, quality of life, satisfaction, and overall a reduction of return visits for hospitalizations. So it's a nurse led team-based model of care designed and tested to do this work. And I see actually someone is because yes, this Charlotte said she worked at the program in Philadelphia, did the, did this. So it's really neat for those of you involved in a bigger system and ACO, it might be something that you really start to think about is how, you know, how do I, if I know I have a lot of patients from one hospital system, how do I move upstream a little bit to get my hands around the patient before they even leave the hospital? What does that look like, Cy? It overall improve, improves the outcome for the frail elder adults and their quality of life. So these findings were from randomized clinical trials from the National Institute of Nursing Research. Let's see if one. Oh yeah. Okay, great. Cy? And here's some, here's some notes on the total cost of savings, right? Because if we're going to generate value and I going to keep connect, connecting the value that you deliver to money, if we're going to do it, deliver value, here's what we need to know. So the total healthcare savings was, you know, in 24 weeks was $3,000 per patient really. And the mean savings was $5,000 per patient. So we're starting to cut healthcare costs out of the system and it makes a little more sense if you go to the next slide, because I see a question about how do we get involved with the, with the RN. So again, this is on page 29, I believe of your workbook. And the patient is admitted. And then you immediately use the TCM screening tool and assessment to say, are they eligible or not? If not, okay, we, we skip it. If yes, we get them involved. And now a transition nurse visits with them within 24 hours of enrollment. Again, with our, within hours, they're, they're talking to the patient and the caregivers, and they're really addressing needs collaboration. You know, who's your primary, how's, you know, how's that working? How, how, you know, what are you going to need? And so we start that, that planning and collaboration from the beginning, and then they visit daily until they're transitioned. And then they continue to follow them within the home. And then they make sure that they follow, you know, or then they, they set up any referrals or community supports that you're going to need. So it really is just starting a little bit earlier. So I, you know, this is RNs and they could be on your staff, they could be on the hospital's discharge staff too. But I think it's an, it's a really interesting model. It's been successful again. And Dr. Naylor, who's a, I should have said is a DNP PhD, or I'm sorry, PhD NP, you know, has made it really successful to move upstream a little bit. And so even if you don't use this exact model, again, more information in there, I do think the idea of moving upstream and trying to find your, your headaches and your pain points is a good one. Okay. So, Medicare transition care management requirements, and we're going to list them here, but just for the sake of time, and because I think Brianna is going to talk more about these in our TCM, which is really where the rubber meets the road of, you know, how do we get paid for these? You know, these are really the transition care components that we need, and we've talked about a lot of these as, you know, the caregiver of two days within discharge, follow-up within ideally seven, could be 14 days, and then some of the work that we would want to do inside of that review the records, review medication, make sure everybody knows what we're doing. So, my final couple thoughts are really preparing around care coordination. So, each organization will define care coordination differently. Your workbook has a sample job description. You certainly don't have to use all of the bullet points within that. I encourage you to think through, again, where are my headaches, and how do I find a solution that is top of licensure resource to help me solve that? So, your care coordinator may be a social worker, it may be an RN, you know, build a job description and be willing to change it as needed, but create these expectations of what they're going to do and, you know, a formal position of how they're going to do this work. I really believe here, and everybody has a different model, but I really believe that, you know, your fundamental care coordination should not be a work around your provider. It should be in tandem and in partnership with your provider. I'll give an example. In our home-based medical practice, it's a subset of dual Medicare, Medicaid-eligible patients, and what we do is we send nurses in first, once they've been established, I guess, we send nurses in if there's ever an acute issue. So, they're non-billable positions, right, but they're going to go in and they're going to assess a situation, they can do an assessment, and they can call, they can do a virtual visit with a clinician to assess the next steps. We can do that because it's a value-based model. Not everybody's going to do it that way. So, we have very traditional care coordination within our organization, you know, more of the paperwork, make sure everything gets filled out, and then we have what, you know, we call kind of a clinical nurse coordinator infrastructure where they really are an extension of the provider. They do quite a bit of hands-on medical care, but the reimbursement model allows us to get really creative for what they can do to support the provider and coordinate the care whenever they have a transition or they have an acute need. Slide. So, once you figure out here's exactly what we're going to do, here's the exact position we need. Slide. You know, then, you know, then we have to really put in there and create a template that says, you know, here's how a care coordinator is going to act, and here's what their function is going to be. And these are some examples of things that you may ask and have them collect the data on, is, you know, and some of them are subjective and a little more objective, certainly, but either way, you start to say, do they have everything they need? Can I get that information? And then what am I going to do with that? As we talk about efficiencies, and I always try to think about efficiencies, never ask a question you don't want to know the answer to or you're not going to do anything with. Those two rules help to find efficiency. So, ask the questions that you really think are going to make a difference in their work. Slide. So, a couple of resources for you. And we can share the links in the chat here. But, you know, there's Connect2Affect, Eldercare, and Aunt Bertha. And I just, I can't remember, maybe someone else could jump in. I can't remember if they're all free. I believe the Eldercare is free, but the Aunt Bertha might be to pay. But this is a way that you can start connecting community resources to the work that you're doing and see, you know, who are their adult daycare systems or adult day systems? Are there, you know, housing supports? Are there food and nutrition supports? And find additional resources. Because, again, they get, you know, patients get sent home with what they need, but not always how they need to get these things. And so, being able to tap into your local resources is really key. Open agency on aging. Absolutely. I mean, the state offers a number of areas for that, too. So, you know, slide, you know, my key takeaways, you know, I think you hear a lot of passion around transitions. We lay this great plan, and then certainly something comes along and screws it up a little bit. And it's usually when there's a change, a transition of some sort. So, regardless of size, you're certainly able to create meaningful transitions for your patients and caregivers. Sometimes it takes a little creativity, and it takes a little time, typically. But then you put in place protocols to ensure, and roles to ensure that we can not only deliver for one patient, but we can consistently deliver it for many patients. So, any final thoughts on transitions from Paul or me or any of the faculty or any of y'all? Okay. Well, thank you. Can you hear me still? Yeah. Sorry. Oh, it's okay. Thanks. So, while we're getting set up, I know Michael's going to speak to us next on medication management. I asked just to come in and tell you a couple of things. First off, I know the networking opportunities in this group and interest in doing that is really, really active, and we love to see that. Staff are going to be working on setting up a discussion board in our HCCI Learning Hub so that you all can continue networking in this way following the workshop. So, stay tuned on that. But in the meantime, we'll also provide in your resources in the HCCI Learning Hub just a list of who's here and where they're from so that you can have that. Finally, one more networking opportunity. We encourage you that if you're going to be sitting at your desk eating your sandwich, if you want to just keep your video and audio on while you're there and just chat with anybody that's in the group that you want to meet and connect with. So, we'll also have about 30 minutes following the end of the conference today where you can do some informal networking that way. So, at this point, let me go ahead and turn it over to Michael. I see Nicole has a question in the chat. Yes, I apologize. My question came a bit delayed. I was just wondering if, I love the Naylor model of care transitions, and this is something that I do want to propose to a hospital. But I was wondering, I was looking at, I believe it's care transitions intervention, their models. And there was a huge program that cost a whole bunch of money for me to do. And I was like, okay, I can't do that. But I was wondering, are there any models out there that maybe you guys can suggest that doesn't involve maybe the nurse from the hospital? Or if you're familiar with any other models? I know the portion outside of the hospital, but I like this. I really like this. But if I wanted to propose it to them, removing portions from the model, like if anyone knew of any other models, or even resources for proposing to a system that's going to ask for information and data. So, can I make sure I understand the question? Is the question, I like the model, I want it to start in the hospital, but I don't want the hospital discharge to be in charge of that person. I really want, or is it, I'd like to start at a different starting point than the hospital? I like to start at a different starting point, because I'm not, I guess I'm presuming that they maybe would not want to jump on board on that level, because it would require, so I was like, what if, maybe I'm just exhibiting fear. I don't know. I was just thinking my thought process was more on the other, maybe discharge level and moving on from there. But if I needed to have a nurse and see them every day while they're in the hospital, like, you know, I was just thinking taking the brunt of the pain off of them, but. I'd let the other faculty answer. I don't, I'm not sure of other models quite like that. I mean, there are other ways we could think about resourcing, or you could get people to help pay for that, but I'm not sure of a model exactly that would do that, but I'd open it up to. Okay, no problem. Tom, I saw your video on, were you going to say something? Yeah, you know, I, so I'm actually, you know, doing this for the organization I'm working with right now, and I'll tell you, Nicole, you are it. And so I think like the forums is a framework, the NALR model is the framework, but you are the best person for carrying that out. And I think where that model is really helpful is to show, you know, ways that there's more of a seamlessness to it, not a fragmented hospital. And so what I think your job is, is to do as much with the hospital to make the transition seamless in terms of excellent communication, but then you are the NALR model, you know, you are the visit. And then the other thing, just to let you know, that might be helpful to those, what I'm also doing to get buy-in from other providers is I am adding things to the transition. So for the first couple of weeks, it's just going to be focused on everything that you guys have said, the medication management, making sure they get their DME, making sure that they get their home health services, you know, making sure that they're following, you know, everything. But then I'm also adding to, let's say the third, fourth, fifth week, things like a home safety assessment, that realm seven word literacy test. I'm adding the Xeret, you're going to hear about this, the Xeret caregiver burden scale. So I'm going to do things that create added value to these patients that really show your health system and, and your, your, your other, you know, office-based PCPs, what a great service this is. And I'll stop there. Does that help? Awesome. Thank you so much. You, I just, you just flooded me with ideas. And quickly here, I was just going to tag onto, I mean, the NALR model is great, but, you know, you can tailor it. There's lots of good transitional care models that don't necessarily involve an RN in the hospital, you know, even just making that connection with that discharge planner or finding out a way for you to get notified for your, you know, when your patients are admitted or discharge utilization, even educating the patient and family, make sure they notify you when they're in the hospital right away. So there's lots of ways you can work around it. You know, you don't necessarily have to have, you know, the nurse employed in the hospital or that relationship. You know, generally the discharge planners, they become very friendly with you because like Dr. Cormel said, you are a nurse solution. So just build that relationship and it could just be a simple communication while they're in, you know, with that team in the hospital. So you can be preparing to take on that TCM role when they get back home. Great. Thank you, Nicole, for bringing that up and Tom and Brianna for your input. I think that was really insightful conversation and worth taking a few minutes to go through. Kind of moving on and thinking about hospital transitions, our next topic is medication management. And as I say, when something goes wrong, it's always the meds. And if it's not the meds, it's always the meds. This topic really covers the four Ms very well, including the multi-complexity matters most, mind, mobility, and medicines. They're all really incorporated here. I'll just point out now we're going to spend a few minutes going over the didactic and then at the end of this topic, you're going to have your first breakout session. So our objectives today are to really look at some evidence-based practices that are out there for you to utilize in your personal practice, as well as your program. We're not going to spend detailed time dissecting those practices, but give you sort of the high points and a way to approach them to use in a meaningful fashion. Identify potential pitfalls and the dangers related to polypharmacy. Think about ways that you can successfully de-prescribe for your medicines and then also think about how to formulate a good plan for adherence through safe and effective regimens that your patient and family can follow. Next slide. So we all know that polypharmacy is bad, but here's a few facts to consider. Although elderly patients make up only 13% of the population, they use almost 33% of the prescription medications annually. So it sort of correlates to that last year of life, you know, where the major portion of money is utilized in that last year. The older adults are using a large part of prescription costs in our country. Approximately 15% of hospitalized or ambulatory care patients or nursing home residents receive one or more unnecessary drugs, and you'll have the facts to prove that in the next slide. Adverse drug events occur in at least 15% of older patients, which can contribute to ill health, disability, and hospitalization. Next slide. So here's a list of observational studies on older adults in polypharmacy, and there's a few articles that are referenced that cover ambulatory setting, the hospital setting, and in the nursing home. And thinking about the elderly population or older adults in the ambulatory setting, ORDO found that one third of female and male patients older than 75 years of age were on five or more prescription medicines. And of those, almost 50% were on over-the-counter medicines and dietary supplements. Rossi found that almost 60% were on one or more unnecessary prescription drug. And in the hospital, Hajar looked at 384 patients hospitalized in the United States and found that 37% were on nine or more prescription drugs, with almost 80% on five or more. Of those, almost 60% were on one or more unnecessary prescription drug. Nobile in Italy studied hospitalized patients and found that on an admission, 52% had five or more prescription drugs. On discharge, they had 67% had five or more prescription drugs, representing about a 15% increase in the number of prescription drugs for those patients. Lastly, the third setting we looked at here was the nursing home setting. And Dwyer found of the 13,507 nursing home patients in the United States, 40% were on nine or more prescription drugs. And Bronskill and the Canadian study of 64,000 patients, it showed that only 15.5% were on nine or more prescription drugs. So it leads me to wonder, you know, what is Canada doing differently with their prescription medications? Next slide. Here are some commonly associated terms that we use when thinking about polypharmacy and older adults. Firstly, the physiological changes associated with age. We know that there's muscle loss, increased subcutaneous tissue, fluid loss, decreased organ size and function. All of these contribute to older adults' ability to process and tolerate medicines. Underprescribing is the concept of not treating conditions that have a possible preventable catastrophic outcome. So this would be patients with AFib that aren't anti-coagulated, hypertensive patients that aren't at goal, osteoporosis patients that aren't being treated. Overprescribing and misprescribing are also the two additional terms that are fairly straightforward. Overprescribing is utilizing too many or too high of a dose of prescription drugs. And misprescribing is a drug that may be prescribed in error, whether it was intended for another patient, just a complete error, or an error given the patient's medical complexity. An example would be a patient on a medication that would not be indicated in chronic kidney disease. Prescribing cascade, most of us, I think, are familiar with this one as well. This is adding another agent to cover some sort of a symptom that's likely caused by a prescription