Good morning everybody. Good morning. We're going to get started just a little bit early today, if that's okay with everyone. Yes, please. If you're here to log in, hope that you had a good night last night, and we had a lot of fun networking with several people that stayed on after our meeting yesterday. That was really fun. It was great to get to know a few more people. Welcome to our second day. Before we get started, I'm going to go over a few housekeeping items. Once again, we would like you to ask you to complete a learning plan. And then later in the day, we will go over how to access and complete your evaluation. Both of these items assist us in improving current content and also creating content that would meet your future needs. We will unmute microphones again today at different times to encourage participation. We just ask that you mute your microphone when you are not speaking or if there's any type of background noise. We remind you that we are recording this workshop, so please silence your other devices when you are unmuted. I'm going to share my screen now. We have a couple of slides to start you off with. Oops. I'm sorry. Hold on one second. I had a little technical difficulty there. I forgot to introduce Amanda. I'm going to introduce Amanda who's going to start off all day today with a welcome, and then she's going to speak on quantifying the value of your practice. Here we go. As we're talking, we're texting in the chat here, and I don't know for what time people are waking up. Oh boy. It's not so bad if you're in New York or something. Yeah, 6 a.m. in Alaska at our own game, huh? I know. Hey, can everyone see my screen? No, I'm not ready for the camera yet. Sorry. My staff does that all the time. I'm the worst with cameras. Yeah, I'm the worst with cameras. I always am like, oh, let's just throw them on. You know, let's just see each other. People are like, you didn't give me enough notice, team. All right, well, welcome back, you guys. I hope you had a wonderful night with your families. It was just chock full of information. We're going to have another day just like that. And we're so glad that you've joined us. To revisit yesterday, I slightly misspoke. I thought this was kind of all of our chat. This is just the word cloud from what you wanted to get out of the two days. So as you look back at this, I hope you feel like out of day one, you're 50% there, and we're well on our way to another 50% to get you all the way there. So if there's something you're not getting out or you have questions, just keep jotting them down. Put them in your individual learning plan. Put them in the chat. Raise your hand and we'll talk more about them for sure. A quick reminder too, Brianna and I are going to stay, as we break up for procedures later, we're going to stay in the main room for anybody who either wants to come and go or wants to be in there the whole time with us. And so I mentioned it last night, but just keep jotting down any questions you may have related to any component that's essentially not clinical. Well, we can't answer any clinical questions. And when we do, you don't want to listen to us. So just a note there as we go through our morning. And at the end of the day, we've set aside time to answer any questions you may have less. And so usually we get lots of good conversation too at the end of the day. So yeah, I'm going to go to the next slide, but any other thoughts people had as we rounded out our first day? Faculty, staff, I know Melissa is going to say some stuff in a few minutes here, or team. Well, yeah, here. I think we wanted to share with you the opportunities to expand your network and that we have great representation from this group. I don't know, do you want to go ahead? Yeah, it just got a lot bigger. So we have team members from Illinois, Indiana, Michigan, Ohio, New York, New Jersey, Delaware, North Carolina, Florida, Texas, Alaska, and California. And Pennsylvania. That's slick. And Pennsylvania. Did I miss Pennsylvania? Sorry. Yeah, so everybody should have gotten an email from me last night inviting you to opt in to a directory that we want to produce to share only with this group. So nobody's going to sell you Amway or anything like that. It's just for the purposes of networking with this group. And so please do respond to that. So I know if you're willing to have your information included and which information you would like us to include. We'll be looking for that and then can share that later. Thank you to all of you who requested that. And for those who, my assumption is many, many people will want their information shared. But if you do not, there is in the Zoom group chat that you can make that to a specific person. So throughout today, if you want to start making those individual connections, because you're not going to share your information, I encourage you guys to do that too. And Tom asked in the chat, did we miss any states? I heard we missed Pennsylvania. Any other ones? Or maybe I just missed saying it. We didn't miss noting it. You just missed it in the roundabout. That's OK. Sorry, guys. I often tell the horrible story. I grew up in Texas. And so there was a large chunk of my life where I didn't realize there were other states other than Texas and Oklahoma. So all right, cool. Should we? Yeah, we have a few minutes. We can go ahead, Melissa. Yeah, OK. Great, I will. So, as, as we kind of think about, how do we take as advanced learners, how do we take some of these components and start quantifying the value of your practice, you know, I put a lot of thought into it last night because I've done this talk, actually a number of times that I have some variation of this talk, really that I've done in lots of different settings because Genevieve is pretty heavily into value contracting, specifically in the special needs programs, the DSNP, and now ISNP in the state of Minnesota. And so, you know, as I've kind of thought about, you know, how do I, how do I, this group is so engaged, I was like, how do I really try to connect the pieces because at the end of it, I was like, there's not like the, the absolutely go do this and then you get into value, it's really more of the, you know, starting to connect all the pieces. So I tried to make it, I try, in my mind, here's my clinical, here's my clinical comparison, you know, sometimes when you add all these things together, and you tell, you start to tell the story from a clinical standpoint, you start to step back and see the full picture. So there are a lot of technical details within this, but I think I may encourage everyone, you know, to start, to start diagnosing your problem. And I'm not saying, you know, you have a problem, but do you diagnose your situation, your problem, whatever you're trying to do, and start to pull some of those pieces apart and try to, try to make it into a linear connection of the steps to try to get you to where you want to go. That was my attempt to try to say, you know, how do we take so many clinical learners and say, you're doing great work, we have all these great stories, we have all the why, and now we're just trying to connect the why to getting paid for the why. So, if you would go to the slide. So, today, really, you know, we'll talk about some of the ways we can, we can talk about maximizing reimbursement under undervalue, what are the different types of value based contracts, you know, how do we think about your readiness of your clinical model to move forward with risk or, or value based contracts, and then, you know, what kind of key relationships, do you need to develop to move forward in those things and again, you know, it's, it's a little bit different than kind of the clinical steps of like you do ABC first and more you start to do and put together a readiness, readiness guide for your, for your organization say where are we and what does that look like. Slide. So I want to take us to a woman we know very well Minerva, right, we understand and we have seven pages on her clinical experience, really from, you know, her from moving from independence to dependence and what she has needed. So if you go to the next slide. So as a non clinical person, here's how I see Minerva. She's community dwelling. She has a long list of diagnoses medications hospitalizations treatments, she becomes what I think of as a high utilizer of health care, she's an expensive person, because of all these things and all of these, all of these things go together. You know, numerous hospital visits, you know, numerous maybe trips to the transitional care she's coming out of the hospitalization. And at the end of the day, she looks to us a little bit like maybe that 23% of the 1% of the cost of Medicare. She's one example of, of many. So then you look at who are payer sources and we specifically put in some information around her payer source to start to connect these things. So she's dual eligible Medicare is picking up 80% they're picking up the traditional medical spend hospitalization pharmacy any visits skilled nursing Medicaid is coming back in and doing a waivered services PCA durable equipment, you know, any potential hospitalization. And all the Medicaid might be a little bit different, but really dual eligible whether it's wrapped up in a special needs program or a fully eligible special needs program or it's completely disconnected in your state really structurally fit the same the same boat right Medicare is picking up the medical components, by and large, Medicaid is coming in with some of the same things. services and picking up the remainder of the 20% of the medical spend as necessary. So Minerva is one example of many of your patients So then we ask from a non-clinical perspective of how you know, how are you gonna impact her? What is that gonna look like and you guys say back? We're gonna discuss goals of care We're gonna discuss who the main point of contact is. We're gonna reduce polypharmacy We've had drug cascading here and we're gonna start, you know, pulling back on the pharmacy. We talked through med reduction yesterday. I'm Minerva We're gonna try to get a waiver services home care supports, you know We need to ask herself. Should Minerva be community dwelling? Are there other spots? Should she live in an assisted living? Should she live in long-term care and then we'll start to address, you know medical psychosocial concerns We're gonna look at her four M's and start to pull apart the story of Minerva and you're doing that no matter how you get paid likely you're getting paid under fee-for-service and so You know, it's you know, maybe 125 bucks per visit for doing this work Mm-hmm, potentially maybe you have her, you know signed up for some form of transitional care management or care coordination And you might be getting a couple extra dollars for that other things that we miss that you are clinically gonna do on Minerva No matter what no matter who are paid resources Okay, could you go back? So So my question to you I guess is you're going to treat her the same way no matter what right? It's the ethical bound of medicine to Not care about who her pay her payer source is and when you start doing all these things You start reducing her cost of medication. You start reducing her cost of hospitalizations Maybe her transitional care costs you start you Start future thinking