drug that you may be able to think about decreasing the dose or stopping. And then recent hospitalization or recent visit to the specialists. This is, again, an important point where transition management is necessary, whether it's a discharge from the hospital or when you are seeing your patient reviewing the chart to see if they've had a recent specialist visit. I like to think that oftentimes in those specialist visits that, I don't know how long they last in your area, but in six minutes, they make it, you know, six minutes with the provider and they're started on three different medicines that may not cover what matters most to the patient. I think in home-based medicine, we have the unique opportunity of time that we can spend with our patients. And in that time, we really can determine what matters most and discuss the risks and benefits of those additional meds and does it meet their goal. Next slide. Next slide. So thinking about the evidence-based tools that we have available to us, AGS has published the BEERS criteria and it was most recently updated in 2019. Last time I looked, it's a little more difficult to find online for free if you're not a prescriber, but that's just an aside. It's still pretty readily available. And the BEERS criteria focuses on over-prescribing and mis-prescribing meds. It provides a category of medications by symptoms or the treatment category. And then it gives you the goal of either to avoid versus avoid when possible. And their format has changed over the years. And I do think that in 2019, they really tried to simplify the approach to the criteria. Secondly, the start-stop, I always say it backwards, stop-start criteria is a European tool that was published and again, is updated regularly. The stop portion of the tool stands for screening tool of older persons, potentially inappropriate prescriptions. So this is sort of the first step to identify medications that you might think about stopping. And then start stands for screening tool to alert to right treatment. So this helps to guide the provider to medications that are more appropriate. This tool, both the stop and the start are organized by system and then sort of medications are the next step and whether you should use or avoid. Next slide. So kind of combining aspects of both of those tools, we've defined an algorithm here that you can use as an approach to de-escalating or de-prescribing meds for your patients. Think someone mentioned that they wanted to think about time management here and incorporating medication review and de-prescribing or appropriate prescribing in your chart review prior to each visit is a way to sort of frame up your approach to the visit and sort of have a plan already. And I think Brianna is going to go over this in future modules, but there's also ways that you can bill for that non-face-to-face time. So firstly, you want to reconcile all medications and indication for them and pay particular attention to the prescribing cascades. So medicines that may have been added on to counteract symptoms for an alternate medicine. I already mentioned that in some studies, over 50% of older adults are using supplements and nutritional supplements. So you want to remember to include those and then think about adherence, medication adherence and a simple way that you can assess patient and caregiver adherence to meds are asking, what are you taking? How are you taking the medicines? Do they work? What's the efficacy of the medicine? If they are or are not taking the medicine, what are the barriers to administration? A simple example here would be a multi-day dosing drug. Oh, I don't know. I usually take a nap in the afternoon and I forget the midday dose. And then the last one is, well, how often do you miss a dose? And I like to add here, how often are they taking the medicine? Not as prescribed. Common found meds would be pain medications. Are they taking more than they're supposed to, less than they're supposed to? Insulin medicines, diabetic medicines, are they taking those appropriately? Antibiotics, are they finishing antibiotics? And if they are or are not, what are the barriers? Next, you want to review the overall skill, overall risk of the medications using the beers criteria or the stop criteria, as well as your knowledge of the patient's wishes and pharmacokinetics of the drug. I just want to take one second to point out here that both the beers and the stop-start criteria don't supersede clinical judgment. So it's not something that's carved in stone that you must do, but if you are continuing a medicine, I think it's prudent to say why you are. So, you know, there are guidelines and they don't supersede the prescriber's judgment. Next slide. The third step is assess each drug for the ability to be stopped. If there is no indication to stop a medicine, then you go back to step one. If it's part of the prescribing cascade and was prescribed to treat an adverse drug reaction, then you should think about stopping it. If it's a preventative drug that's unlikely to provide any additional benefit based on the patient's prognosis or goals of care, you should think about stopping it. If it's a particularly burdensome drug for the patient because it costs a lot of money or you have to monitor blood values, EKG, or those types of things, you may think about stopping it. And then the next step is prioritize which medicines you're going to focus on discontinuing. And this is really what's most important is what medications come with the greatest risks. Try stopping those first and which are the easiest to stop with to minimize withdrawal. So, is it something that you have to taper to off or is it something that you can simply get rid of right away? The one thing I'll caution about if you're new to the patient or the patient's new to you, if you go in and you start changing a lot of medicines, especially things like anti-hyperglycemic medicines that they've been told for 20 years, you know, this is what they need to be on and this is why you may get some pushback from the patient or family. And then finally, you want to implement your plan and monitor closely. Next slide. Okay, so here we're going to break into four groups and you are going to get to know Minerva a little more closely. In your small groups, you're going to use the evidence-based tools available to you to think about Minerva's medications and their indications and is it a good idea to continue them and then create a plan for de-escalation. You'll have a pre-populated table with all of her medicines listed already for you. That doesn't mean you have to stop them all. It's just for ease of use. And in your small groups, please identify a reporter who will sign off after you review the case and talk about the meds. We'll talk about them as a group. Everyone will have a faculty member in your group to help with your conversation. You'll have about 15 minutes in your group setting and then we'll come back together as a larger group to discuss your results. Okay, any questions for me before we break out? Okay, we'll see you all in a second in your rooms. recap, high-level kind of based on, whoops. Brianna, an email would be great if you've got it. If not, I'll muddle through. Maybe our group can go last and I'll get that to you. Is everybody back? Group 3 is back. All right. What about Paul? Dr. Lee's group is back, I believe. We're all back. We're back. Okay, great. I hope you had a meaningful discussion. Now we're going to review sort of what your recommendations were by medicine. So I'm just going to call out a group by the provider member, the faculty provider member that was on your team, and you'll cover I'll tell you the few meds you'll cover. So Tom, if you'd like to start with whoever was reporting off for your group, if you can cover denepazil, memantine, and isosorbide. We have wonderful Jennifer from Florida who runs a practice down there. Right, Jennifer? Do you have to unmute or do we have to unmute her? Here I am. Is that better? Hi, Jennifer. Hi. So, you know, we looked at her medications and we kind of grouped denepazil and memantine into one and addressed them both. Just thinking about the need for it. The indication is obviously there she's got Alzheimer's with behavioral disturbances. So that is certainly a concern. Now denepazil does have some side effects with some GI problems. It can lead to some bradycardia. So we don't know if we really want to take her off of that. That might be a possibility. But increasing the, I think, now I can't remember what kind of dose she's on on top of me, 10. I think that was the maximum dose. I think the biggest change was considering memantine and maybe increasing that to see if she benefits from a higher dose because she's on five milligrams twice a day and she can go up to 10 twice a day. Of course, you have to consider the side effects of possibly some dizziness with that. So I think we were thinking of increasing that one. The isosorbide, you know, we're not really sure if there's an indication for it. She's not currently having any chest pain or heartburn, but maybe she did for some time and that's why she's on 60 milligrams. We could consider decreasing it to see if it makes any changes. But I think we were going to leave it for now because it's not really her top concern. The furosemide, I think we're going to remove the evening dose. Thanks. Sorry. Thanks, Jennifer. We're just going to cover the top three and then we'll move on to the next group. All right. Thanks. Great job, Jennifer. Great job. I love that you covered denepazole, the GI upset, and possible insomnia, and memantine, the risk of dizziness. Paul, if your spokesperson could go next and cover furosemide, potassium, and the MAG. All right. Dan? Okay. Are you ready? Sure. So furosemide, we're not sure if it's necessary to have her twice daily. We're not sure if it's necessary to have that dose. But certainly looking at reducing it down to once a day, we were discussing how difficult it will be to monitor whether or not she's going to need that because we can't get her up and weigh her easily. She's a pretty challenging transfer. As a result of that, we also need to look at the potassium because we figured that was just an add-on due to the furosemide. We discussed whether or not we can switch her to something that would be more potassium sparing to get her off of that altogether, and whether or not we could just simply combine the potassium chloride to one daily dose. As far as the magnesium chloride is concerned, we would first like to know why she's on it at all. There's no indication in the record whether she is magnesium deficient. It certainly is an easy check with a simple lab, but it seems like something that we could easily and fairly quickly take her off of. Anything else from your group? That was a great summary, and she's cured. I love the idea that you addressed by trying to limit multiple daily dosing. We know that that leads to missed doses, and that may be why she's had so many decompensated heart failure admissions. We'll hope you fixed it. Okay, Rosie, my group is next. Rosie, we're going to report on metoprolol, the Norco, and the levocyroxine. Is the Tylenol tied in with the Norco? Oh, I'm sorry. The metoprolol, the Norco, and the Tylenol. Our first question on the metoprolol is, is this tartrate a succinate? Once a day, if it's tartrate, that's not an adequate dose, so we need to verify that. There was some question if it's really the most effective thing for her possibly switching to Carvedilol, but that requires BID dosing, so figuring out tartrate versus succinate. And then as far as the hydrocodone and the Tylenol, we were talking extensively about limiting the hydrocodone use, really only for pain. She was taking it twice a day, so we wanted to increase her scheduled Tylenol to 650 or maybe even 1,000 twice a day with the option of a third dose if we need it, and then reserve that hydrocodone for severe pain. She's got the arthritis in the knee, but she's not really moving. Is it really bothering her that much? It could be causing a lot of constipation. There's no constipation, but maybe we need to dig into that a little bit more. It could be causing some daytime sleepiness and constipation, which could cause other behaviors. Oh no, that's right. All right, anyone, anything else from the group? I love that you were trying to get her off the hydrocodone, as well as thinking about what her bowels are doing. Is that contributing to her confusion? And Ina's group, the last three, the Omaprazole, Ocuvite, and Multivite. Okay, thanks. I think Barbara from our group is going to report out. We're getting rid of all of them. That's right. We decided there wasn't probably a good reason for it. Well, she has GERD, but more of a PRN on the Omaprazole and the vitamins, as long as she's eating reasonably well, which is questionable, I suppose, but not necessary as much. That's really it. Great job. So just a couple thoughts for the entire group. What was the most important thing that you were trying to get her off the hydrocodone? What would your priority be? Thinking about the evidence-based tools, what would you pick? What are the one or two medicines that you'd target for stopping? The Norco and the Denapazole. And why? I would take off the Norco because it's Norco, and she doesn't seem to have an indication for severe pain, and it can add to her confusion. I think a lot of groups said she's also bed-bound, so how much pain is she having? Anybody else want to prioritize something different? My priority is something that I can stop today with the information I have right now. So like Barbara said, those vitamins, at least one. We don't need both of them, the Omeprazole, so something that I can stop right now. Some of the other things I feel like I need to dig into before I can confidently say we don't need it. Good. Yeah, that's one of the points in the tool. And then lastly, thinking about under-prescribing, are there any medicines that she's missing in the remaining minute or so we have? Yes, an antidepressant. Yeah, for the agitation. Not just the agitation, she's scored high on the PHQ-9. She's not being treated for her depression. Agree. Any others? It's also not on an ACE or an ARB. Next. EF is 35, right? Anybody else? Jocelyn says the Omeprazole may be contributing to low magnesium, so this could be part of the prescribing cascade. Excellent. All right. Thank you guys so much for your active participation. I hope this was helpful. You will continue to talk about Rosie in our future modules over the remainder of today and tomorrow. I think, Michelle, I am standing in the way of lunch. Yeah, thank you, Michael. We hope that you all enjoyed your Zoom breakouts. Sounds like they went great. We encourage you to be active in both the chat and during question and answer time. We will now break for a 30-minute lunch. As already, if you choose, you can hang out in this room and network. If you're not networking, please mute your mic and turn off your camera. And we will see you back promptly at 1255. Thank you, everybody. And fill out your learning plan. I'd now like to introduce Paul and Aina Lee, who will be covering our next two topics, management of advanced dementia and behavioral disturbances in the home, and supporting caregivers in a home-based setting, where we will touch base again with Minerva. Thank you all and have a great session. Well, welcome back, everybody. I hope lunch was fulfilling and the time away was refreshing. And get recharged and stretching your legs. Next slide, please. Next slide. Before I get started, I just want to take a moment and thank Dr. James Ellison for graciously providing us with the slides and sharing with us his expertise and experience in the management of patients with dementia and neuropsychiatric behavioral disturbances. Next slide, please. So the objectives this afternoon, we're going to discuss optimal care, treatment goals, and management strategies for homebound or home-limited patients with moderate to late-stage dementia. We want to identify some triggers for behavioral disturbances and assess appropriate prevention strategies. And finally, we want to talk about pharmacological and non-pharm approaches to treatment of patients at home with dementia and behavioral disturbances. Next slide, please. Before I get into this, I think behavioral disturbances in patients with dementia and management at home is one of the more challenging scenarios that I face in doing HPPC. There are several reasons for that, I think. One, there's not a cookbook or guideline. There's no FDA-approved medicine for this. It involves a lot of trial and error in patients from family members and with providers, as well as we try to help navigate the landscape and try to use different medication to control their behavior. And also, it is distressing for the patients and possibly the patient, and certainly for us as providers, since the families are reaching out to us and asking for help to remedy often a dire scenario. I was at a patient's home recently, and I still remember the son barricading the front door with a large desk that he had moved from another room simply because dad was a flight risk. And despite the locks and so on, he was able to find a way to get out of the home, and he had to do some additional modification to secure a place for dad. And that was causing him not only some degree of anxiety, also a lot of sleep deprivation at night, and it's causing a lot of caregiver stress, which we'll talk about in the second part of our presentation about supporting the caregivers at home. So more than 90% of the people with memory impairment disorder will experience neurocognitive behavioral symptoms, and they are associated with significant morbidity and more functional decline. And as I stated before, there is no FDA-approved medication for this, and there is no established standard for the management of this condition. And again, I think that adds to some of the challenges that we face as providers in the management of these patients. Next slide. So what are some common symptoms that we're talking about? There could be changes in the patient's mood, such as anxiety, depression, or even some degree of mania. There could be changes in the patient's thinking, such as delusions, hallucinations, or suicidal ideation. And there can be changes in the patient's activity level, whether it's agitation, aggression, wandering, sexual inappropriate behavior, sleep-wake cycle disruption, or sometimes it's just apathy that we see with our patients. Next slide, please. So what tools do we have today for the management of neurocognitive behavioral disorder, behavioral symptoms with our patients, in our patients? Well, I want to go through some of them, and Ina as well, later on in this talk. We're going to talk about some assessment tools that we can use. I'm going to review some non-pharmacologic approaches. And then later on in the talk, we're going to talk about different medications that we use for the management of this condition. And some of them are listed here. Next slide. First, we're going to talk about some assessment tips or strategies as we are facing a challenging patient who might be agitated or combative. One is data gathering, finding out, you know, what is the best way to when is the onset? Is it daytime, nighttime? Is it related to bathing or hygiene activities? What precipitants family can identify? What is the context during which the patient might behave badly? And importantly, also, you know, what has been tried in the past? What worked and what didn't work? Also, don't forget to identify, you know, a lot of these patients lack decision-making capacity. It's important for us as providers, medically and legally, to identify who is the person that can legally authorize a medical intervention during a challenging situation that we often face. Are there unmet psychosocial needs that needs to be unpacked or addressed? Are there medication or is the patient's behavior related to an adverse effect related to a medication? In the last session, we talked about or one of the group talked about maybe the Norco was or hydrocodone, excuse me, was leading to constipation. And maybe that's why the patient was agitated. And you can see that on the right-hand side there. And our group talked about is the patient agitated because of uncontrolled pain. So, therefore, perhaps more hydrocodone was necessary to get the patient to calm down. So, it's important to look at pain issues, constipation-related problems, is your urine retention problem that can be resolved with changes in medications or possibly temporary use of a catheter. And if that symptom was relieved, maybe the patient wouldn't be as agitated. Is there sleep disturbance that needs to be addressed? Is the patient agitated and confused because of an infection? Metabolic derangements can cause behavioral disturbances as well. And, of course, intoxication with drugs or withdrawal can add to behavioral disturbances as well as a TIA or some other neurologic events. And during COVID, about the communication barrier and sensory deprivation and sensory deficits, that also in the past several months, we've seen a lot of increase in terms of psychiatric need and psychiatric manifestations in my patients with dementia. Next slide, please. In terms of talking with a patient who might be disoriented, I think it's important for us to identify ourselves and explain our role. And there's an additional challenge during the pandemic now. Many of us are going in with face shields and masks. And the patient may be wearing a mask as well. And they may have hearing difficulty or vision impairment. And that adds an additional barrier to our ability to identify with our patients. So for us, in our practice, we carry a badge. We show ourselves what I call before the makeup. This is what I look like before the makeup. And this is what I look like after the makeup with COVID-19. So they get a sense of what I look like without all the protective equipment. Make sure you have good eye contact. Speak slowly. Not necessarily yelling. Use short, simple words. Offer patient yes, no questions. And do one question at a time. And repeat the question if the patient does not seem to understand. Using the same wording and not trying to confuse the patient with a slightly nuanced question that's different from the first question that you asked. Nonverbal communication can be helpful. Again, I've learned to use my hands more during COVID. You know, pointing to my lungs, pointing to my heart. Asking about, you know, belly pain and so on. That may be able to help us communicate, you know, with our patient in terms of what we're trying to get across. Be careful of joking. Jokes may fail. Patient may not understand, you know, your humor or completely missed the joke. Don't, you know, I tell my providers, don't argue and don't try to be, you know, out there trying to convince that, you know, it is, you know, 2020. It is not 1984. Don't try to go there with our patients. Try to embrace their reality. Adopt the patient's perspective rather than trying to convince that, you know, their reality is not correct. Next slide, please. There are different ways, there are different non-pharmacologic approach to behavioral disturbance in the management of patients with behavioral disturbances. And this is one approach that was published by Dr. Helen Kales. She's a professor of psychiatry at UC Davis. And it's called the DICE approach. DICE stands for describe, investigate, create, and evaluate. In under describe, we ask the patient and the family members more often, you know, who, when, what, where, in terms of situation in which the problem behavior occurs. Investigate, you know, we talked earlier about investigating all aspects of health, medication, sleep, psychosocial. The goal here is to discover how these might be combining with other factors that produces a certain kind of behavior. Create a plan to prevent and respond to behavioral issues. And then obviously evaluate and see if your plan is working. And then see if any changes or modifications in your plan is necessary. Next slide, please. Other non-pharmacologic aids include caregiver training. Emphasizing keeping the patient in their routine. Certain degree of acceptance of agitation. How to assess and address underlying causes. About distraction and not arguing with our patients. We talked to our families about modifying the environment. Lighting, providing safety, such as having rails. Or block out certain microwave buttons so that the patient will not accidentally overcook a meal or something. Allowing certain buttons to be pushed. Tailor activity programs, whether it's crossword puzzle or getting them involved in family activities, such as folding clothes and so forth. Other interventions including music, aromatherapy, the use of robotics and animals. And also having a simulated presence. And that's a personalized video recording by family members to help manage behavioral issues. These are all things that you may want to consider in terms of helping to deescalate a behavioral challenge. Behavioral problem with our patients. Next slide, please. So one of the medication we often use in the management of this condition is atypical antipsychotics. And you can see here the one that have some modest benefit in terms of reducing agitation and psychosis. Two medications are aripiprazole and risveridone. The other medication there are questionable or with investigational data or inadequate data. That includes quetiapine, olanzapine, brexipiprazole, or clozapine. And you can see the dosing to the right there in terms of the suggested dose to begin with as well as the recommended maximum dose. Next slide, please. So what are the harms? We're all concerned about the use of atypical antipsychotics. There's a black box warning, which we'll talk about in the next slide. Some side effects include fatigue, orthostatic hypotension, trouble walking, tardive dyskinesia with long-term use, diabetes with all atypical antipsychotics. And then the FDA warnings about cerebrovascular events and increased mortality rates. Next slide, please. From 2005, FDA mandated this black box warning with the increased risk of death compared to placebo. Those treated had a risk of 4.5% versus a placebo of 2.6%. Most were heart-related or sudden death. And also risk of pneumonia. Medication included in these studies. You see them there. And next slide, please. So the APA, that's the American Psychiatric Association, published new guidelines in 2016 in terms of what should be our approach in the management of patients with behavioral disturbance. They talk about trying non-pharm interventions first. And use antipsychotics when agitation or psychosis is severe, dangerous, or causing significant distress to the patient. They do not recommend haloperidol as the first drug of choice. The medication with modest support for psychosis and agitation is risperidone. And monitor treatment response with an assessment tool. The 8MPI, Neuropsychiatric Inventory Q, I think Q12. It's a questionnaire. It takes about five minutes. It asks about the severity of the symptoms as well as the amount of distress that the caregiver is experiencing. And it calculates a score. And always try to taper and discontinue after four months unless there are significant comorbid psychotic disorder or past failed attempts. Next. So before we start antipsychotics, here's some recommendations in terms of how the approach should be. We need to document what is the behavior that we're trying to manage and what environmental intervention have we tried. And education and consent process needs to be had with the family members and caregiver so they are aware of the concern as well as the FDA warning regarding the use of this class of medication. And coordinate the care with other clinicians that are involved in the management with your patient, whether it's a home health nurse or is there a psychiatrist that's involved as well to help you manage these patients. Establish a time frame for the assessment of the results rather than just put the patient on and just kind of forget about them. Visit with the patient in a couple weeks to see if the medication is working or not. Always be on the lookout for adverse effects. And as the saying goes for our seniors, you know, start with the lowest dose necessary and go up slow, titrate up slow as needed, and keep the duration of exposure of these medications at a minimum to our patients. And evidence suggests that typical antipsychotics are as potentially harmful as the atypical ones. Next slide, please. Ina, I'll turn it over to you. Just realized I didn't unmute myself. All right. So I also have been tasked to try to get us back on time. So how I'm going to do the next quite a few slides is I'm going to just pick out highlights of each slide and not read through everything. I'm sure you guys can do that on your own. So OK, so let's get started. So the next slide. All right. So, you know, the typical antipsychotics are not first line, as Paul just told you. You know, the main thing I think we reach for is Haldol. All of them are highly anticholinergic. And anticholinergic is not good for the elderly, causes dry mouth, constipation, urinary retention, and the most frightening thing is the delirium it can cause. So definitely don't reach for this as a first line. So next slide. So antidepressants is, you know, something I do turn to in some head-to-head trials of citalopram with qutipine and lanzapine. It has been shown to be equally efficacious and demonstrating less adverse events. So I do reach for this. I like to try this first, especially with agitated patients. Because they might be depressed and, you know, if it's depression, we have good medicines to treat for that. So I do try to reach for that actually before I reach for antipsychotic. Next slide. So one of the, you know, some common side effects, you definitely have to worry about QTC prolongation. Happens in about 2% of the population. So you want to get an EKG before you start citalopram, especially. Escitalopram, a little bit less QTC risk, but still so wise to get an EKG there, too. The other common thing just to kind of look out for when you get labs is hyponatremia. That could be due to the SSRI. Next slide. Okay. So then the other ones I've also seen people prescribe is anticonvulsants. The probably the best literature for anticonvulsant use is really for carbamazepine, and it has a modest benefit, limited, but still limited. I have seen people put people on like Depakote and the other ones that are listed, but they're really not very good evidence upon it. And, you know, Dr. Ellison, the geriatric psychiatrist who put this slide set together for us really frowns upon it. I should work with Dr. Ellison. And he is one of those things, he's just like, why, no, really stay away from those medications. He really does not put anyone really on an anticonvulsant for dementia with agitation. So next slide. Sorry. And, you know, there's a lot of different side effects with it. I'm not going to read through all of it. SJS stands for Steven Johnson syndrome, which is a horrible condition where your skin blisters and just flops off. So, you know, clearly these are not benign medications. And, you know, with these medications, there's liver toxicity you have to worry about. So you need to check LFTs with these medications and Depakote, carbamazepine. They all have blood levels that you have to keep in range. So again, more monitoring that needs to happen with these medications. So another reason not to reach for these. Okay, next slide. So here's an interesting medication. So the pseudobulbar effect. So what that is, is a condition that's characterized by episodes of sudden laughing and crying, secondary to neurological disease like dementia, it could be from MS, could be from traumatic brain injury. So people call it like emotional incontinence. So if you have a patient that is demonstrating that there is a medication that can help with that, is the brand name is called Nudextra, which is really combination of dextromethorphan, sorry, and quinidine. And basically the quinidine slows the breakdown of the dextromethorphan. And so it kind of makes your neurotransmitters like excite you, it kind of dampens it down. So something to think about if you have a patient like that. All right, next slide. So here is all the harm it can do. So quite a few, like any drug has side effects too. All right, next slide. All right, so this is an interesting class, especially the medical marijuana. I'd be interested to hear what you guys have, if you guys have been using medical marijuana for agitated depression, sorry, agitated dementia. It's something, I come across it once in a while where families actually ask for it, ask for marijuana for this agitation. And I have to tell you, I have not gotten great results from it. And so, and you can see that there's really no trials around it, just anecdotal. So I was actually surprised that it made it onto the medical marijuana form, at least here in Delaware is on it. So, but you can see that dronabinol does have some small positive evidence. So I have, I did it once or twice with it, with again, I'm not sure if it really helped or not. Can you go to the next slide? And, you know, the, you know, they do have side effects. The patients that I have started medical marijuana on, they actually, you know, really became more, I felt like more agitated with the marijuana than calming them down. So it didn't really have the effect that we thought it was. So we quickly stopped that, but it does have other side effects obviously with it. So, okay, next slide. All right. So other things that, you know, we, I have also tried is for people who are really apathetic, people who are really flat, you know, and you're kind of like, is this depression? Like what is going on here? And so, you know, you can try stimulants. So, you know, methylphenidate is really, you know, is Ritalin and Modafinil is Provigel. So there is, again, evidence is best with Ritalin, shows some modest benefit with the apathy. The other two, ephedermine and Modafinil, the evidence is lacking. There's a stimulating antidepressant, which I like to try actually before the Ritalin and that's bupropion. And so that actually I thought was, I have seen actually some good results with that. So something to think about for those, specifically for those people who are apathetic, like really flat, you know, the kind of just like, they just sit there, like, you know, they just sit there and you're like trying to almost want to shake them to just be like, are you there? So this is something worthwhile trying. Next slide. I think the main thing with the bupropion side effect is that it does lower the seizure threshold. So you want to just be careful with that. So people with seizures, you know, you would want to stay away from the bupropion because they can lower the seizure threshold. With any stimulant, you just think about, if you were stimulated, you will have anxiety, you'll have restlessness, anorexia, and that's what you would get as side effects by starting these medications. Okay, next slide. So here's a kind of a smattering of other things that you can use to try. Prazosin has actually been studied and there actually is a small positive effect. So that's usually a blood pressure medication, but it can be used with dementia with agitation. Paracetamol is just a fancy way of saying Tylenol. So, and I think somebody in the chat box talked about pain causing agitation. And absolutely, I think that's something you absolutely have to take in consideration because the patient might not be able to tell you they're in pain. And as you can imagine, if they're in pain, it can make them agitated. So having Tylenol, or if you think they are actually in severe pain, upping that kind of that titration up to Trabinol, Tylenol number three, Zykinib. Again, we want to stay away from them if we can from the elderly population, but if you can't and they really have pain and you think that's the reason why they're getting agitated, you should treat that. One of the things sometimes I do with Tylenol is I make it a standing dose. So, you're not kind of waiting for the patient to become agitated. If you're like, we know they have bad arthritis in their knees, they must be in pain. I think they are in pain just to make that Tylenol dose like standing, like two tablets twice a day, two tablets, three times a day and see if that has any beneficial effect. And the other one is the Cyprotiron. I actually had to look this up, but it's basically a synthetic steroid that inhibits the action and secretion of testosterone. Dr. Ellison gave us a great study where there was an 82-year-old male who was very agitated, very aggressive. They tried both Namenda, they tried Memantine, they tried the antipsychotics, they tried benzos and nothing was happening. He wasn't calming down and they gave them Cyprotiron and that actually worked. He actually calmed down with this synthetic steroid. It's an anti-androgen. ECT, obviously this would need to be worked with. You have to collaborate with a psychiatrist with this, but there is some small positive evidence for use of ACT with agitation. And the last one I have to say I don't know much about is still, Dr. Ellison's like, don't worry about it, it's still investigational. So, more to come on that later if it gets approved. All right, next slide. Oh, yeah. So, Prazosin, here are the side effects with that. Weakness, blurred vision, Cyprotiron, is really the anti-androgen effects. So fatigue, some people have talked