about how to reduce her future costs You know and that's in that goals of care and that pulse completion advanced care directive you start to pull those pieces apart And you're starting to save Potentially money into the future. Let's say her goals at the end of life are cost or comfort care now. We're saving money in the future Because she's not going to you know die in the hospital and spend 10 days in the hospital before she dies hypothetically So who gets that money slide My argument is right now that the health insurance plans make money when you do that work So you get the fee for service for doing it, but for the total cost of minerva's experience in a year in her lifetime You know medicare private payers commercial payers. They're making the money on this and so our argument Here is to start thinking about capitation um Really under a capitated contract. It's you there are some components of these and again You can kind of mix and match and we're going to have some time coming up here to talk about you know What you guys are doing innovative ideas that you've done or have seen done but you know really You know under a capitated contract. There's typically what we call a per member per month or this monthly payment for her care coordination So again, you're treating her the same way You you may get your fee for service still under your agreement for these billable visits every time you see her You're still getting that, you know that widget based return but you know now you get 100 a month to to to kind of coordinate her care and that and that may mean Varying levels of work on your side, but you get paid that no matter how many times you see her um You know, then maybe you have a risk or shared saving model for a pool of patients. Maybe you have 500 minervas and you say I think I can lower the cost of care for everyone And if I do that, i'd like to share some money with with a medicare with the health insurance plan, you know, i'd like to i'd like 50 of whatever I save You know, i'd like 50 of whatever the gain is if there's gain there You could share in savings with an aco like model maybe you're signed on with a health plan that really says and attributes here all the or excuse me a health system here all the The patients, you know We as the health system care for 40 000 patients and you say I think I can make a dent in those like minerva in the home-based model And i'm going to carve out 500 for myself per member per month to be able to do that work. It's an additional supplemental income you could share in quality bonuses and say I Well, you know, maybe I have some money tied in with minerva if I can reduce her total cost of care, but I can certainly You know manage her statins Right a star measure I could certainly manage her stance I could certainly make sure she gets her eye checks for diabetes, you know, and if I do those things then you get You know better star ratings on your private payer and you are getting more money I am sharing essentially in that money but with quality bonuses by getting to that point and you can get Any of these are all of these and you can tie them intricately together um, but My you know, my argument to you guys is you're going to do the same great medicine No matter what you are lowering the total cost of care. Now. You just got to figure out how to get paid for it So if it sounds too good to be true You know possibly is it you know, make sure that you're completely ready for it Slide And what I mean by that is understanding the clinical model is the foundation I get all the time Asked to be a speaker because we have value contracts and I continually tell people Value contracts are not the most interesting part about us The clinical model that we have that support the value contracts is and it has to be the number one priority It has to be the best funded Uh, you know piece of our house, you know, we can't spend a ton of money on a beautiful financial system Or a beautiful office set or all the best xyz. We have to put it in people And tech resources to support people doing their jobs And so again, it has to be number one priority and the best finance thing in your house is your clinical model And you have to say is your clinical model fully ready for this? Have you spent the last 20 years of your practice in fee-for-service and your providers? Know how to maximize fee-for-service into within an inch of its life And they're directly getting paid for maximizing fee-for-service You know, maybe they're not on salary They are on a work rvu model in which they are just pushing and pushing and pushing and they're in that That model and you know and you're like I can't you know It's i'm not sure I could turn the ship with this group in two years. I need more time I need to start transitioning their mindset to how we're going to rethink this work um so You know as you look at your organization and you start to build this business model of why you should be in value You start to say what are my strengths and weaknesses? What are the things that I really do well and what are the things I do not do? Well, we don't have a great infrastructure for quality and for understanding quality So I we're not in a great place for being able to pull information out of our ehr Or being able to put in information into our ehr aggregate that on a consistent base Basis and look at it over time in a trended way. Okay, that's a weakness on a strength side, you know what everybody in my group is salaried everybody in my group is Totally motivated to think outside the box people are coming to me with new ideas every day about you know How can we get more efficient? how can we you know do xyz and maybe it would lower the cost of care people are See our financials and they understand the mechanisms of inputs and outputs to create a profit Okay, that's a strength right? That's that's a fantastic spot to be in, you know And so how do you kind of line those things up and say my team's ready? My resources are ready What I need to see into the future is ready for what supports I need there So as I build out my longer-term strategic plan, that's ready And if that's not just the case, who do I need on board? Is it the board? Is it the administrator that I work in if i'm in a bigger health system? Is it my community partners that I need to be ready? Like i've started to form and we talked about efficiencies of um forming community partnerships yesterday, but hey I I know some of these groups and I have great relationships with them But they don't really understand anything about my business And so I need to really get them there and maybe we can talk about some innovative ways to start paying them If i'm going to get paid in capitation Maybe they should get a different structure of my money instead of just again a kind of a fee-for-service click so um You know, I I would have I would open it up to questions If anybody has any other thoughts around things that they think they do well or they don't do well If you guys think you know i'm heading in the right direction about halfway through But for me we have seen in the state of minnesota and certainly nationally where people sign risk contracts today And they expect a different outcome tomorrow and they fail because they've not prepped their business They're like we our goals in getting to value was to build a patient population large enough A thousand patients five thousand patients, whatever that is And then we to go to all the payers and say we're big enough now sign us up for a risk contract And they can't really move the dial on connecting those cost and quality measures together for value So thoughts is a as a pausing point All right, I'll keep going. You guys throw in the chats. I can't tell if I'm hitting it out of the park here or if it's maybe too early for all this or what. So you guys, you know, keep pushing me here. I'm hooked up, I'm excited. All right, good. So for me, you know, again, what we're trying to connect together, and I know this maybe sounds a little too simple and that's why I opened with, it's really not that far from you. And it's not as easy, it's not like you do A, B, C. It's really, you build a business plan to say, and you put in these details of telling your story. You are creating your story. And you have the why you do it. Now you need everyone else to get in the why you do it. And so, you know, the ability to take your clinical model and be able to do your, I think it was Tom or Paula said, come up with that two minute elevator speech, you know, that's built in here. And you have to think about, you know, what's that value proposition? So what can you prove that you do really well? You've gone through and you've said, we're good at this, we're not good at this. We need to spend a little more time or money here to get us to where we wanna be. You know, and then you say, I can for sure prove that I'm great at this. I can for sure show that I reduce readmissions. I can for sure show that I understand, and we're gonna do another talk on this right after, I understand risk adjustment and I understand how Medicare is paying them. So I can tell them what value I'm bringing, you know, and then be really honest with yourself. I cannot tell you enough how many people are just trying to get to a certain volume number to ask people for more money. You really have to say, I built an infrastructure that's ready for more money, you know, and probably wanted it all along, but you do need some size component, right? But it's that infrastructure that I built. And then you say, when you have that, this story that you're telling, exactly how you're telling it, you know, when you're tying the why, the value, you know, the clinical quality pieces, you say, how does it fit within where I live in my current system? Does it fit within healthcare for a neighborhood, for my community, my state, within a larger system? You know, I've had groups who've said, oh, I think I should, you know, I'm gonna go to a payer and, you know, they should start paying for this. And then come to find out they live in a city where, you know, 95% of healthcare goes to the ACO, you know, and it's like, you know, the health system. You can skip the payer, go right to the ACO and talk to those guys, right? You don't have to see if you're chasing down Aetna or United because you think there might be patients. You know, pull a list of all your payers, see who your biggest payer is. See, pull a list of all of your hospital referrals, who are you getting the most hospital referrals after, you know, or who are you sending the most patients to which hospital, right? Who are your nursing home or facility partners where you're spending most of your time there? And then if, once you identify who your facility partners are, who are their partners? Here, we have some of our facility partners are large enough where they've started teaming up with health systems. So they're not owned, but they're teamed up with. So then we can kind of get both of those people at the table to talk about that. So again, who are you within the context of where you are? And for those of you who run practices large enough to be in multiple different cities, you may, or even states, you may have a different strategy for different areas, and that's okay. So once you can show that you can improve the value and reduce costs, and ultimately at the end of the day, the patients are better for it, you know, how are you gonna get paid for it? So who's getting paid today for it? And how are you gonna get paid for that? How do you leverage that piece, right? And so that component is kind of interesting. It's always right, sitting down and just writing out some of these relationships of saying, who's getting the money? And am I following the money when I do this work? You know, one example might be, you might be tied in with an ISNIP. You might live, especially in Florida, you may be going into nursing homes where they have their own ISNIPs and you're partnered with them. They're making more money than they're giving you $25 per month or per patient to see those patients. They're making more money than that. And they're making it in a risk-based model. So is there a way to kind of, you know, connect what other people are into and how you get into that? So again, you know, figure out your value proposition, figure out who you are in the larger context. When you figure out who you're gonna go after, how do you leverage that? Who's the partner that you're willing to work with and is willing to work with you? As you think about forming partnerships, you're thinking about long-term sustainability. You know, the deals I sign, sometimes they start as, you know, a one-year deal with a verbal promise of longer, but I just signed two ISNIP deals. And one is almost completely open-ended of when it's gonna end. And one has kind of a three-year contract negotiated rate. And all the details are ironed out for three years. You know, and some of my DSNIP contracts, you know, now I do two-year contracts. So we've been doing it for so long together, for, you know, 15 years, that now I do two-year contracts, but the terms really don't vary too much from, you know, every two years or so. And then, you know, as you figure that out, you know, who do you wanna work with? The data you're gonna get for your partner is incredibly important. So as you start to build that relationship out, you know, don't like put a bunch of stuff in there. I put things in my contract like, you'll give me a dedicated account rep and that account rep and I will meet on a quarterly basis. And when we meet, they will bring financials. They will bring their clinical quality. We will talk about stars. They will bring their pharmacist, right? And we will expect these types of things out of that relationship. And if those things do not happen, then this is what happens in those contracts. So it's the data of how people can get you information, actionable, meaningful information in a timely fashion. Then when you start to form these partnerships and then you start to put those things in writing. And even if it's maybe not an incredibly sophisticated organization, put it in an email. Just say, we're gonna, I'm not even gonna, we don't have to sign a letter of intent. We just wanna start exploring X, Y, Z. And here's kind of the outline of this. We have one local payer where essentially we've had a number of calls. And after every call, I just write it in the email. Here's everything we said, and here are our goals of what we're trying to accomplish in the next 18 months as we explore our relationship and try to build a foundation for what we're trying to do. So, and don't be surprised, don't be surprised if you don't make money the first run out of the gate. There are some things and we kind of talk about inching into them. There are some things that you can do and you may not make money the first couple of years, but as you get better information and you have a partner that's willing to stick with you, that's okay. If you do make money, don't be surprised when they want more of it and they start coming back and renegotiating. the terms. So it works just like any other financial negotiation. So, you know, as you think about, okay, now I kind of have the general structure, building this relationship is really, really important. You know, we talked through just a couple of these things, but make sure you have a champion on your team, leading the discussions, either you or on your behalf. And I like to bring like people. So when I talked to a payer, and they're going to sit their medical director or CMO down, I bring a physician. And I sometimes we have a medical director, so I bring him with and I will script out this is what I want you to say this is exactly the points I want you to take home. This is what I'm going to say and you're going to say this back to back me up. You know, and I, depending, just given who I am, depending on the relationship, I typically will bring a man because I'm often deal sitting across the aisle from a man. So what I will do sometimes, depending again on the relationship is I will say something and then I will have him repeat it again. And, and sometimes that's just more hurt. So you know, like, I don't want to, I'm not going to hit that idea home too much. But again, find, find the person that they're going to listen to the best and manipulate the heck out of them. Okay. And then understand what your potential partner values. I always start with a potential partner by going to their website, what are they posting as their mission, vision and values? Where are they taking this company? Is it publicly? Is it publicly traded? Is it private? You know, is it nonprofit? You know, and then what do they put on there? And then can you tie any of their initiatives? Can you go back and look at the last year of all their news articles? Can you tie those initiatives directly to their value statement? And then as they start to outline those things, you say, what are they really driving towards? And you listen to them as they talk back to you? Is a fewer days in the hospital beds? Is it? You know, is it more community partnerships? Are they trying to grow volume? For example, in the state of Minnesota, Medicare Advantage really only exploded here, because we had the we had a cost product. And that was sunset in 2019. So it's really only exploded in the last two years. And so it is a like for the first time in Minnesota, excuse me, we have all these for profits coming in and bringing in, you know, Medicare Advantage. And so these nonprofits are today, pretty uniformly acting the same way. They're all trying to get as many patients as possible, promote how nonprofit e there they are, and how community oriented they are, and how patient oriented they are, and continue to one up each other's benefit sets, but all focused on value, they want bigger shares of the market, because more people are coming in. So while they've maybe these three groups have had maybe a third each, which isn't exactly true, you know, now we have three new players, and they're worried about their portion being cut out. So what I come to the table with is, you know, this is that speak directly to fill in their gaps, I come and say, you know, I want maybe a volume metric in here, I'm going to I'm going to help you grow, I can help, you know, I bring these patients to the table. And I'm happy to, to work with you and a health system and talk more about how we can get more patients in your program. They might say, I'm really focused on a quality metric or hospital reduction, or I really like to improve my stars, you know, bring them the quality data you collect and say, these are your stars measures, all this is publicly available, CMS post their star, these are the star you're at, I'm sure you want you're at a 3.5, I'm sure you want to get to a four, I'm really interested in helping you get there. And then, you know, make sure you get the right people to tell your story. This is the point I think that Tom made, or again, Tom or Paul, around this two minute elevator speech, I find in any interaction, if you say the same thing over and over again, kind of the same way, eventually, they will say it back to you. And I do this manipulation technique, constantly, especially with my employees, I say this is what we're doing. This is what we're doing with this what we're doing, and then something and then they say it back to me. One thing that I'll do all the time is I'll say with our internal plays, I'll say what does it mean the mission is it let's do the mission test. Let's do the mission test on this. If we did XYZ, would it mean our mission? And so within about two months, I had all of our directors, you know, you know, something would come up and they did I hear them over say, does that mean the mission test? Does it feel like you know what we're trying to do here or whatever? Just keep going, you know, and how many of you have been, you know, personal professional relationships where all of a sudden you're like, I never said that word before, but now I say it all the time, you know, think of all the business speak we do, you know, we all have those things of like, it just gets it sinks into your head. And so when you tell a consistent story, that is going to get you to the table, you keep pushing through that. I'll take I'll do one more slide. And then let's talk about let's talk some more here. So maintaining that relationship. So you get to the table, you got your value proposition, you build that relationship, you know, think of it as like a brand new dating relationship. It's super exciting. It's all new and fresh. Everybody has the enthusiasm. Okay, make sure that you keep that enthusiasm, like I said, build it in to your contracts of what you want to do, make sure you can show and demonstrate performance. If something happens, and things happen, global pandemics happen, right, and you have not been able to continue to show whatever you were trying to show, then bring an adjacent metric, right? I have an example, we started a nice nap, we roll it out, boom, global pandemic happens. Well, I, I don't have a lot of enrollment in my brand new shiny ice nap. And so what I have said consistently, when I got on the phone with the payers, as I've said, I believe in the ice nap, the ice nap is transformational healthcare, we are in it for a very long period of time, we look forward to your partnership. And I want you to know that we are taking care of 1300 COVID, COVID positive patients, a third of those patients are dying. Or there's a third of those patients who have who are expected to die based on our long term mortality rate of this disease. It is horrible. We have so appreciated your support. And I want to talk more about how we can continue to work together in the future to take care of patients on site. Hey, Brianna. Oh, just a question. Just so I am. I have what I have done here is I've taken the comment that they made, or that around ice nipper that they're concerned about, and I've completely pivoted it. So when they tell their, they tell my story internally, and someone says, gosh, they have really low enrollment or something to say, Oh, they're taking care of so many COVID patients right now. And they're really, you know, they have built all these great relationships. Boom. So again, find an adjacent metric, something that's really heartfelt. And you keep going with that if you can't deliver. So one question was around the ice nap. So I have I didn't put it in here. I certainly for those of you who are interested, I do have some slides that I from other talks that I could bring up if anybody wants to know