about that. And so fatigue is usually the one I know with my other patient population, male population, if they're on anti-androgens, they talk about fatigue. All right, and next slide. All right, so I think the other biggest class, if not the biggest class compared to antipsychotics for use of agitation are the benzos. And so I'm gonna just give you my little spiel of this. Benzos as a whole should really never ever be used in the geriatric population. Is on the BIRS criteria as a big no-no. It can absolutely increase falls risk, okay? So we really try not to ever prescribe it. I'm not saying that, if I see it on my patient list and I inherited a patient and they're on it and they're doing well with it, I tend not to stop it. But I really try as a provider, never to start it on a patient. Just again, with all the side effects that goes with it. Alprazolam is really not the one to reach for. It's short acting, as we all know, it works very quickly, great, but then it wears off quickly. So then you're caught into this bad pattern where then you have to keep dosing them over and over again. You develop tolerance to it, and then it becomes very hard to kind of get them off of it. So really just stay away from Xanax. If you're gonna reach for a Benzo, that's one not to reach for. If you're going to go for Benzo, probably the best one to go with is a medium half-life one, which is lorazepam, which is Ativan. So that's probably the most useful. Clonazepam is very long acting, sorry, very long half-life. So it stays around your system for a long time. And anything that can't really be cleared out of a body, we tend not to want to use because then it kind of just builds up and builds up. So if you're going to reach for a Benzo, I would stick with lorazepam. But I, again, going back to my first statement, just try to stay away from them altogether. If you want to try something that's not a Benzo for, you know, to kind of calm them down, one very kind of, I think, pretty easy one to use is Buspirone or Buspirone. And again, not, you know, not maybe great evidence for it, but it's really well-tolerated, very, I honestly don't have many people that have side effects to it, and it does work. Even if you just kind of want to take the edge off of their agitation and aggression, it's really not a bad medication to turn towards. It's usually not a first-line antidepressant, though, so you can't use it as like the sole antidepressant. If you're going to use it for depression, you usually have to, you know, pair it with another antidepressant, like an SSRI. Okay, but it is good as a kind of adjunct medication. Okay, next slide. All right, and so I kind of went through all of this. Big one is fall sedation. You know, again, the dependence on it is really hard to taper people off of it. So again, try to stay away from that. All right, next slide. All right, and then the medication is just to help people sleep, right? We get so many complaints where families are calling in, and it's like, I just need my mom to go to bed. I have to work, and she's up all night. You know, she's wandering around, and I get it. You know, if they don't sleep, then the rest of the family doesn't sleep, and you can't survive with no one sleeping at night. So, you know, the one that I turn to is Trazodone. Trazodone for sleeping. Start at 25, and you, you know, ration it up. And, you know, the max dose is 250 milligrams. So, you know, I see people, like, just stop at 50 milligrams, and I'm like, okay, you can do more, you know? And so don't stop at 50. You know, if 50 doesn't work, go up to 100, you know, go up to 150, like, keep going up. So that's something to really turn towards. Zolpidem I have used, but it's really not approved for long-term use. People sometimes get a hangover effect the next day with Zolpidem. So really, you know, be careful about that. I have used Mirtazapine, for sure, especially if you can kill troopers with one stone, if they're depressed and they have insomnia. And the triple effect would be if they're also not eating well, then you can do, you know, do all of it and recover all of it with Mirtazapine. And Mirtazapine does sedate people. You know, I had a patient take it, and she was like, my God, that thing was great. I never slept so well in my life. The thing to not recommend is Diphenhydramine, which is Benadryl. So all the, so I have patients I stumble upon when we do MedRack, you know, you have people on Tylenol PM, and that PM is Diphenhydramine, right? So Diphenhydramine is not great because it's an anti-cholinergic. So all the things I talked about before about constipation, dry mouth, want to stay away from that. And then the Dilurium with the anti-cholinergic. So you definitely want to stay away from that. Anything that has a PM behind it that people are using for sleep, you want to try to get them off of that. I do recommend, so this graph is not completely correct. I do recommend Melatonin to help with sleep. Very natural. Try that. And the Ramanti, I can't say that word. I always say the other, the Roserum is actually the brand name, is that's, you know, I have not used that often. It's basically Melatonin, but it's just stronger in potency. Supposedly lasts six hours, whereas Melatonin lasts about, you know, two to three hours. So it is, you know, more potent than Melatonin. Unfortunately, a lot of insurance plans don't really cover that. So, you know, so that's why you probably haven't really used it that much or seen it around that much. All right. And then last slide. No, sorry, not last slide, next slide. All right, so we kind of talked about that. All right, next slide. All right, and this is just for a very specific type. This is for psychosis, Parkinson's patients with psychosis. So it's really only been FDA approved for that subset of population. It is an atypical antipsychotic. So right now is in phase three trials for Alzheimer's, for dementia patients with psychosis. It's not been FDA approved for it. So you shouldn't use it for dementia patients with psychosis but if you have a Parkinson's disease patient with psychosis, you can use this medication. So that's really kind of the really for a very narrow group of people. All right, and next slide. Okay. And then this is the side effects associated with that. All right, and next slide. And I just wanna say that you're not gonna be able to fix everything with medications. I think we as providers all know that but sometimes you really just have to educate families that the rejection of care, I think is one of the hardest things for families, right? They wanna give their family members a bath and their family members like swap them away, you know? And they're like, what can we do that? I was like, well, there's really no pill for it. I mean, I had one lady in a nursing home who literally screamed the minute she was in the bath they were showering her. The minute the water hit her, she screamed bloody murder until the water turned off. And the nurses will come to me. He's like, can you make her stop screaming? I'm like, what do you want me to do? I'm not gonna give her something to knock her out during her bath. I was like, you just got to deal with it and just get the bath over with quickly. So not just educating the families about it but educating staff about it. So it really is hard. I mean, I know it's not easy but there's some things you're just not going to give a pill for. And really, and this is where education really needs to, you need to push on that. All right, so next slide. All right, so I think that's our last one. And I think, you know, we talked about the behavior analysis and non-pharmacologic treatments. So really try that first. Sometimes just little, little tweaks in their daily routine can make a big, big change in how they behave. And, you know, and just, you know, look at all the medications. There's a lot out there. Trial and error. You're sometimes not gonna get it right the first time. Right, and that's actually expected. And it's also okay to increase the dose up. I think sometimes we start at one thing and then we're not comfortable at increasing the dose up and, you know, do that. Increase the dose up and see if you get a better effect. And obviously if there's adverse effects, you wanna stop the medication and have the effects clear up before, you know, trying something different. Okay, I think that's it. Any questions? Okay, I knew the chat box was going, firing off. So thank you for everyone for putting it in. And hopefully we got to all the questions in the chat box. Okay, great. Yeah, Trazodone works great. I agree. All right, I think Paul and I are also doing the next one, right? Yes, we are. All right, so we're gonna just jump right into it. All right, next slide, please. So we're gonna talk about supporting the caregivers in the home-based setting. And many of us have done this for a while and I've said it before. Next slide, please. It is really important to support, to take care of the patient and also support the caregivers because if the caregiver is distressed, if the caregiver's questions are not answered or they feel like they're left out of the loop and so on, then the care of the patient is not going to be optimal. So the objective for this section is, again, show the importance of caregiver support in HPPC patient and discuss the impact of caregiver burden on the caregivers. We're gonna talk about assessment tools and screening tools related to caregiver stress. We're gonna talk about resources for caregivers to provide support and to help them cope and define the types of in-home support and aid for the HPPC patient and their caregivers and talk about resources for HPPC practices that don't have a social worker embedded within their program. Just the last example that Ina was talking about, about the no sleep, right? That's a very common scenario. Our caregivers, they're just so desperate and we feel so bad for them, whether it's a no sleep for the family members who's got to work the next day or the professional, the hired caregiver is about to storm out of the house because he or she's not getting any sleep and the family is seeking advice and some guidance from us. So it's really important for us to support them. Next. So why is it important to care for the caregivers? Because informal caregivers suffer from stress and financial hardships, which can increase their level of depression or poor medical health overall. These caregivers often provide care to their loved ones with no financial reimbursement and often they go without any kind of recognition and they do this day in and day out. They rarely have a backup to help them cope with the stress and many of them have limited resources financially and socially. Next slide. Next slide. So the caregiving burden has become a major public health concern as the population ages and we're trying to find ways to take care of our patients outside of just putting them in a facility. The caregiver stress can be a physical, psychological and also can be a financial stress as well. And about half of the caregivers rate their burden as moderate to high. We're gonna talk about one of the tools that we often use to assess caregiving burden later on in the talk. So what are, next slide please. What are some other factors that increase the caregiver burden? Cognitive impairment, low education, depression, anxiety, low socioeconomic status. Next slide. Being married, living, well, that thing that's being disputed. I think there was a JAGS article in 2019 that talks to that being married didn't increase caregiving burden as we once thought before. Living with a caregiver can increase the burden and also female caregivers report greater caregiving burden than their male counterparts. Next slide. Other factors influencing the burden to a caregiver includes cultural differences and roles. What are the expectations for the caregiver within a particular cultural context? Does the caregiver feel they have a choice in terms of duties that needs to be performed? Are there other support in place or the lack of support in place for the caregiver and the care recipient that can increase the caregiving burden for our caregivers as well? Next slide, please. And here are some assessment tools regarding caregiving burden or caregiver burden. The one that's commonly talked about or used is the Xeret Burden Interview. There's a long form and I think there's a short form of 12 questions. You can see additional caregiver burden assessment tool there as well. Next slide, please. So what are some of the support that's out there for caregivers? Well, the primary support is often informal, kind of a social network through social media or just through church or our neighborhood network. You know, it's part of our job as providers to explore how much support from family and friends is available to the caregiver and also provide some educational resources as well as referral to other resources, both national and locally, whether I think somebody mentioned in the Alzheimer's Association, it's a good place to get additional information and support and also your AARP. A certain church or religious organizations may offer some caregiving support. I ask you guys, all of you to consider exploring that with your patient and their caregivers as well to see if there's some additional resources that can be provided. Next slide, please. So in terms of providing the support for our caregivers, we educate them on coping strategies to help them reduce anxiety and increase the overall satisfaction in terms of the work that they're doing and have a positive impact on the lives of the caregiver. We encourage them to focus on problem solving and it's key here is accepting help. Many of our caregivers have the attitude of kind of a martyr syndrome. I don't know how many of you have experienced that. I've come across many caregivers who are just going to give up kind of everything for the care of their loved ones and it's part of our job is to explain to them that's not necessarily good for them, not necessarily good for the patient, encouraging them to open up to others to get help, whether it's professional or informal support from the community. Next. And again, our job as providers going into the home and we really have a golden opportunity to really sit down and talk with the patient and the caregivers to really experience what struggles they're having and get a sense of the challenges that they face day in and day out in taking care of these patients. We really, and I have said this before, we have such a unique opportunity to do this and to make a positive difference, not only in the lives of our patients, but also in the lives of our caregiver. Next slide, please. Ina, I think we're gonna go into the case study, right? So next slide. So just going back to Minerva, I think just to tie it back to Minerva and caregiving, as mentioned in the case study, the daughter is a paid caregiver in the home, the son has the healthcare power of attorney, patient unfortunately has had recent hospitalization and signs of decline. And you guys can probably guess that children are not have different perspectives around the goals of care. So there might be some conflict down the road. So one of the things about, next slide, sorry. One of the things to first, just to talk about caregiving, we're gonna actually, Paul and I are gonna talk about prognostication a little bit later, advanced care planning later. It's just first mainly to educate them about what is dementia and really have them understand the disease stages and progression. And there's a lot of education that needs to happen. People really don't know what to expect. And if our job is to educate them and know what to expect, I give a story often where I showed up at a patient's house, daughter was very well-meaning and, but you could tell she was stressed. And she told, and she's like, she then apologized. She's like, I have to clean my mom. My mom just had a bowel movement. And I was just like, oh, okay. And I followed her into the home and I was just like, would you like me to help you change her? And she was like, yes, would you mind? And I was like, no, let me help you turn her. And then she was turning her. She then was like, mom, are you done? Are you done having a bowel movement? Her mom had end stage dementia, right? So you know, like her mom's not gonna respond. And the mom didn't respond. And she's just like, oh, and the daughter turns to me. She's like, oh, she does this to me all the time. She won't respond to me. And then I turn her back, I clean her up. And like half an hour later, she has another bowel movement. And she's like, why should she do this? Why is she so mean to me? And I'm like, and I literally was like, Pat, she's not mean to you. She doesn't know anything. And her daughter was like, what do you mean she doesn't know anything? She's being mean. And I'm like, no, Pat, you know, I'm like, she's not being mean at all. This is end stage dementia. She has no control over her incontinence issues. And so we spent like half an hour talking about what is end stage dementia? What should we be expecting? And it was a real aha moment that, you know, just because we as providers know, because we live and breathe it, our families, caregivers don't know about this. So education is very important. So next slide. So, you know, caregiving is, you know, we all see it. It's very stressful to family members. You want to explore stressors, what else could be stressing them out? There's a really great thing. And I have to say, I did not know this was here, but I'm going to use this more. It's called the Provider Caregiver Bill of Rights. Just Google it and it comes up. And what it is, is that it really gives, you know, there's like 10 bullet points and really just serves to remind caregivers that it's okay for them to take a moment and care for themselves and to acknowledge their feelings. So now it's like caregiving is hard. So like, for instance, one bullet says, I have the right to take care of myself. This is not an act of selfishness. It will give me the capacity to take better care of my relative. Another bullet, which I really like, is I have the right to get angry, be depressed, and express other difficult feelings occasionally. So really just helps them normalize that what they're feeling is okay, is normal. Next slide. So you will also, other things that, you know, they're up against is the financial stressors. You know, how can they pay for more help in order to relieve, you know, for them to take a break? You know, one of the things that I always worry about is the caregiver is gonna get so burnt out that they're not gonna wanna take care of their loved ones anymore. So I'm always looking for ways like, are you taking a break? How are you taking a break? Who can help you come in and take a break? Medicaid