a lot more about it. In the in the breakout when Brianna and I do the business breakout, but CMS has, you know, or excuse me, Medicare as the four parts and Part C is Medicare Advantage. And under Part C, they have something called the Special Needs Program, SNP SNP. And it really is Medicare taking a look at the landscape of all their beneficiaries and saying there are certain patients in our in our portfolio, they're falling through the cracks. And so Medicare carves out the dual special needs. So Medicare Medicaid, which is how we come up with D dash SNP, and then they, they carve out I, which is institutional special needs. So anybody who lives in a nursing home, or who could qualify to live in a nursing home, they say, hey, we're going to build a special insurance product just to wrap around you. And it's going to be run through CMS. And so and then they have a C SNP, too, which is a chronic condition. So there are 15 to 20 chronic conditions, you know, diabetes, and you can build a special insurance product just that has special benefits to wrap around a patient with these things. So yeah, that's because our state hasn't spent much time in Medicare Advantage, the SNPs have been a way that we we've really expanded into value for Medicare beneficiaries locally in Minnesota. So hopefully that helps. I think that was Mary. But, but it but if you want to learn more, I we can I am happy to talk more at the breakouts too. So as we think about again, this kind of this, this transition to value based care, I doesn't as you hear me talk about this, it doesn't make you in my mind, it's not, you don't have to do anything different. Clinically, you don't you don't have to restructure your work, you just have to do this analysis of what you do well and not well, and put it together to try to tell a story to other people who will listen. So to open it up. For questions, I do have some value types of contracts to go through. And there may be even more people want to add, but it's really your time to talk to me about things have worked well, or questions you might have. Hi, Amanda, thank you very much for that. For that talk. That was great. My question is, how do you know, especially when starting off, you have a number of patients that you're seeing, how do you know that you are fulfilling those key metrics, you're at the point where you can pitch to larger organizations, you know, your value, what you can contribute, what at what point do you think that it's it would be, it would be worthwhile to do that? Yeah, well, you know, this, you know, as you kind of think about value metrics, I kind of break them into two, two buckets, one things other people care about, and things you care about. And if those things are not aligned, you want to, you're going to want to see if you can start to connect the dots. And so one example would be other people care about readmissions, right? So can you track, even if it's an Excel, is there any way to start pulling out readmissions and partnering to understand that, that metric for them, something you may care a lot about might be reducing an expensive medication, it, it might be utilization of hospice or utilization, you know, of, you know, home care or innovation around a community partnership. And, and those are metrics that as long as you can kind of connect, and this is the best part about geriatrics, right, as long as you kind of connect the value, and the quality piece, because the geriatrics, almost everything that we do, increases value, and lowers the cost of care. And that's, that is a super cool component of really, I would, I would extend that for those who care for folks with chronic conditions to the higher touch, we see that with, you know, the IHI, the IAH demonstration, that higher touch, whether it's with, you know, in that outpatient space can reduce long-term costs. And so you're doing those things every day. So then you say, this is an important metric to me, and now I want you to care about it. So just start to put it down and say, you know, here are the four things that we either track, make a couple of your metrics, a couple of other people care about, and then get them to care about why that's really important. And I think there's no time better than the present to start just trying to write down some of those metrics. That goes back to the model, making sure that you have the model, your model from the beginning must speak to that, I guess. Yeah, and so a lot of us think there's more like, you know, sometimes you get so used to doing something, you don't think about talking about it, you know, and we are faced with that, you know, when we're trying to learn a new language or a new culture or trying to learn a new IKEA setup, right, of now we have to figure out something we didn't know before. And we apply all these assumptions of what we didn't know to our new problem. And in many ways, that's great. But what I'm asking you to do is I want you to completely deconstruct your practice and your care model and pull out those benefits, because we assume that everyone knows what you're doing. And I would tell you that they don't. And we assume that you can even fully articulate what you're doing. And you probably can't, right? And even we're not there completely at either. But we are trying and I have a three year plan to succinctly connect our care model. I pull out these tiny little pieces, I say, oh, we do this great care management thing, or oh, we do this great blah, blah, blah. You want to start at the very top of the sky and say, this is why we're doing it and then start connecting those things, right? This is my mission. This is my vision. These are my values. These are my five tactics to get us there. And no one knows those things. So I need to tell people over and over and over again. Thank you. Yeah. Other questions for me, thoughts? Amanda, some of the back and forth in the chat was about a bad experience because the PMPM was too low and didn't kind of appropriate the care. And they had a bad experience with one payer and wanting meds that weren't reasonable to be refilled every month. Any insight on really how you know the cost of care and how you go about making sure before you get into a contract that it's actually a good fit for you? You know, you guys may not love this answer. So some, but you know, I really do thinking, I really do think that, you know, you take who you're serving and you try to see if there's kind of the math piece, you know, I have 40% are Humana, whatever. Okay, great. Now I'm gonna go to Humana, you know, and you really look at their mission and vision and you try to tie those things together. But don't take risk on anything that you don't feel 100% confident in. And then one way, you know, we're gonna, you don't have to do it next, but on the next slide, we'll kind of talk about the value contracts. And one way is, you know, maybe don't be put at risk right away, right? Like let's dip our toe in this. And then, you know, start pulling together and you can put in there and say, look, I'm a smaller group. Like, I don't know how much these patients cost. I'd love for you to help pull the data on their RAF score. And you're gonna talk about that, Brianna. But like, I'd love you to pull the data on the RAF score of these populations. They're already your Humana patients, right? Like you know who they are. They're attributed to my primary care. Pull the data and let's see what their RAF score is. And then, you know, you and Humana can say, this is how expensive they are. I'm gonna multiply it, you know, they're, you know, roughly a multiplier of $1,000 or something times your RAF score. So you know how expensive they are or how much revenue they're bringing in. And then you say, gosh, those are really expensive patients. You know, I really think I can make a dent by focusing on these things, you know, but to get my practice started, I'm gonna need $500 per member to month to really, to be able to try this. You know, would you start a pilot with me to just look at the data for two years and track everything and get our roadmap built of how we're gonna build this new relationship? Because I think what people sometimes do from the payer side is they try, you know, they try to treat everybody kind of the same. And you're trying to say, I'm not the same. I'm totally not the same, you know, and I need help. Like, I'm gonna make a big difference for your very expensive people, but I'm gonna need your partnership. And so I find that people love a bit of humility and ego stroking in this, right? And I think there's some value in building a little bit of a bridge for yourself before you go too, too deep in. Now, let's say you come to the point, and I think I saw a couple notes around like, that PMPM was absolutely too low. It's unsustainable, like, and you should maybe have a general sense of what your expense costs are gonna be. So you should be able to do kind of an ROI of like, you know, my time and my staff, but, you know, I thought it was gonna be X, and it really turned out to be Y, and that difference is a huge amount of money. If you have a partner that you think, you know, that you've really built a relationship, and you put a lot of energy to, you go to them and say, I'm getting paid just two less. Like, this is not gonna work. And if they say, we're not gonna pay you more, then they're not the right partner, right? Because you're, again, continuing to show them that value, and you're trying to back into them seeing it. And so, you know, how do you kind of connect those thoughts? You know, I had one where they wouldn't pay us any more money. So I lower, I negotiated a lower admin fee to get the money out of the deal. And in four years, because I didn't tie it to the right metrics, they were just like, you know, they had new staff, and they're like, we wanna raise your admin fee. I was like, well, I'm gonna stop doing that then for you, because I'm not gonna, I mean, I'm not getting paid to do that anymore. Like, let's see if we can bury it somewhere else, and maybe put some different metrics to make you care about it a little more. So in the end, I think they want the same ideas, you know, that you want. They just need handholding to get there. And we think that they're super sophisticated. We think that ACOs or health plans are super sophisticated. They're not. They sit on a ton of data, they don't know how to use, and they want people to partner with, because they want a competitive edge. So you are that competitive edge for them. I'm gonna go to the next slide on value contracts. So here are just a couple of kinds of value contracts, so that are, and I'm really, I'm using a very broad term. Fee-for-service, you know, would conceptually be at the bottom, right? Augmented fee-for-service, kind of a term I made up, but just the idea that you still do a per-click basis, care management, TCM, you know, I deliver a service and you pay me for that service. It's just an addition to the traditional fee-for-service. So I'm getting kind of two buckets of money, but I still have to do something very clear for that money. Then you get maybe a per-member per month or per-member per year, or, you know, per, now I'm seeing per enrollee per month. So PE, PM, they could come in lots of forms, but that is, you know, maybe I have a couple loosely defined things I have to do, but I don't have to see the patient necessarily every time. You're gonna pay me a set amount, no matter what, for that patient to care for their wellbeing or to deliver care management, whatever that looks like. Bundled payments, I think these, you know, these were made very popular by like joints. Some cardio could be in there. Really, when you start to think about some of the DRGs, you may have some bundled payments. There are CMMI posts on their website, all the bundled payments, and you can go and search by your state and see everything that's going on in your state. And there may be some that you're like, hey, I actually am doing a pretty nice impact on X, Y, Z. You know, I'm gonna look at a bundled payment. But the general idea is we take, you know, one DRG, one diagnosis, and, you know, you get a set amount of money for that experience. So regardless of how you get a set amount of money. Pay for performance was popular a few years ago. It's kind of been morphed into kind of quality bonus structure. But really, like, there's some metric outside of some of these things where if I do, you know, if I hit a quality metric that they define off an AHEDIS or STAR measure, then I get paid a set amount of money. And it could be, you know, a per member amount, or it could be a flat amount. Like I have one where if I hit the total metric, you know, I get $10,000. Okay, great. There's a gain share. So now in a gain share, now we look at everything. We say, okay, patients are bringing in this much revenue, they're bringing in this much expense, and then we have a net profit. And at the end of the year, if that number is positive, I get a piece of that positive number. Now these can be, you know, then we go kind of, the next ones are, we go into shared risk, right? Now, so now, you know, money's coming in, money's going out, there's money there. If it's positive, again, a gain share. Likely you don't get big numbers on a gain share. This would be, if you were like, I do want to take some risk, and I want to start exploring this, this would be a great way to start and say, I don't know if we're going to make any money under this. Do you want to develop some muscle memory of just collecting, you know, all of the revenue and expense? Start showing it to me because I've never seen it before. And hey, I want, you know, if there's a lot, if there's money there, if it's positive, I want 20% of that, I want 80% of that. Pick a number. And then you say, okay, hey, there's money in the, there's money in there, but you know, to get even more money, I want shared risk. And it can be with or without a floor or ceiling. So you could say, you know, on my gain share, I was getting 20% on this, but I'm willing to share in some of the risk here if I could get up, if I could get 50%. In fact, I'll put, you know, I'd take 50% of the risk on the downside, right? And you could do it open-ended, so without a floor or ceiling, or you could do it with a floor or ceiling. So you could say, I'll take 50%, but I can't afford more than a million dollar loss. So there's a lot of money in that pool. I'm willing to take 50%, but I want a floor of a million dollars. And often it comes with a ceiling of a million dollars, so you can't make more than a million dollars. Okay. Or full or significant risk. Whatever is in there, I want it. And I want, you know, significant, I think of over about 75 or 80%. I want access to it. And if it's 70, you know, if it's negative, I'm willing to pay it all back too. So there are ways to kind of tip your way in. You can tie some of these concepts in with other risk contracts, you know. Okay. Slide. So this is a visual that I built a while back that I really like. Again, you know, your clinical model is your foundation. Your organizational readiness is key as you think about, you know, tying into risk. When you find that right partner and you build that sustainable relationship, your job then is to continually deliver results. I like to tie quality metrics or results as to individual years. I really never have liked the ACO model of where you have to constantly be better than you were the year before. I like the model where we're just constantly improving and we're making things better because things change. And so then you deliver on those results. The final slide here is some abbreviations. So I'll let you guys look through that at a later date, but these were just some of the abbreviations maybe I've used them for you to go back. And I'm sure given all of our experience, you could add a hundred more of these, right? Healthcare is no shortage of shortened words. So I will, so there were some key takeaways, but I will certainly take questions. We have a couple of minutes of things that I missed. I'll go back and look at the chat. And if I know my colleagues have filled in a bunch and you guys have filled in a bunch too, but if there's anything I can add, I will. I know this one is a little bit like, you know, you want me to just say, don't you? You want me to say, track this one metric, go to this one person and then you will get paid more money. That's why I say it's more of like a, everybody looks at their own journey and put, you know, and sees what you can do. When you mentioned partnerships, so what are some, maybe you said it and maybe I missed it, but some examples of a smaller practice when you say partnerships, people that you will partner with that will be willing to. Like I was thinking there's a community council that's over each area, like something like that, or you're speaking about a larger ACO or a larger company, like for example, individual practices that are not as large, how would you be able to partner or what are people that you suggest we partner with? Yeah, you know, no, no. Yeah, I think there are two aspects of partnerships. One is a, you know, revenue and improvement company, you know, partnerships and one is expense management. So when I think of like community partnerships, a council on aging, you know, basically, you know, maybe some oversight, you know, by and large, they might be ones who can help us some expense management. So, hey, I go to them and I see if we can arrange kind of a quid pro quo of some arrangement where I can help them, they can help me and I can lower my expense structure. When I think of revenue partnerships, I really think of groups that like where you track back the money. You say, when I do XYZ, when I lower hospital readmissions, when I keep someone in their house, when I, you know, refer someone to hospice, someone's making money on this transaction and I'm not the person doing it. That's then where you wanna start going to track the money. And I would say almost all of my examples are really, you know, payers, ACOs, Medicare, and even through Medicare, primary care first or direct contracting in the next couple of years as those become more popular and more information comes out on those, who's making money when I help people in it, because it's not me, I'm not making enough money, you know, you gotta find it. And also like primary care first and some of those models, you need to have some data from the year before, correct? Before some of these models will even, that you can even sign up for some of these models? Brianna might know more about that. I certainly know there's some volume components that are limiting. Yeah, so there are eligibility requirements and I can put in the chat the link to the CMMI primary care first page. There is, you know, a patient tier of, I believe it's 200 patients for primary care first and some other requirements. It is always a look back period when you're talking about the quality performance, but the application period itself would look at, you know, what's your census? They have defined what they consider a comprehensive primary care practice as far as like having systematic care management and things like that in place. So it's a great, I love it, even if, you know, it's not in your area and the practices have already been selected for the first cohort. So primary care first practices, you know, that initial application period for the 2021 performance period is closed, but stay tuned, you know, direct contracting just yesterday, you know, that's a risk-based model and for larger scale, but they even just released a request for information and letters of intent for interested practices. So direct contracting has more opportunity. Primary care first is selected already for the first year, but I think even just looking at that model framework on what they're requiring their practices to do when they participate could really help you kind of think about, you know, how you might wanna frame and evaluate your own practice. And I encourage for those who have not, you know, I'll put in the chat too, that just, or maybe Brianna can, of the general CMMI, again, go to your state, search all the initiatives in your state. This is the innovation group within CMS. So this is the people who are trying to do and make different money, right? Outside of like Medicare Advantage in your state. So this is a way to look at that. And then I gotta tell you, I've always, CMS puts out the best emails. I think they're very clear. Their website is pretty easy to navigate, you know? So I would encourage sign up for listservs on primary care first, direct contracting, CMMI. You can opt into so many informational pushes that are very valuable. So I know I'm into the time of taking time for HECs, but Brianna and I will be around, you know, to continue the conversation too, or later, or even if you are going to the clinical stuff, we'll be in the general session questions. So thank you. Great. Thank you, Amanda. What a great start to our day. Chat is active again. That's awesome for us to see. We'll be moving on to our next session with Paul and Brianna, covering HCC scoring for house calls. Take it away, Paul. Thank you, Amanda. That was a great talk. Really appreciate it. And it is a segue into what Brianna and I are going to talk about, and that is the importance of HCC scoring in the context of APM and value-based contracts, as we're talking about this morning. I'm just curious, how many of you have heard of HCC scoring? Let's just send it through the chat box. I'm curious. Yes. So the majority of you have heard, and some have not. Hopefully we can strike a balance between reviewing some old information for those who have heard of HCC scoring and perhaps sharing with those who have not heard about HCC scoring some new information about HCC scoring. So the objective for this morning about HCC scoring is that we're going to talk about this risk calculation about this code and the impact it has on HPPC providers. We want to help develop a workflow that ensures HCC codes are signed accurately and apply strategies to support quality documentation for signing HCC codes. And Brianna is going to help us review Minerva. There she is again, in terms of how we can properly code for the complex work that it takes in managing somebody like Minerva. I tell my providers, I know we often have meetings with my APMs at New York City, I often have meetings with my APMs and we talk about how complex our patients are, how sometimes it could be draining. And I remind them that ACC, I jokingly say, the ACC code, it stands for how complex is your case code. I