waiver programs are wonderful. I try to get as many of my patients, if they qualify on a Medicaid waiver program, because then the state will pay for aides to come in to help not only give care, but provide the caregiver with some time where they can go. And honestly, like I have one lady who was so burnt out, she hit her husband. And I told her, I was like, that's a no-no. I was like, you cannot ever, ever do that again. And she was self-aware. She was like, I know, I don't know what happened. I just snapped. And I was just like, you know, so when she had aides, and the thing is, she actually had aides. And I was like, what are you doing when the aides are here? And she's like, well, I still, I'm still around. I have to like, you know, be around to help them. I'm like, no, that's the aides job. I was like, and I told her, I was like, from now on out, when the aides are here, I need you to leave the apartment and I need you to take a walk around the block, you know? And she was just like, what? I'm like, you need to walk around the block. And she was just like, and literally, I had to like coach her to say, take a walk around the block. And then when she realized that nothing was gonna, that was gonna happen to her husband when she was not hovering over him, she was like, I'm gonna go to CVS. I'm like, you do that, you know? I was so happy she went to CVS because that meant she took a half an hour of break for herself. And she even realized that she needed a break. And now she really, you know, anticipates when the aides are coming and takes that break. Adult daycare can't recommend them highly enough. Unfortunately, some of our patients are not social or it's a real big deal getting them out of the house. So they don't go. But when the patients that do go, both I think patients and families really benefit from it. Next slide. Okay, so, you know, health aides are expensive. You know, Medicaid, you know, if they qualify, great. And state will pay for it. But you know, most of our families don't qualify for Medicaid. So they have to pay out of pocket. And that's a really big out of pocket cost. I think $18. I don't know who has $18, not where I live. I think the lowest I've ever seen it was 25 bucks per hour. So it is really expensive. So you can be very formal about it. And there's a lot of home health aid agencies that will provide that. Next slide. I have families that just go out and hire people. So they have their own kind of, you know, care.com. I have patients that have, families that have gone to care.com and got caregivers. They find, you know, family friends. They put out job listings. They go to church and they put up a posting. So I have all things. I mean, I think the craziest thing I ever had was I had a patient who's son hired a caregiver to supervise the caregivers. So it was like a secretary for the caregivers. And there was like four caregivers that basically just rotated, you know, and took care of this elderly gentleman. I was like, this is not a bad setup at all. So you can definitely hire your own if you need to. Next one. And I'm sorry, next slide. And then there's of course, respite. Respite is really, you know, I think sometimes hard. Medicaid will pay for it. Long-term care insurance, if the patient has it, will pay for it. Medicare does not pay for it. The only time it will pay for respite care is if the patients are enrolled in hospice. And I think that takes us to our last slide. Yeah. So, you know, I think, you know, I'll just leave you with this. And I was actually taught this by my, you know, when I was in training. And one of the things that he taught me was that with caregiver and, you know, really to, what you should do is at the end of the exam, you need to turn to the caregiver and ask them, how are you? You know, patient, honestly with dementia, they're oftentimes there's really not that much more we as provider are adding, especially as they move into the late stages. But what you are adding is that you're recognizing the caregiver and you're saying, how are you doing with all of this? I can't tell you how many times when I've asked that question people break down and cry because no one has taken the time to recognize them and also to thank them. So what I do is I say, how are you? Give them time to vent a little bit, show emotion, whatever they need. And then at the end of it, be like, if no one's ever said this to you, I just wanna say, thank you because what you're doing is absolutely heroic. And it's amazing how many people respond to that, how many caregivers really respond to it and are happy that somebody recognizes it. And again, the more you do this, the more experience you get with this. And this was actually taught to me by a patient member, patient, actually a caregiver. She was a great, great caregiver, one of the best. I wish I could clone her. And she was taking care of her husband who had dementia and she was a dynamo. She went to caregiver support groups, dementia support groups. She knew dementia like the back of her hand and couldn't be more pleased with her. But she said to me, pulled me one time, to the side one time. She's like, you know what I just miss? She's like, you know, I do all this for him. I'm willing to do it. I love him. You know, I wanna do it. She's like, what I really, really wish is if you would just say, thank you. And I was just, and I realized like, she was never gonna get that thank you from him. So I was like, well, you know, he's probably never gonna say it, as you know, but I can say it for him. So thank you. And she was like, she was just like really pleased with herself. And she was like, thank you. You know, she's like, you're welcome. I'm like, okay. So I think those are kind of things that we have to do as providers is not to, you know, take care of the patient, but at the same time, remember the caregiver is often the thing that's separating them from staying at home versus them getting placed into a nursing home. And so they're just as important to, you know, to recognize and appreciate. So, all right. So I think I'll end it at that. And, oh, I ended six minutes early. I really, we did well, Paul. You got us back on track. So do we have any questions? Seeing that Paul and I did the last two sessions with you, we have six minutes or five minutes now. Does anyone have questions to talk, to ask us? And you feel free to take yourself off mute or we both do have our chat box up. So if there's anything. You know, Ina, as we wait for questions, I echo so much with what you said at the end. I've gotten into the habit of closing my laptop at date on the visit and just turn, just facing the caregiver before I go. I just say, you know, how are you? And you're absolutely right. You know, the lip starts to quiver and the tear starts to flow. Yes. And in your comments, exactly what I hear, it's just like, nobody's ever asked me this. Nobody really cares about me. It's always about dad or it's always about, you know, whoever that they're taking care of. You know, so much of what we do, it's about relationships, right? HBPC is about relationships. Relationship with a patient, with a family members, with a hospitalist, with a home health agencies and so forth. And it's that building of trust and it's building of that relationship that is so critical. We're gonna talk about prognostication in a little bit. And then when we have those difficult conversations, right? This is where you build that trust and you acknowledge the hard work that they're doing. And so absolutely, I encourage all of us providers, don't forget to take time and take care of the caregivers. They are such an important part. They are the heroes. Somebody mentioned in the chat box, they are the heroes in the care of our complex patients. I often call myself, I'm just a cheerleader that comes and cheer you on. Thank you for doing the hard work. Yeah. I think one of the things that is so heartbreaking for me with COVID is the impact on caregivers. And at our, in like our CFEs, they're not allowing visitors. They can't see their loved ones. They, you know, there's a heartbreak with that. They may be, have lost jobs. I mean, it's, it just is heartbreaking to me. I absolutely agree with you. And, you know, I was just rounding in a senior high rise and they pretty much locked people down there too. And my 91 year old was like, you know, she was fine, you know, and literally I was like, well, I could get up and go, you know, you know, but I was just like, but you could sense she was really lonely, you know? So I was like, you know what? You want to talk about the election that just happened? And she was just like, I would, I would love to talk about it. I was just like, all right, let's talk about it. You know? And she thanked me. She's like, thank you for spending time with me. Right. And then, and then later on the daughter called me and was just like, hey, I heard you talk to my mom for a bit. She really appreciated that. I was like, yeah, no problem. You know? So, so right. I think, you know, our visits sometimes are sometimes the only people they see, right? You know, the caregivers aren't leaving because they're tied to the patient. And so sometimes we're like their only, you know, you know, connection to the outside world. So they're happy to see us. And sometimes I'm like, well, I'm happy to see you too. So, you know, let's do it. Let's have a happy visit, you know? So I, so I think we are, you know, we do have to bring a little cheer to them too. Yeah. Yeah. I also have, go ahead. When I am beginning to see a little more often is the family member taking out their loved ones out of the facilities and not expecting the amount of work that has to be done to take care of them. So the stress is almost sudden. The shock of the whole thing. They miss the family members. I saw a lady yesterday and her mom has been living in a facility for the last nine years, but because she couldn't see her, she brought her out. Yeah. And she was one day into it and she was already stressed out. Yeah. And so I was explaining to her about different option about paid caregivers. And she's like, I can't afford that. And I'm like, well, you also have to, you know, think about your health because you're going to be it. And so at least this morning she's, she asked for some more information about that. But her mom is like stage, like stage seven. She's just more than growing dementia. She's total care. Total care. Right. And families don't recognize how much care that is. Absolutely. She's recognizing it now. Like full on, full on. Yes. I know. It's in the right place. I think there's also this element of guilt often that I see in caretakers, right? The guilt when they transition them into long-term settings. And you can tell they have a hard time of letting go and sometimes acknowledging that, okay. I know all the work that you've put in up until now and it's okay. It's really a lot of work that you put in and now it's your time to still take care of them but without the burden, having it at home, right? So I think just sometimes giving them that permission to let go of that, you know, I have to be the one. You really don't. Like you still coordinate that you're a great resource. You're the advocate, you're the voice, but you no longer have to do the body, the physical work, right? Often an elder spouse. So I think sometimes just acknowledging that guilt and relieving them of it. They're all like, thank you so much. I felt so guilty for doing this but allowing them to let go of that responsibility. I think sometimes it's really also helpful. Oh yeah, absolutely. Sometimes I'm like, I'll be the bad guy. Like you don't have to tell them that they're going into a facility, right? Like I'll be the bad guy because I'm not family, you know? And I was like, and I'm the bad doctor, right? Like the bad doctor. And the doctor's like, yes, yes, you tell her. You tell her that she needs to go. And I'm like, I will take that burden from you, you know? So you're absolutely right. Sometimes you just have to give permission that it's okay. Yeah, so, okay, we're at time. So, and I think we have a, do we have a break? Yes, thank you, Paul and Ina. Such great information and what great stories to end our session on. Thanks. Just to let everyone know, slides for this workshop can be accessed on the HCCI Learning Hub. We've seen those comments in the chat. And as a reminder, we're asking you to please continue to fill out your learning plan. We will now break for 15 minutes and we ask that you mute your mic during this time and turn off your camera. We will see you back promptly at 2.15. Thanks. Break. The chat has been busy and we are looking forward with connecting with you all. So for those interested, we will be staying online for about 30 minutes after the workshop ends today. We hope that you will take this opportunity to get to know each other better and make some connections. As we know, it takes a village and we'd love to have you be part of ours. We'd like to welcome our next speakers, Michael and Brianna, who will be discussing enhancing productivity and reach through telemedicine. Take it away. Hi, everybody. I was just thinking, this is the first virtual conference I've spoken at, not the first I've attended. And as I still have a little piece of dark chocolate in my mouth, I was hoping that everybody was taking an opportunity to spoil yourself a little bit and have the special snacks that we would probably be having if we were meeting together. So our topic, our next topic, enhancing productivity and reach through telehealth is really a conglomeration of best practices from folks in home-based primary care and sort of meant to give everyone some insight on our response to the pandemic and the extension of billable telehealth visits. Telehealth has been around for a while and before this Medicare expansion, there was payable use, reimbursable use in the hospital setting for specialty consultation for telehealth. And through the latest, the pandemic, it's been expanded to us. The other thing I wanted to mention before we start is we're all brand new in this together. There are best practices that are coming out regularly that are being published. And not only for the provider, but for patients. I've recently seen articles like an AARP that says, I'm gonna meet with my provider virtually. How do I do that? I'm sure that it's not gonna go away. And we're likely gonna see core competencies in this area based on our specialties going forward. So with that, next slide. Our objectives today are to examine various clinical scenarios that either are supportive or not so supportive of a virtual environment, discuss the challenges and solutions to virtual care with complex patients that we work with. And then we'll work on the review of coding and documentation that's required in response to the pandemic. Next slide. So why telehealth? There's no denying whether you like it or not. I'm sure that we all have our ideas on the topic, but there really is no denying that it can expand access to care, the timeliness of care, some coordination efforts around care. It can allow you to define your market share, your market distinction, where you wanna cover, expand your market. There are some ways that it can improve the culture among your staff and patients and caregiver satisfaction, and as well as educational opportunities for the residents or trainees. And then most importantly, in the pandemic situation that we're in, it can improve safety by limiting unnecessarily exposure. Next slide. One thing I wanted to mention, just this week, Hopkins in the realm of continual process improvement has just sent out some numbers about our telehealth program within the community physician group of which J-Home is part of. There's been tens of thousands of virtual visits, and they are currently compiling patient satisfaction data on that. Preliminarily, they said that overwhelmingly the patients were satisfied with it, even though there were recognized technical glitches. And the next aspect they're going through is to evaluate the provider's experience. So the telehealth experience, as I mentioned in the previous slide, gives opportunities for greater patient access to care. Depending on the model that you build, they may have sort of on-demand access to a provider. As I was mentioning, the Hopkins evaluation of our telehealth program corporate-wide, it was a way to continue a revenue stream as well as keep our schedules open to see patients. It's also a way to do just sort of the virtual check-in that we've kind of mentioned, an opportunity for social workers or nurse or end-even providers to check in on the family and care recover. And early on, that's primarily how we used the visits was, you know, originally, do you have your medicines? Do you have food? That kind of thing. And I already mentioned that it's a way to limit exposure. The challenges that most of you are probably already familiar with if you're using a computer in the community-based setting regarding hardware and software are you were already familiar with. There are so many sort of working parts that I think we totally forget about that can go wrong. And you're left wondering, you know, is it my internet provider? Is it my security system? My firewall? Is it the EMR? That doesn't go away with virtual visits. And then there's the challenge on the patient's end and their ability to manage technology. And then how do we interact with other practices and providers? Next slide. So when you're getting started and thinking about your virtual visits, there's some things that you want to keep in mind. First, identify, is there a need? And what patient population? And how are you going to use it? Some things that we thought about were, you know, is this best used for a high utilizer where we can do more regular check-ins virtually? Or is their clinical care so complex that their needs can't be addressed virtually? The other one I already mentioned is sort of is this an opportunity for a simple virtual check-in that doesn't necessarily require a provider and can be a nurse or a social worker or another member of the team checking in. When you're getting ready to start, as with any sort of test of change, starting small is recommended. And when, so you want to start small and then you want to do your training and conduct a mock scenario. Our office did do mock scenario sort of behind the scenes. It was really just meant to test the reliability of the hardware and the software that the providers were involved in. But going forward, we did identify a small group of patients that agreed to participate. And I have to say, one of my patients we picked because they were sort of a special population, husband and wife who are deaf and the ASL interpreter couldn't come, they weren't coming out. So in that scenario, we kind of, we had to have the, I had to be in the home with the interpreter on the other end, that's a separate entity. So special scenarios, you might try to think like that. You may try to think to include them in your small test of change. And then you want to make sure that your EMR is ready and that you have the capability for telehealth billing all ready to go. This at Hopkins was done at the corporate level. It really didn't require much in the way of our, of J-Homes to do any work with. Next slide. When you're identifying a platform, you want to decide is it for long-term use versus short-term use? And for us right now, we don't know. I think a lot of us are thinking that this is probably not going to go away. I think even if the billing opportunity goes away, now that sort of the option is there, there's probably other uses for the virtual visit, whether it's, you know, another provider that's not a billable provider's visit over the phone or over the virtual visit. Next, think about the number of providers that are going to utilize the platform. There may be a per provider fee that may impact your choice on which platform you decide to use. And of course, each provider has to be trained before starting the use. You need to pay special consideration of HIPAA compliance. That's been one of the considerations with Hopkins about which platform we use, which ones are allowed to use and which ones we aren't allowed to use because of HIPAA. And then ease of the providers you should be considered. My mantra is count the number of clicks because it drives me crazy when I have to click six times to submit an order for something, but that's just a little side soapbox. And then again, the ease of the use for the patient, and I already talked about the cost, ease of the provider and patient use, we'll talk a little more about in future slides. Next slide. Here are some examples of telehealth platforms that are out there, FaceTime, Facebook Messenger, Zoom, Doximity, Google also has one, I can't remember the name of it. I've used most of them, but this is just an example of some of the Citrix. What's the, anyway, there's several. If you use Epic, Epic has a platform embedded in its Epic. I don't know if that's across Epic's entity or not, the same or not. Next slide. So regarding ease of use for the provider and sort of the end user, whether it's a patient or someone else on the other end, we found this very important to have available what the provider sees and what the end user sees, the user is the one who's going to be able to see what the provider sees and what the end user sees, the patient or the caregiver, whoever's on the other line. And these are example screenshots of what the patient sees using Doximity. And when your front office or whoever is helping with your IT is aware of what they're going to see when there's an issue, they know kind of how to help troubleshoot or instruct the patient on how to get through the steps. The Doximity invite on the left, it's pretty easy. There's, but there's several sort of screens that you have to navigate through before you're given a secure connection with access to the video on the patient's end of the call. Next slide. Consider facilitators during telehealth visits. So this sort of begins the conversation about your model, the model of care that you're going to use for your telehealth visit. At J-Home, we do often use facilitators for our telehealth visit. Our learners may be in the home, our residents, fellows, med students, they may be in the home or the provider may be in the home and the learners on the other end. Either way, the person that's with the patient is helping to facilitate the visit. We've also used home nursing to facilitate visits and we've had specialist provider, we've facilitated specialist provider visits with our J-Home staff being in the home. Next slide. So getting your staff ready, you need to determine who's going to do the education, how will the schedules be adjusted related to telehealth. So originally I would say initially and on sort of our first peak in the springtime pandemic, our telehealth visits were almost as long as in-person visits for whatever reason, whether it was just what our patients and families were going through in the home, they were anywhere from 20 to 40 minutes a visit, which was much longer than we predicted. So something to think about how you adjust your schedule. Now we're reconsidering our approach and thinking about how many we can see in a day if we decide that we're going to have a day that is a complete day that's virtual. Right now, realistically, our schedules are blended. So we have in-person blended with virtual visits. Will you use telemedicine facilitators? We already kind of talked about that. For those of you that have MAs going out in the home, it may be another option for you to sort of extend your reach. If that's the case, how will you make sure that they're all trained in their role? How will you develop and adjust and document workflows? That's what we're going through right now as we're re-navigating the surge again is thinking about how we can optimize our schedule for virtual visits. And then how are you ensuring success, quality, and patient satisfaction? For us at J-Home, I have to say that anecdotally, of course, we monitor this. And because we work so closely with our patients and with our Hopkins Home Nursing staff, we get feedback pretty regularly. But our program at this time is not doing anything formal to evaluate satisfaction. But as I alluded earlier, our larger entity of Hopkins is looking at this. Next slide. And then to determine patient's readiness, the one way that we did this initially is in our weekly interdisciplinary team meetings and our daily huddles. We started daily huddles while working remotely. And just sort of to touch base on whatever was coming up, whether it's clinical or otherwise. And this is one primary way where the providers said whether or not the patient and or family caregiver could participate with a virtual visit just by what we know in the home. And that is, do they have the skillset? Do they have a smartphone or a device that will foster a virtual visit? Do they have Wi-Fi? And then the other thing is sort of, can the patient navigate that or is there a reliable caregiver that can navigate that? Then we determine sort of our approach to virtual visits. And what we generally do, if the person is appropriate for virtual, and I haven't reiterated the fact that they also have to be clinically appropriate. If it's someone that needs close monitoring for glucose, wounds, heart failure, COPD, that it's just too complex to do over the phone, even if they had the ability to do virtual, we probably would say that they needed an in-person visit. If possible after screening. But once they're determined to be virtual appropriate, generally our standard is two to three virtual visits and then followed by an in-person visit. And most of our patients we see every four to six weeks, in some cases longer, but this way we roughly figure that we would see the patient in person every three months. Michael, I was just gonna mention, I know some people have put it in the chat too, this is something you can use your team for, doing it on intake or doing proactive outreach to your patients. Do you have a smart device in the home? Do you have internet? I've even seen practices take that farther and they're doing proactive social determinants of health screenings. Do you have food? Do you have your medication? Have you been isolated? Is your caregiver no longer available? So use your team, document that in your EHR and these telehealth visits, especially with this population take time. So if you do have that staff that can even, just go over it with the patient and caregiver or that informal facilitator, explain how it works, set it up before you pass it to the provider to actually do the visit. All of those things are really gonna help with efficiency. Yeah, thank you, Brianna. So we do screen for MyChart if they can get on the patient's EMR platform. If they're interested in doing that, they have to be given access and our schedulers do that. You triggered some other thought I was gonna mention. What was it? Oh, it's gone, I'm sorry. What was it? Well, nonetheless, if I think of it, I'll mention it. The next thing that we wanted to be careful to do was if we're in a virtual visit and there's clearly a need for an urgent visit or an urgent concern that needs to be handled in person, was that we wanted to make sure that we had room in our schedule to schedule an urgent visit, say in the next one or two days, given the scenario. I don't think that we've had a scenario where any of us have had to go out on that day. So what I'm saying is that we, no, I take that back. We have regularly switched from a phone visit to an in-person visit and vice versa. So it's something to keep in mind. It's also where the daily huddle has come into play. In those cases, we were able to do it before the day starts and said, no, this patient can't be virtual or yes, this patient can be virtual. Next slide. So to Brianna's point, this is, and to several of the points in the chat, this is sort of the patient, an example of the patient screening for readiness for telehealth. And it asks, do they have access to internet? Do they have a data plan? Someone said, we wanna be thoughtful about them going over their minutes and all those types of things. And then as I mentioned, do they have access to the portal? And then what device are they going to be using? Desktop, laptop, tablet, or smartphone. Next slide. So some of the best practice thoughts for the provider end are listed here, avoiding loud colors, bold clothing. They can be blurred on the video screen. You wanna try to look at the camera, avoid backlighting. Don't yell, let the microphone and speaker do the work. I think you've seen a number of folks using headsets. You want to try to be in a quiet room, avoid a lot of movement behind you, people walking through a hallway or staff coming to answer the phone if you're in an office space setting. And then avoid overuse of hand gestures. I've seen other comments that are practical, you know, that you still wear your name badge. Some people suggest that you still sort of portray that clinical image you might put on a lab coat you might put your stethoscope around your neck, those types of things. As I mentioned, sort of these best practices are evolving from the provider's perspective as well as the patient's perspective. Next slide. So sort of the practicalities of the visit with a video telehealth visit, you can only document what you see. So you do have to modify your documented physical exam if you're using a templated form. You do need to make some adjustments. You may think about making a virtual visit form. This gives you examples of how you can document what you see. And it's perfectly acceptable to record the vitals if the patient or family can record those in the home. In our templated form in Epic, it specifically says patient measured vital signs. Next slide. This continues how you can document your visual physical exam. For cardiac, the one that's missing that I would say is documentation of skin tone that would indicate adequate perfusion. Next slide. So I alluded to these things, establishing your workflow for telehealth. And these are some specific examples where maybe telehealth cannot be well-utilized, a new or acute concern, new abdominal pain or new flank pain, something like that, fall with worrisome for an acute injury. You may decide are not good telehealth options. Worsening wounds I mentioned, suspected narcotic misuse. We actually, some patients, we see all of our patients on chronic opioids monthly. In some cases, now we'll see them virtually monthly if that's the primary reason why we see them. That's when we do our refills. And it's really cut down on calls and that sort of thing. Also enables us to better manage their pain and their medication use. I also mentioned already serious cardiopulmonary diseases may not be appropriate. Changes in cognition. Definitely the lack of a reliable caregiver impacts whether or not I'm going to say that a patient can have a virtual visit. And medication titration, I have to say, I almost never say that they can have a virtual visit because as I said previously, it's always the meds. And when it's not the meds, it's the meds. So I just see too many errors when I'm titrating a drug to do it virtually. Next slide. Next, we're going to go over some models, use cases or models. Next slide. So these are three approaches to telehealth models that you could consider. At J-Home, we utilize all three. First is direct to patient. And this is where the provider's on one end and the patient's on the other end. Phone calls may be also an alternative. In some cases, what we've done when the video visit's not working out or the Wi-Fi, you lose connection for whatever reason, we'll switch to phone. One thing that we've done, which has been sort of a change from the spring, is now we always call first. So we have a phone call before we initiate the video, the text that they're going to get to make sure that they're ready, the phones are within reach, they can hear it, all that stuff. And it's really to avoid missed visits. Works much better than just sending the text multiple times. And then there's the facilitated or tele-presenter model. And I mentioned this is there's usually the providers on one end, and then there's someone on the other end that's helping to facilitate the call. And we do this with our visiting nursing staff, our learners. Those are the primary two types that we've done. We do have MAs. We haven't utilized them in this format. We don't have scribes. We're marketing for our social worker at this time. We've just retired, so we haven't utilized them. But those are options that you may think about. And then provider to provider, this may be an option where, in our experience at J-Home, I'm in the home and I can connect the patient to a specialist visit virtually. It works very well. One recent scenario I had was a patient that had a laminectomy with 78 staples that I sweated my way through taking out. Anyway, I had a co-visit with the orthopedic surgeon just because he wasn't able to get back for his post-op visit. Next slide. So J-Home telemedicine model and learning, what did we learn from all this? Primarily, all visits are virtual. And that's really what we've decided to keep everyone safe in the surge in numbers in the state of Maryland. Whenever possible, we do virtual. And then if there is any exposure concern in the home, they're screened the day before and then again the day of the visits converted to virtual. Always making sure that the patient and caregiver readiness is so important. And that's really where we've learned that calling ahead is best, just really ensures the success of the visit and that you don't have a missed visit. IDT meetings or however you meet daily huddles are a great way to really make a determination of whether or not virtual is appropriate. And it takes the worry of the front office team to have to make that decision. You make it jointly. Doing this, the front office actually started keeping a list of who is appropriate for virtual and who wasn't. Allow scheduling flexibility to accommodate urgent needs I mentioned. Minimize risk while creating access, so avoiding exposure but still getting their regular visits in. Partner with home health and other community partners to facilitate the visit. And then as I mentioned, we think about two to three virtual visits immediately followed by an in-person at the next scheduled visit. Next slide. So this is an example, a model from a facilitated tele presenter model from the Cleveland Clinic. They use this model using the American Well Express care platform. They employ EMTs who travel to the patient's home and do an initial assessment with vital signs on that. And then that information can be shared in the virtual visit. That's actually what I lost my train of thought about. Some models, an MA may start the virtual visit. And they may collect the chief complaint. They may enter the patient's home vital signs. And they may start the documentation of the visit for the provider, much like in an ambulatory setting does. For that to work well, I think you really would probably have to have one type of visit for the whole day with an assigned MA sort of opening the visit for you all day. I've seen it work. But we haven't done it because, as I mentioned, our schedules have been blended. I'll just, as an aside, before the pandemic, University of Maryland actually employed this EMT model in virtual visit for high utilizers. Next slide. Telehealth may also be an option to expand care within a limited workforce. We mentioned this sort of in the beginning of today's session. There's over 6 million homebound or semi-homebound patients out there. And of those patients, only 12% are getting regular primary care services in the home. Utilizing a model like this, including things like an RN triage platform with protocols that they can follow, and adapting that to incorporate with home-based primary care may be an option to expand access to care for our homebound patients. Next slide. So evaluation and pitfalls, sort of in the continuous process improvement, you want to consider tracking areas of opportunity for improvement. And these are some of the ones that we do monitor. How many visits are being converted to telephone only instead of audio or video? This is likely due to reimbursement. We want to get paid as much as we can in home-based primary care. And the audio-only format is paid at a lower rate than the video. Create and track visit types, telephone versus video versus in-person. This was relatively easy for us because we were already tracking visit types like urgent hospital follow-up, close follow-up, those types of things. How does telehealth productivity compare to in-person visits per provider and for the practice as a whole? There is no denying that eliminating the travel time and all that, that there is a good degree of efficiency with virtual visits if you can incorporate them. Patient satisfaction scores are something that we probably need to formalize a little bit better than we do right now, something I would recommend looking at. And then ER visits or hospitalizations, are they increasing? This is something that we always look at. So it's not new. Every acute encounter for our patients, we look at and monitor sort of why did that happen. Was it a missed visit? Was it a missed phone call? Did they not call on call? Those types of things. Next slide. This is just some additional resources that are available to you regarding telehealth. And next slide. And next from here, I will turn it over to Brianna. And