encourage them to document the complexity of the situation and the clinical dilemma that we're facing with our patient. Gone are the days of COPD unspecified, but now we're talking about much more specific codes and diagnoses because it reflects the acuity and the chronicity of the care or the condition that my patients are struggling with. Next slide, please. So what is ACC risk adjustment? So ACC stands for hierarchical condition category code. It's a risk adjustment methodology developed by CMS. It is used to, it's kind of a predictive, it's not kind of, it is a predictive modeling based on ICD-10 codes, patient's demographics and their disability and their comorbidities. I'm gonna talk about that later on. Comorbidity status to predict the annual cost of healthcare utilization, right? This is, it's important to note, this is not a claim-based dollar amount, but rather it's a predictive spend aimed at a group level and not so much specifically at your one patient in your EHR that day. So it is meant to be a predictive model geared at kind of a population of group level. This is really significant for Medicare Advantage payer and APM payment models as it determines the premium or capitation amount they're paid to the members that they insure, all right? For example, the PCP, the primary care first, the SIP or the seriously ill, the SIP or the seriously ill population model, the practice is paid based on the risk score of the patient population attributed to the practice, meaning that the higher the ACC score in theory, the sicker they are and the more financial resources it will take to take care of them. So it is imperative for the providers that as we're out in the field and taking care of sick patients, accurately document that so that the practice is gonna get reimbursed at an accurate, a more appropriate, well, accurate and more appropriate fashion. Next slide, please. Oh, that's just an example in terms of, sorry about that, yeah, the example of, in terms of your ACC scoring and the payment per member per month that can be expected. Obviously, as your ACC score goes up, your payment level will go up accordingly. This particular graph was the risk tiers for the primary care first model we were just speaking about too. And then when we're done here, I'll put some links in the chat. But just to show you that PMPM is all tied to your patient's HCC scores. Thank you, Brianna. Next slide, please. So this risk adjustment has been around. It's not a new thing. It's been around since 2004, but the CMS ACC model was implemented in 2017. And we will be transitioning to a new acronym, APCC, Alternative Payment Condition Count, starting, started this year and going on for three years. In a staged approach. And CMS has been working on ways to improve the accuracy for the risk adjustment methodology used. The major change in 2020 was the use of a fourth factor that considers the multiple comorbidities that our patients have and assigns additional risk value to patients that have anywhere between four to 10 ACC diagnosis code reported within a calendar year. And Brianna can talk a little bit more about that later on as we kind of go over the Minerva case. Next slide, please. Now this slide shows how a patient risk score is calculated. We've got the demographic factor, the ACC diagnosis code, the interaction, which I'll talk about. That's basically when patients have multiple diseases and also a disability status that adds to their total level of risk. And CMS then publishes a denominator value and that's updated yearly, that is multiplied by the raw risk score to convert it into dollars and estimate the annual expenditure per beneficiary for the plan. It is important to code, here it is again, it is really important to code at the highest level of specificity. The unspecified codes are really discouraged because seldom or often there is no risk score or low risk score assigned to them. The other thing is, as I've been, we're coming to the end of the year, as I'm talking with my nurse practitioners, that Medicare, that the patients are, in Medicare's mind, the patients are reborn every year. And it is important that we re-document the condition that the patients have on a yearly basis. An example that's commonly used, like the amputation of the foot. Medicare believes that the foot is regenerated next year and then you have to go back and document again that the foot has been amputated due to say, you know, peripheral vascular disease. So it's really important to document on a yearly basis and again, to the highest specificity that you can. Next slide, please. So the earlier slide I talked about, you know, what are the interactions? One of the bubbles, it talks about, you know, the interactions. There are two kinds of interactions. We've got disease-disease interactions, diabetes and CHF, for example. On the next slide, you'll see more example. And the other interaction is between disease and disability status, such as, you know, disability and opportunistic infection. You know, why is this important? It's about the risk score. Next slide, please. Here you see just some examples of the interactions that we commonly encounter in HPPC patient, as well as the disabled-disease interaction on the right-hand side. Next slide, please. You know, there's some good news. There's some example of changes from the old ACC model to the APCC model. The good news is that dementia became, as of 2020, an added value for the patient. So we're seeing a lot of changes in the patient's health and, as of 2020, an added value with the ACC coding. Previously, it was not. And the other thing is now that all pressure ulcers between stages two and four are all assigned an ACC score as well. I do wanna highlight here that there is a big difference between a stage two pressure ulcer and a stage three pressure ulcer regarding the level of the ACC number it's assigned to those two different diagnoses. So again, I just want to remind all of us to code at the highest level, the highest specificity for the condition that you're managing in the home. Next slide, please. Again, this is the added, as we discussed before, if the patient has multiple comorbidities that carries risk adjustment, that it means extra dollars. This is a big change with this new risk adjustment model being implemented this year, taking into consideration the multi-complexity that our patients often have as we try to manage them at home. Next slide, please. I don't wanna get too bogged down in all of the numbers. This is kind of an illustration and kind of a fictitious mock-up, if you will, regarding just the importance of documenting the ACC scoring. On the left-hand side, if you saw a patient for upper respiratory infection, but then the diabetes and the heart failure, they were not coded, then you can see that your score, your risk adjustment score is low. Moving on to the middle column, now you see a URI symptom, but then you did not see a URI symptom but then you did manage their heart failure and their diabetes, and that increases your risk adjustment score a little bit more. And the last one on the right, you can see all of the conditions that the patient may have, including colostomy status and so on, that all adds to your risk score and that translates into more reimbursement for you and your practice as you are managing this patient and all of the medical complexity. And I think I'll just pause here and just reflect back on a couple of things that Amanda said in terms of ACC score and an HPPC, and Amanda talked about, what does your value add? Oh, I tell my providers, I'm not asking you to do more work, I'm simply asking you to code for the work that we are already doing. In terms of our value, what we're doing, working with the ACO, what can we do to help them improve their performance and get the savings and the payment that they need in terms of being a good player within the health system? The other was about, I think Amanda talked about relationships. By that I mean, over the last, this past couple months, getting information from my health system and working with an ACC coach within my health system. I'm really interested, I had my last review of my ACC score about five months ago and in another month, we're gonna have an update and see if changing my mindset and better documentation has resulted in improved scoring. So looking at your value, working within your organization to find partners to get you the information that you need. And the last is about educating your staff. Why are we doing this? The importance of it in terms of the health and the financial viability of the practice. I will end it there and Brianna, take it away. Thanks, Paul. So we wanted to kind of help you understand at least how the RAF score is calculated and what HCC risk adjustment really is. There's actually lots of different models here. I know we have some PACE representation attending. PACE uses risk adjustment. Medicaid has a slightly different model. This is the most common. And so that's why we're focusing on the CMS, now the APCC and previously the CMS-HCC model. But it's used in many different ways and it's expanding different payer types, value-based care contracts. HCC is not going away. And unfortunately, it's all tied to how good you are at ICD-10 diagnosis coding. You can't just search in that EMR and click the first unspecified diagnosis that comes up. And your EMR could be doing you a dissatisfaction if the descriptions are vague and things like that. So I'm gonna try and kind of take us through actionable steps. But if we go to the next slide, we're gonna start by thinking about Minerva. So you'll feel free to look at her case. You don't have to. Here are her ICD-10 diagnosis codes based on her case. You can see the four that I bolded. Those are the ones that carry a risk adjustment factor or risk adjustment value. There was a question in the chat about Alzheimer's and dementia. So from an ICD-10 coding guideline standpoint, if your patient has Alzheimer's, dementia, you code both the Alzheimer's and the dementia. The dementia code is the only one that risk adjusts. So that's why on the previous slide, you saw a risk adjustment factor for dementia and not for Alzheimer's. So again, also important to know that when you're coding things. You'll notice the heart failure. It's not just congestive heart failure unspecified. What stage is the pressure ulcer? Major depressive disorder. Very important to use that rather than depression unspecified because if you're just using depression unspecified, that does not risk adjust. So if we take all this together, we have some tools I'm gonna share with you on a future slide, but Minerva's risk score, which right now we're using a blended of the CMS HCC and the APC model comes out to 3.284, which is good. That would get her in the highest tier if we go back to remembering that grid of the primary care first models. Generally at what's considered a high HCC score, meaning you have a very sick patient is greater than 2.0. So when Amanda was talking about being able to tell your payers or these Medicare Advantage plans that you're potentially approaching in these partnership conversations, if you can say the patients that I take care of have an average HCC score of X. I care for them and keep them out of the hospital even though they're this sick and