she's going to talk about opportunities for billing using the telehealth model. Thanks, Michael. So we realize, obviously, whether we all like it or not, you've probably all been doing telehealth. So maybe you can just, I know we're getting in the afternoon, a reaction of raising your hand if you're using telehealth, or kind of share in the chat what you're familiar with and what you're not familiar with and what you have questions on. So I can kind of tailor how much content we cover as we finish up this section. So just kind of framing our minds, before the pandemic and before we got these, what are called the 1135 telehealth waivers that came out of the emergency declaration and the COVID Preparedness and Response Act. For Medicare purposes, to cover a telehealth service, it was limited to rural areas or metropolitan shortage areas. And they expected the patient to actually travel to a health care facility that was called an approved originating site to receive that service. So we greatly got expanded to telehealth on a temporary basis during this pandemic. The reason I like taking time talking about it is because although these have been around and we've all been using telehealth for a few months now, we had two different interim final rules with different guidance and changes that kept happening. And for anyone that might not be aware, Medicare telehealth services is an active OIG work plan item. So what that means is that the Office of Inspector General plans to do nationwide audits to compare the telehealth services that were submitted to verify they were actually reported appropriately. And there's a lot of options. So hopefully, this clarifies what you're already doing. But I would encourage you to go back, do some internal auditing, talk with your staff about what kind of virtual services they're billing, because it's really easy and the codes are very similar to get them confused. And then hopefully, people are aware actually yesterday, we got the Medicare Physician Fee Schedule final rule for calendar 2021. There's still a lot of lingering policy changes that will let us know if we have access to telehealth beyond COVID-19. But there's two legislations, if you want to keep an eye on them, it's the Burgess Bill and the Barra-Burshon Bill, that if those get passed in December, will have a significant impact. So I plan to do a HCC intelligence webinar in January when I have more of an update. But just know there was a lot of policy and information released yesterday. But there's also still a lot of pending action that we're waiting on to see what happens. Next slide. I'm going to take a second to just kind of look in the chat here. So talking about kind of broad definitions here, generally telehealth refers to a broader exchange of health care services. It's not necessarily clinical in nature, whereas telemedicine, as defined by HHS, is very specific remote clinical services. So again, for traditional Medicare purposes, if you're billing one of their E&M codes, which is typically the home, the DOM, the TCM, the same thing you're doing. It has to be a video visit. You need to have that two-way audio and video connection. There is some option for phone calls. We know some of these patients, the phone call is really their only access. So we'll talk about that. And then communication technology-based services and remote patient monitoring are other ways that you can use technology to care for patients. Next slide. So if you're using telehealth today, if you're doing a video visit, you should be billing your normal E&M codes, either your home or your domiciliary. Again, this is for traditional Medicare guidance. If you do a video visit, you can bill as normal. You report the same place of service where you would have seen them in person, and you use modifier 95, which was one of the changes out of the interim final rules. That'll get you paid at the same as in-person rates. Again, that's only temporary to not disadvantage people. But if you are doing phone calls, there are options. There are the 99441 through 443 for those telephone calls. Also, advanced care planning. Hopefully, you're using these codes in your daily practice, but those can be audio only right now. So I get a lot of questions about, how do I get paid for goals of care conversations with patients and family members? Well, if it was an advanced care planning conversation, you can bill that as just a phone call right now. It pays about $80. And we're going to talk more about care management as we move on. If you're doing your video visit and billing your E&M, your documentation should be the same as in-person. We still have to think about all of these core requirements. We've provided a sample macro here. The reason I'm recommending in this example is that you're clearly identifying the type of methodology that you used and that the patient and you were located in different locations is because that will validate it's a true telehealth service. There's been a lot of questions around, what if the patient and I are technically in the same site? Or what if the video was disconnected? So using a statement like that will just really protect you and validate the integrity of the encounter. You're welcome to use this or modify appropriately. And also, if you do get disconnected and you have to change to a phone call, if you are going to bill it as an E&M video visit, it would need to be at least 50% of the time where you had that real-time interaction. That's a common myth and question I've gotten, too. Next slide. So Michael talked about exams. Again, you have to have a video to do that. I'm not going to spend too much time on it. Just make sure you're, if you are having someone assist or patient self-reporting vitals, you're kind of making a note of how you got that information in the medical record. Next slide. So you have options, too. You're either billing on documentation and complexity or time, which with the more kind of limited exams or things, time-based billing could be an important consideration for you. It still has to be dominated by counseling and coordination of care. But you can make that case pretty easily for the type of services that you're providing. So again, just total time, greater than 50% of it was dominated by counseling and coordination of care and a description that's specific to that patient and that encounter. For example, 45 minutes talking to the patient or caregiver about coping skills for social isolation supports the 99349, which is our second-highest level established patient health call code. Next slide. So these are the telephone calls. No, these are temporary. CMS clarified in their final rule yesterday they will not continue to pay for these whenever the public health emergency officially ends. But right now, they are reimbursable. It does have to be documented as a patient-initiated encounter. You could be educating them about the availability. But this can't be related to a face-to-face or an E&M visit within the past seven days or within the next business days. So what that means is this isn't you calling your patient after you saw them to follow up on things. Or if you're able to address an acute issue, maybe a skin tear or a rash or something simple like that, where you're able to address it without having to see them face-to-face, then you can use this. Rash might not be the best example, because you probably need a video for that. But you have an acute concern. You address it during that phone call. No immediate visit is needed. Then this is when you can build these codes right now. And this reimbursement was increased recently, too. Again, these are all temporary. Brianna, I forgot to mention this. This is one opportunity that you may have if you have a designated provider that deals with the on-call issues. You may have an option to something that would normally just be a telephone note. Now you may be able to convert that to either a video visit or a billable telephone visit. Yeah, absolutely. Think of all the things in between your face-to-face visits or even your telehealth visits that you address. If it really is an unrelated new acute concern that you address, this has kept a lot of practices afloat. Moving on to the next slide, please. I mentioned earlier, licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech pathologists can all build this different subset of codes, too. So really thinking about your interdisciplinary team and the billing opportunities that might be available for them. If you have social workers and are not used to billing for their services, at least right now, this is a great opportunity for them to get some added revenue for you. Next slide. So really specific, again, this is more informational for you all to go back to. Go back to your documentation. Make sure if you're billing for telephone encounters, you're using that. You're documenting total time, that it was some sort of evaluative in nature. What was the problem? And what was your treatment advice? And that you obtain the patient's consent. Informed consent is actually usually a state policy barrier. It's more of a best practice to get it for every single service-specific encounter, because it's not required for CPT purposes anyways. But you don't want the patient to not understand what they're being billed for, things like that. And your states may have requirements for service-specific consent. So that's why I always recommend consent as a best practice. Moving on. So just a comparison. I'm going to talk more tomorrow about chronic care management. If you're not billing for some sort of care management service, I highly recommend you do that. It's a way for you to get bills paid for all that non-face-to-face time. And I just wanted to highlight the difference in reimbursement. CCM can be great revenue for your practice. So rather than trying to remember, was this an acute concern? Did I see the patient? You could just be capturing all of that phone call time for something like chronic care management, but you can see the difference in reimbursement here. Next slide. So these are communication technology-based services. These actually became available in 2019 before the public health emergency. These are not considered telehealth. So these will remain payable now and after the public health emergency. And we're actually going to be getting a new G-code for 11 to 20-minute phone call discussion, that G2012 in 2021. There will be another option where they indicated it's going to have higher reimbursement. So if you're looking for ways to get paid for phone calls after the public health emergency, remember this. You can also get paid for the review of a video or a photo if your patients are using patient portals or some sort of digital platform, and you're reviewing and providing information and interpretation back to the patient within 24 business hours. That would be when you can use G2010. And also, right now, your clinical social workers, I know I'm plugging them a lot, but they can bill for these services too. Medicare actually just clarified yesterday those other types of professionals are eligible to bill these services. Next slide. So the next type of digital service, again, this is not considered telehealth. So this is payable regardless of if these waivers are in place. Again, this would rely on them using a portal. The difference is this is not live interaction time. This is just a digital communication, and you can actually add your time over a seven-day period. So the patient's daughter sends in a message about their high blood pressure that's elevated. You're going back and forth on that patient portal over a series of days, and you're counting your time, and then you're billing it at the end of that seven days. And again, those G codes are for other types of professionals, such as our licensed clinical social workers. Again, they have billing opportunities too that it's important for you to be aware of. So next slide to kind of tie this all together. This is something, I mentioned the high blood pressure example. This is what I would expect to see in the documentation for an e-visit. It's not very extensive, but you're telling me the total time. You're telling me the date range. You're telling me what the issue was and how you kind of resolved that or what your clinical guidance was. Next slide. And Rosie, there was a comment when you're value-based, you usually have a lot more flexibility. So you have to consider if it's built into your care management via your PMPM. But I've seen a lot of flexibility around a low patient monitoring in particular, where there might be some opportunity for that augmented fee-for-service revenue in addition to your value-based contracts. So it's certainly something to look into. So what is our value-based contract? What is RPM? The difference with this is it's physiological data. So the patient is using some sort of medical device that's automatically digitally sending you, maybe their pulse ox or their blood pressure or their glucose, remote glucose monitoring. You're getting that data, you're interpreting it and you're developing a treatment plan and guiding their care. Before we dive into it, RPM does have a lot of requirements. So there needs to be a clinical indication for it. So there should be an order actually placed with what the diagnosis is and what the treatment goals are. Why are you gonna use RPM for your patient? Right now it can be for newer established patients, but it has already been clarified as final policy that moving forward, this will only, you have to have an established provider-patient relationship to bill for RPM. You also need to get consent, but it can be at the time the service is furnished and it does not have to be your provider. It can be actually auxiliary personnel, meaning non-clinical staff could actually get that consent for you under your direction. And remote patient monitoring could be an incident two scenario where you're providing direct supervision of another if you are using clinical staff to help you with RPM, which is really helpful. But also there has to be at least a minimum of 16 days of data within a 30 day period. So if you're just getting a couple of days worth of information, there is a flexibility right now, but only for when it's related to a COVID diagnosis. So think about that. This doesn't require hospitalization. It's really just, if your patient has a disease where you want to remote monitor their data to make treatment decisions and you think that would increase their care, then you can certainly do so. There's not like very specific clinical indications. You just need to make sure you're doing that. This has to be billed by a nurse practitioner, physician assistant, or a physician. It's not for clinical staff, it's the billing under your license. So just keep that in mind. And what it's not is just your patients and caregivers calling you to report vitals and things like that. You really have to understand, you have to be using technology if you're billing remote patient monitoring. So I'm gonna talk about this in sequence. So when you first start remote patient monitoring, you supply the patient with the device. There's a code that you can bill 99453 for that initial setup in patient education. Again, and this could be someone else, clinical staff under your supervision doing this. This is billed one time per care episode. So no matter how many devices, if you're gonna monitor glucose and hypertension, this is still billed once, no matter how many devices you give the patient. And it's for that entire time that you're treating them. So care episode is defined as it starts when you start recording the data and it ends when the treatment goals are obtained. So that could be longer than 30 days. So it's a one-time initial setup in education. You also get to bill each 30 days 99454. That's for actually providing the patient with a device that's digitally storing and sending you that electronic data on your patient. If we move on to the next slide, this is what happens after the first 30 days. And if you're interested in kind of seeing this sequence, providers, I don't wanna put this burden on you, but I'd encourage whoever your practice leadership staff is or billing staff to look at both the Medicare Physician Fee Schedule proposed rule and the final rule for 2021. They actually laid out a really extensive explanation of ROPM that I have not seen clarified anywhere else. But at the end of that first 30 days, if you, the provider, this is not your clinical staff, so nurse practitioners, physician assistants, physicians are taking at least 30 minutes to review, analyze. You're gonna start to develop that RPM specific treatment plans, what are their goals that you're monitoring? You can bill 99091 for your time. Again, non-direct patient time, you're just reviewing and interpreting and analyzing that data. Next slide. So these are probably the most popular that I've seen, 99457 and 99458. These are considered care management codes. So the difference with these is, this is after you have that data, you have to have a formal RPM care plan. CMS loves their language of you created it, you implemented it, and you're monitoring that care plan. And you're spending, you or your clinical staff, at least 20 minutes per month of interactive communication, which of course they gave us a formal definition for that as well. Interactive communication is a live, two-way synchronous interaction between you and the patient, that at a minimum is having that conversation so that audio only, but it has to have the capability of being enhanced with video. So you have your formal care plan, you're talking to them throughout the month about all this data, you're calling them when you get those readings or clinical staff is, and you're capturing your time similar to chronic care management, you can bill for this. It can be under general supervision too, which doesn't need your physical presence. So that's really helpful to use that interdisciplinary team to help you with this for your patients. But again, just keep in mind, RPM does have care episodes tied to it. So it's not supposed to be an indefinite service that you're just never ending and never stopping the service for them. To kind of tie this all together, if we go to the next slide, this is just to show you the financial impact it can have on your practice. And this is not bundled with chronic care management or transitional care management. You could potentially be billing both as long as the time is separate and distinct and you're not duplicating work efforts. I actually have a practice that was willing to share some data. They're using both remote blood pressure monitors and glucose monitors for their patients. They have a census of about a thousand patients, so keep that in mind. But in a short five month period, they had $10,000 in billable revenue just from RPM when they were just starting out. So it really does add up. Again, it's all those care management codes are time-based. So you've got to have a process for that. You have to be documenting how that time was spent, making sure you're getting all those readings and things like that. But it really can help your practice be sustainable. And RPM is not going away. This isn't subject to the telehealth regulations, like the video visits and things that we're billing. So this could be a way, regardless of what happens with the telehealth policy barriers that we might face, if it goes back to being restricted to rural areas until we have legislative change. RPM is considered a subset of virtual services. So this is always an option for you to enhance clinical care for your patients. So we have some resources. I know I went over a lot of information. You can go ahead to the next slide. Not expecting you to remember it. Really encourage you to go back to the telehealth during COVID-19 and remote patient monitoring tools and tip sheets we've included in the appendix. These are also on our website. They're great cheat sheets. These have a lot of requirements. So just make sure you're taking the time to strategically implement RPM services. I think we're going to see a lot more expansion of this in the coming months and years. And then to just kind of wrap us up, if we go to the key takeaway slide. So telehealth comes with opportunities and challenges. No one is saying that, you know, this is going to replace your gold standard in-person care, but it really can supplement your care. So I'd encourage you to be innovative. Think of how you might use this, even for like we talked about social isolation and just check-ins with your patients moving forward. It's more than just selecting a platform. If you go back and take a look at those West Health resources that we provided a link to earlier in the slides, they partnered with Northwell and did a really expansive pilot and they have free resources on the workflows that they've developed, the use cases, a lot of really extensive information that I would encourage you to compare to what you're doing, but it can take many forms. So know your patient population and what use case, you know, does it make sense to do a direct-to-patient where you're relying on them for the technology and connecting with you? Do you need a facilitator? Who could be that facilitator? Could it even be, you know, someone at the ALF or the home health aid or a nurse that's seeing the patient and then provider-to-provider, how can this increase access to specialists for your patients and really expand your team in ways that your patients may have not had access to previously? And I know we're a little over, I apologize, but that wraps us up. Thank you, Michael and Brianna. We are now going to hear from Paul and Ina covering prognostication, advanced care planning and communication. Thank you again for that wonderful presentation. I always learn something when Brianna and Michael talk about telehealth and RPM. Certainly it's an evolving field and we're definitely gonna switch gears here. So I need to take a deep breath here just to clear my mind of all the numbers and the RVUs and stuff. And I'm not gonna talk about prognostication, advanced care planning and communication. Next slide, please. The goals here, we're gonna review some material for estimating and communicating prognosis to patients and families. We're gonna show the importance of advanced care planning for patients that we see at home. And we wanna talk about steps for communication with patients and families about goals of care and advanced care planning discussions. Next slide, please. So what are the core elements of HBPC? You can see there are four big buckets in terms of what we do. Symptoms, symptom management and assessment, functional assessment, looking over social support and caregiver burden that we talked about. And the last bucket is advanced care planning or goals of care discussion. A question often we're asked by patients and family is about prognosis. How much time does grandpa have as they either see grandpa decline or as they see grandpa come back from a hospital stay after a prolonged hospital stay and grandpa just not quite the same as before and that they have to make some choices and some decisions. Next step, please. Or next slide, please. So we're gonna talk about prognostication here. And I don't know about you, for me, when family and members ask me about how long and so forth, I still get a little bit, and after all the years of doing this, I still get a little bit uneasy when it comes to answering their question. Couple of weeks ago, when I was at the bedside or the kitchen side of a family member with a family, extended family and a patient who's struggling with a brain tumor, her course waxed and waned and the conversation came up, how much time does she have? Should I continue to work remotely? Should I call the siblings to come in and have them take off from work to come and see the patient? How much time do we have here? Do you think it's wise to get hospice involved and so forth? These are the questions we get asked that we have to offer advice to our patients and families. And I wanna hopefully give you some information that you can use next week as you engage with a challenging situation or scenario. Next slide, please. So when question like how much time and so forth comes up, it is really a great opportunity for us to have that discussion about prognosis. There are benefits to having that discussion. You see them here. We avoid crisis decisions. We get a better understanding of the patient's values and choices. We allow time to consider risk benefits of intervention. We take away some more, not take away, we reduce some of the stress and anxiety for the patient and their caregivers. And we give them time to process medical information because often we unload on them a lot, not intentionally necessarily, but they have to adjust or digest a lot of information when we visit with them. Just a real life scenario here about the crisis decision situation. A few months ago, I was visiting a patient who's 95, 96. And I had that discussion with the daughter about goals of care, about post-forum. And she couldn't quite decide the post-forum. I said, you know, I'm gonna come back in a week. I want you to think about it. And we can follow up on this discussion next time. And then several days later, before the week's up, the patient ends up in the emergency room in terrible respiratory distress. An emergency room doctor called me and said, hey Paul, I see that you guys are in the process of discussing this and nothing was formally executed. Can you help me here? We're about to intubate her. She's 95 years old. And that's when the anxiety level of my heart goes up and we're trying to find a daughter and everything grinds to a halt here. We pulled over to the side of the street. And at that moment, we really had to get that thing, that issue addressed and taken care of. So it's just moments like that reminds me that it's really important to have that discussion early and trying to get a decision made with your families to avoid crisis decisions. Next slide, please. What are the impact of a good prognostication discussion? We can reduce unwanted medical interventions. For example, this 95 year old, does she really need a pacemaker or is that consistent with what mattered most to her and her daughter? We can increase palliative care and hospice care utilizations. Dr. Cornwall talked about at Home Care Physicians, we use a lot of hospice care for our patients and providing the support that is consistent with their goals of remaining at home and passing away with their loved ones at home. We give patients and family time to prepare personal financial affairs, get them settled. And we increase the likelihood of patient dying in their preferred place. A study tells us that most of us, 70% of us want to pass away at home, surrounded by our loved one, the smells that we know, the faces, the room, but unfortunately 70% of us die where? We die in an acute care setting. Where's the disconnect? How can we make that a better correlation between where we want to pass away and where we actually pass away? We can certainly reduce the moral distress in a provider as in the case that I illustrated, having that kind of a crisis decision where I had to advise the ER doc in terms of what should be the best next step for that 95-year-old. Next slide, please. So if prognostication discussion is great with all those benefits, how come we don't do it more often? And you can see some of the reasons that's been referenced here. Lack of time, it does take time to focus and tackle a lot of maybe nuanced scenarios and questions. Lack of training and that fear of taking away hope that's often talked about. Like if I tell you you're gonna go on hospice and so forth and people often believe that you're just gonna stop caring for grandma, which is definitely not the case. There's a lack of certainty in the prognosis. Does grandma really have three months or maybe it's maybe six months, we're not quite sure. There are cultural variations in terms of having that discussion. Who should be at the table making decisions? At the same time, there could be family conflicts. I've been in the middle of the kitchen or in the bedroom where one half of the family believes strongly in terms of doing certain intervention and the other half says, I don't think that's what it's beneficial to the patient and so forth. And being in the middle of that. Some patients and families are not ready to have that discussion. And there could also be the lack of clarity in terms of who is responsible in leading the discussion. Is it the specialist? Is it the oncologist? Is it the PCP? Is it the HPPC doc that's in house? Is it the palliative care provider? So there could be a lack of clarity there. And also there could be a physician bias in terms of, I don't think grandma's that bad. Maybe give grandma another chance. I think she can pull through and so on. There could be biases in our own hearts in terms of having that discussion. Next slide, please. So when is it a good time to have a prognostication discussion? And there's some opportunities here that you see. Newly diagnosed serious life-limiting illness has been revealed. Or when the patient is home again, often, home again from another hospitalization for heart failure or COPD exacerbation, for example. If there's been a change in a condition or function, such as after a major stroke, for example. When there's consideration about starting or stopping a medical procedure or intervention, whether you're talking about turning off the EICD at home or stopping a dialysis, for example, that's a good time to talk about prognostication. And certainly it is a good time to talk about it when the family or the patient brings it up and say, hey, can we have a talk about what my wishes and my goals are? Next slide, please. So what are the steps in terms of having a good prognostication discussion? This is a busier slide here. I just wanna highlight a couple of things. It is really important to go in with up-to-date information and current conditions. So make sure you do your chart review, get as much information from the hospital, for other providers as you can, so that you are current on their recommendation and on their thinking and the latest imaging studies, for example. Set aside time for discussion. As I said before, it is time consuming and certainly turn off your devices, your cell phone, your wristwatches or whatever. You don't want any distraction because the conversation can be long and it can be emotional and you wanna minimize any distraction. You really wanna focus your time and your attention in this conversation. Talk about who should be present in a conversation. Again, some culture prefers the patient and be the decision maker. Other cultures or family wants maybe the oldest son or perhaps more of a family decision rather than an individual one. Be comfortable with silence, pauses and emotions and give enough time for question. And then also acknowledge the patient or the family's emotion. I can see that you're sad, I can see that you're upset and acknowledge that. Try not to be dismissive. Summarize and write out the plan for your next steps. Document the discussion and make sure you share what, you know, you put in a lot of work into this. Make sure you share the information with relevant providers. If you're at a facility, a nursing home or an assisted living or if there's home health agency that's involved here, make sure everybody is on the same page so that all your hard work is not kind of, you know, out the window when there's a crisis situation. Next slide, please. In terms of discussing prognosis, I often read and I'll talk about the tools that I use to help with prognostication discussion because it is challenging. And I wanna give as good as information as I can. Prognosis is really important for a patient's planning. You know, if I have that much time, I may have lived differently or I might have rearranged my finances differently or have closure with my family members in a certain way to, you know, just to close some old wounds and allow some healing to occur. It is also important to give a warning before sharing difficult news rather than just kind of dropping a bomb like, you know, you have cancer in your brain kind of out of the blue. Open it up by saying, you know, what I'm about to say to you may be hard to hear. I wish things could be different, but I have some difficult news to share with you after reviewing the CAT scan, for example. And deliver current medical conditions clearly. And I catch myself still, try not to use medical jargon, use a layman's term clearly, provide treatment options and ranges of outcome. For example, if the patient's trying to decide between chemo or hospice and so forth, you can say that if you want chemo, the best scenario is a few side effects of the chemo and you can live months to years. Worst case scenario is that with the chemo, you can have side effects. That may mean you're in the hospital more often, with complications and may cause you to have an earlier death. With hospice care, the best case is that you live several weeks, even a few months, but you'll be home with less side effects from chemo and less hospitalization. The worst case is that, you know, the cancer can progress and we might have to use more and more medication to control your symptoms, which may mean that you pass away possibly faster. So give them a range of outcome and treatment options. Next slide, please. Again, these are just some of the tools that I use in terms of helping me have that prognostication discussion rather than kind of, you know, it's my gut feeling. There's e-prognosis, there's CALCULATE by QXMD that has multiple calculators for different conditions. FAST FACTS also is an app that I use that has multiple diagnosis with guidelines. These are all tools that I use, again, to help me to be as precise as possible. Now, having said that, now there are limitations to these tools. The main limitation is that HBPC patients often have multiple comorbidities rather than just like brain cancer or just COPD, right? So most of these tools are designed specifically, say, you know, Seattle Heart Failure Model that is mainly for heart failure. It doesn't include all the other comorbidities that our patients have. So just keep that in mind as you are using these tools in your day-to-day practice and try to give as best information as you can to our patients and their loved ones. Next slide, please. Ah, okay, and now we're gonna do a little role play. Now, there are a lot of uncertainties with prognostication, but there is a certainty here. Ina, Michael, and I stayed up all night. We practiced a lot. I promise this will be an Oscar-winning performance, and the three of us will be signing autographs at the end of our time today. So we can get going with the Minerva role play here. So what we're gonna do is that I'm gonna be the doctor offering some advice to Ina and Michael, and they're the children of Minerva. And I encourage you to listen to the dialogue. What did we do well? What you maybe think that we could have done differently. So jot down some comments here as we enter into the role play. Okay, so Minerva, just for review, Minerva is a 86-year-old female we're seeing at home, remember, for two days later after a discharge visit at home. Remember, she had CHF and cellulitis of the legs. She has had multiple admissions for similar conditions in this past year. She also has a history of a UTI with mental status changes. She has dementia, and her behavior has gotten worse over the last six to nine months. The power of attorney is her son, and some of the history we got from him via telephone. Patient lives with her daughter, and she is the main caregiver. Both the son and the daughter have noticed increased forgetfulness in the patient, and words are sometimes incoherent. Minerva becomes agitated when personal cares is performed, and an increased frequency of verbal aggression, loud voice, foul language, and sometimes there's some physical aggression as well, such as swinging of the fist or pushing the daughter away. The daughter states that the patient is physically weak. She can barely walk. She's spending more time in bed. She cannot sit up straight in bed, and then she's having increased difficulty swallowing. As with most of our patients, just to refresh your memory, she has multiple comorbidities, CHF, CAD, CKD, stage four pressure ulcer in the sacrum. She's depressed. She's got hypothyroidism. She's got GERD, and she's got this generalized pain, possibly from osteoarthritis. So I'm at Minerva's home, and Minerva's son and daughter are here, and I introduce myself, and I explain the reason for the meeting, and the role play starts. I'm here today to conduct a post-discharge visit. Before I examine your mom, I would like to ask, what are your concerns regarding her condition? Well, we're looking for some advice about what stage of dementia she's in, and what can we expect? Yes, we can discuss her dementia, but before I begin, who else should we include in this conversation? Do you want mom to be included in this conversation? I know that this is difficult. I'm going through some of the same things with my parents. No, I think she'd be upset, and I've talked with her, and we have a good understanding of what her wishes are. So what is your understanding of your mom's current condition? Well, we've both noticed her dementia is getting worse. So we're going to talk about that. We're going to talk about what we're going to do

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