this is why this would be a good partnership. So knowing your patient's risk scores and EMRs should be able to do this for you. If you're not sure, check with your EMR vendor. Almost all of them have new modules that can show you in real time, which codes risk adjust so that you don't have to remember this all on your own. The other thing, a couple of considerations. If Minerva had hemiplegia or hemiparesis following a CVA, that would risk adjust. You can only code CVA when they're active in the hospital. That's a common ICD-10 error I see all the time is seeing active CVAs coded for these out-of-the-hospital, just complex patients. It's a history code when they're in the outpatient setting. But if they have a residual effect from that CVA, you should be coding that because that potentially could get you. The only other idea, and again, it needs to be supported by your documentation, which I'll talk more about later, but if Minerva had an indwelling Foley catheter that had an infection because of that, that would be something you wanna code. So just to give you some food for thought on other things that might come up with Minerva, but these four, just by coding these four chronic conditions that carry a risk adjustment weight, she already would have a high HCC score of 3.284. Next slide. So this is just to highlight the assessment and plan. You go to the next slide, please. So here's one of the tools. I thought the link was on the slide. I'll put it in the chat when it's not. The SCAN Foundation has an HCC risk score calculator. If you're trying to wrap your head around this or wanna look at a couple patient examples, there's also apps you can get. I have one on my phone. That's just called the HCC Coding Tool. Keep in mind, all of these risk adjustment weights that you see, they do tie into patient demographics. So I used a female non-dual eligible patient. So things like that are gonna affect their risk score. So if you notice some numbers are slightly off when you're looking on a zone, there are those demographic factors that affect their score as well. But the SCAN tool is very nice. Next slide, please. So I mentioned depression. Again, this comes down to, unfortunately, taking a little more time when you're, before you submit that claim and you're associating your diagnosis codes, really being specific. Actually, if we take it even further than that, I think a lot of people don't realize when ICD-10 was implemented, they technically said they were only gonna allow unspecified codes during the first year. ICD-10, if you look at their coding guidelines, said all chronic conditions that were evaluated or considered during encounter need to be coded and they need to be coded to the highest level of specificity. That impact hasn't really caught up, but if you're using unspecified codes, now's the time to stop. The other point I wanted to make here, which I think if you're really trying to take risk adjustment to the next level, is using combination codes. So if your patient has hypertension, is it just hypertension or do they have hypertensive heart disease? Because that's a different code that carries a much higher risk adjustment weight than just hypertension. Hypertension does too, but do they have hypertensive heart disease? Do they have hypertensive heart and chronic kidney disease? Using the correct ICD-10 code is gonna, again, show how sick your patient is. Next slide, please. So, we're waiting for the slides to catch up here, too. How you can think about this, too, is, and I think it's easier said than done, but prioritizing your assessment and plan, right? So, all of these patients are sick. They have multiple chronic conditions. What were the most severe that you addressed during that specific encounter, right? You know, and then really only focus on, don't just click the first diagnosis code that comes up. At least prioritize them. That's, you know, one strategy to make sure all of their chronic conditions are captured within that calendar year. When it comes to HCC coding, you want to think every chronic condition that your patient has, every, you know, colostomy status and toe amputation, it's not every single claim every single time, but it has to be reported once during a calendar year. Your patient is reborn every year in the eyes of HCC coding. So, you need to implement a process, and we're going to talk about some specifics on how you do that when the slides catch up here, but really thinking about a process is, okay, if there's a certain type of encounter that you're going to use, that your provider's going to spend extra time on, like annual wellness visits, what are you going to do to capture all of your patient's chronic conditions, at least during the calendar year, and are your providers, you know, really prioritizing the first top four diagnosis codes they're associating with a claim? So, I mentioned, go ahead, Paul. Yeah, if I can, this slide to catch up with us. Just an example, this past two weeks or so, as we're doing chart review, you know, this gets into like efficiency of the visit and so on, I, you know, my practitioners would always review the chart prior to the visit to make our visits more efficient, and as you're doing that, as you are reviewing the old records on your patient, they're just common things that can be captured, and I encourage you to consider them, things such as cerebral atrophy on a CT scan of the brain. How many of our patients have that? A tortuous aorta, calcification of the aorta, they all carry ACC scores. C-Niopepara carries ACC score as well, along with, instead of just coding, say, you know, chronic anticoagulation, rather, put in hypercoagulable state, which carries the ACC score. So, as you are doing chart review, you can populate in your problem list appropriate diagnoses to get you the ACC coding and the reimbursement that's appropriate. Thanks, Paul. Yeah, it really does make a difference. I was kind of filling in some time as we were talking here, but Charlotte, thank you for, you know, calling out, too. I purposely left a couple unspecified diagnosis codes on that Minerva slide, and, you know, Charlotte was saying, based on her case, already saying, you know, she had secondary hyperthyroidism and C-Niopepara, which would be ACC values as well. So, just really showing you the difference it can make. If we go to the next slide, please. So, we talked about this, but really, again, you know, you want to show your payers the quality and the cost savings, and you want to be showing them how sick your patients actually are, which right now, unfortunately, the methodology is the risk adjustment tied to your ACC scores. This could also help you risk stratify your patients. You know, if you're trying to look away at, okay, out of my patient panel, what's my, you know, we all know that we care for typically the top 5%, but what's my, really, out of all of my complex patients, that top 5%? Looking at their ACC scores could also help you prioritize care and think about how you might want to go about providing additional resources. Important distinction, too, yes, all of the dollars, per se, for ACC technically go to the payer, right? This is how they're paid and their capitation amount and things like that, but it also affects you if you're in an alternative payment model, but you need to be a good partner to that payer, right? If you're, especially if you contract with a bunch of Medicare Advantage plans, if you're not able to support accurate HCC coding, well, don't bite the hand that feeds you. You're not being a good partner to them. They care about that. That's why it's important for providers and practices, especially if you're in value-based care, but it matters now, too, even if you're not. Move to the next slide, please. So, Moses, I saw you put a comment in the chat earlier, too, which I really appreciated. You have to be able to support the HCC diagnosis codes that are being reported. So, there's been a change, part of the change with the methodology, too, is they used to look very much just at claims-based data, but now CMS is actually auditing the MA plans, and what they look at is your face-to-face notes. They want to see that your assessment and plans. There's an acronym. Many of you know SOAP. What we use in risk adjustment is MEAT, which stands for Monitor, Evaluate, Assess, and Address, and Treat. And so, what that means is if you said that your patient had all of these, you know, chronic kidney disease stage four, senile PURPA, you know, complications with their colostomy stats, whatever it may be, they want to see a supporting note where you address that condition in your assessment and plan. So, very important to remember, too, again, this isn't just throwing every diagnosis code you can think of on the claim. It really needs to tie back to what you did and how you evaluated that condition throughout a calendar year. Again, you have a year to tell them how sick your patients are, but really make sure when you're selecting ICD-10 codes, they're supported by the documentation. And I also wanted to read you guys a definition here, too, and I'll put some follow-up information in the chat, too, so that you guys have this. But the AMA, because of all the changes with the 2021 office visit coding set, they've actually defined what they consider a problem addressed is, and this is a point that auditors have kind of been making for years, right? Like, if I'm looking at your assessment and plan, I want you to show me that that problem was addressed if you're saying that the patient had it and it was addressed. So, I'm going to read you this definition, and I'll put it in the chat later. A problem is addressed or managed when it's evaluated or treated at the encounter by the physician or qualified healthcare professional, nurse practitioner, or physician assistant. This includes consideration of further testing or treatment that may be elected by virtue or risk-benefit analysis or the patient and surrogate choice, notation in the patient's medical record that another professional is managing the problem without additional assessment or care planning by the treating provider does not qualify as that problem being addressed or managed. So, what that means, and I see this all the time, is if you're saying the patient has diabetes and the only thing in your assessment plan says managed by endocrinology, number one, I'm not considering that for your medical decision-making, because you didn't tell me if you considered the diabetes as your care for that patient, even though they're seeing an endocrinologist. You can have specialists that are involved in the care, but I would, words matter, I would encourage you to think about did you consider that patient's diabetes in your treating that patient? You probably did. So, at least say something about it. You know, diabetes, you know, blood sugars have been stable, you know, patient is seeing an endocrinologist, but reviewed good diet or something like that. If you're just saying you referred or you're deferring care to another specialist, that's not supporting that the problem was addressed. Furthermore than that, you know, referral without evaluation, an evaluation, they even went on to say that's by history exam or diagnosis or study, like if you have to order lab tests or further workup, that also would not qualify as that problem being addressed. So, if you're just saying, you know, this comes into problems even, you know, with home health and hospice, if you're ordering PT, but your notes not telling you why the patient needs PT, what's the, you know, frailty diagnosis or thing that you're working on, that's an issue. And that's becoming more important for the home health agencies based on your documentation because of their new payment structure as well. So, in your assessment plan, why did you need to see that patient, you know, how did, like your clinical judgment, almost your thought process of considering all of those conditions should be in your documentation. But especially be careful about deferring treatment to another provider without, you know, your notation that you at least considered the problem. Next slide, please. So, I won't spend too much time on this. Actually, we can go on for the sake of time here. But so, here's just some other ones, too. No, I'm sorry, you can go to the next slide, that are, you know, commonly missed or people don't realize are HCCs. So, there's a resource, too, that we've given you in your appendix called the HCC, I think, Cheat Sheet or Resource Guide that you'll see later. But here's just some common ones. And we've talked about some of these. You know, again, those residual effects after a CVA, making sure it's the right pressure after a stage. If your patient has obesity based on their BMI, that's another one. So, consider all of these things. And think about how I talked about earlier, the diagnosis is on the claim. For the CMS 1500 form, you can report up to 12 diagnosis codes for quality and a risk adjustment reason. But they're only considering the top four to support coding or to support, you know, the service that you're billing for. So, again, think about what top four diagnoses really matter at the encounter level. And if you're prioritizing how you're associating that with the claim, that's also going to make sure you're capturing these throughout the calendar year. Next slide. We can go ahead. This is just a scan calculator. A couple of these, I think, might have gotten messed up a little. But again, I mentioned the audits earlier. They're called RADV audits, if you've ever heard them talk about it. These are audits by the plan, so the Medicare Advantage plan themselves. But they do this every year. And again, they're looking at your face-to-face documentation. That's part of kind of the additional, you know, to prevent fraud in the Medicare program because there was, unfortunately, some cases of, you know, all these plans reporting a lot of HCCs that were unsupported by documentation. So, again, it's important for you to know that, you know, there is an integrity factor here. If you're coding a diagnosis, it needs to be supported by something in your documentation. Next slide. So, tie this all together. Actionable steps for you to take away from this talk. Always code at the highest level of specificity. Stop using those unspecified diagnosis codes. If you're not sure if your EHR has the capability to help with HCC scoring or highlight those diagnoses, I highly suggest that you do that. It's really helpful to have an HCC champion. Paul's been that champion for his practice. You know, his health system has the supports of an HCC coach, which is even great too. But, I mean, peer-to-peer, your team wants to hear from whoever their clinical leader is that, hey, this is important. This is why we're going to do this. This is how we're going to take steps to do it. And do some of your own internal monitoring. You know, look at your charts for your providers. Are they coding appropriately? Did they miss things? Can you talk about that in an IDT meeting or, you know, during our annual review or something like that? Give them education. This is not taught. You know, this is coding. You know, if you're lucky enough to have some certified coders on your team, they can be great resources too. They can do some chart preps. I know some practices that even started trying to train their residents and having their residents prep their charts for them, which I thought was awesome. So, get creative with how you can really make sure you're maximizing it. On this next slide here too, this is a resource, just a screenshot of it that's in your appendix. It's the HCC quick reference guide. So, we've taken all of the major categories at risk adjustment and just thrown some example diagnoses on there. It'll just help you familiarize yourself with what diagnoses carry a risk adjustment weight. So, I encourage you to look that over with your team, talk about it in a staff meeting. And then to just kind of wrap us up here, be specific like we talked about. The other thing that I haven't really mentioned is make sure your problem lists are up to date. That could be a best practice. Again, you know, strategically, are you going to do this during annual wellness visits? Are you doing annual wellness visits for your patients every year? Because that can be a really good opportunity where you say, okay, as part of our annual wellness visits, I'm tasking my providers to update their problem lists and capture every, you know, chronic condition on that claim so we can make sure those HCCs are captured. Do some internal monitoring. And again, every chronic condition that the patient has or every, you know, valid diagnosis, even like a toe amputation or their colostomy status, at least once during the year. It's not every claim every single time, but, you know, if you prioritize and those conditions that you're addressing are specific and you're reporting them as you're seeing them, and then you think of a more strategic process. You know, can I run, have my team run reports towards the end of the year? Am I just going to make this part of my annual wellness visit process? What kind of encounter can you really do good work with this on? And I think for the sake of time, we need to move on. But if you have questions, write them down so you don't forget. And again, we have that open Q&A at the end or if you're with Amanda and I, we can talk more about questions. Thank you, Paul and Brianna. Lots of great information. Slides for this workshop can be accessed on the HCI Learning Hub. As a reminder, please continue to complete your learning plan. 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. Please mute your mic and turn off your camera during break. We will see you back promptly at 1055 a.m. central time. Thank you. Welcome back. We hope you enjoyed your break. We are dealing with COVID, both in our personal lives and our work lives. We've added in a special session with Amanda and Ina to address the challenges and strategies for HBPC and COVID. Thank you. Hi, everyone. Welcome back. We're going to switch gears a little bit and talk about COVID and HBPC strategies around COVID. Amanda and I will do our presentation. It's not supposed to take up the whole 30 minutes at all. We do want to spend at least hopefully half of the time we have together, which I believe is 30 minutes. Fifteen minutes of just conversation about COVID, how everyone is coping with COVID, strategies on managing patients with COVID, and just some information sharing with everyone. Let me jump into it and get our portion done so we can really hear from the group. Here are the learning objectives of what we're going to do today or talk about. Next slide, please. Next slide. The role of the HBPC during COVID-19. I really take it as a mission to try to have our patients remain at home during this COVID pandemic. Any acute issues that come up with our patients, we run out and take care of them. Maybe not run out, but at least get on the phone with them and try to take care of them. It doesn't escalate where it then requires an ED admission or ED stay, hospital admission, and for some of my patients, once they get into the hospital, it's almost like they're going into a nursing home. As we all know, right now nationally, 40 percent of all COVID deaths are in long-term care facilities. I'm sure everyone has personal stories about patients that go to the hospital for maybe congestive heart failure, go to a subacute facility and there's COVID in the facility and they have died from COVID. While they're in there for not COVID-related issues at all. That's always very just demoralizing for us. Really taking care of that acute issue in the home, having them stay at home, and obviously to continue to manage the chronic issue. I think we can talk a little about how much depression and loneliness is happening with our population now with COVID, being at home, being isolated from families, from friends. I was visiting a patient yesterday. She used to go down to the dining room and sit with the three other old ladies. Now the dining room's closed. They can't socialize with meals. They're not even really allowed to go into each other's apartments. She just misses them. She's like, I just miss seeing my friends. There's a lot of depression and loneliness out there. Our visits are a source of bringing cheer into their lives. I take that seriously now and try to leave them happy. Give them a little happiness when I'm there. Next slide, I think, Amanda. I just, slide please. I have a couple of slides just on some of the operational pieces and interested. Again, we'll go through this and then we'll talk about it. For us, we all, the collective world, but our leadership team and our communication team, we really had to figure out how in the face of constant changing information are we going to organize it and disseminate it. For us, it was, does it follow a traditional organizational structure? Is it a hierarchical of information flows down or up or however organizations work, or is there a temporary team? Many groups formed ad hoc task force to focus on different issues. Some things you guys have thought of and probably have already done, but really, if you're having any rubs with anything, maybe some of these questions might be helpful. Who is the authority and when can it be used? At what level, for us, for example, we put the head of nursing was in charge of buying all of the PPE and keeping all the PAR levels. That really meant a blank check for writing and procure a blank check for procuring PPE. That's not something that we would typically do, right? What is your communication tree look like for disseminating information? For us, we were like many organizations that have more than one person. We met on a monthly basis and we get together and talk about practice updates, models, clinical changes that might exist. Well, now we're talking about a day to day minute by minute change of information. And even though I think the information has varied over time, we felt the crunch in the beginning three months of how to, every day we need to talk about it. The summer months were a little bit different. We have upped our connection points again and that so to think about that being a fluid structure. What we did is right away, we convened everyone on a call every morning for an hour. The entire company, 180 people around, here's what's going on. Here's what we know about the disease. Here's what we know about the spread. Here's what we know about PPE. And then here's how we look at our facility. So we initially started and still continue to this day collecting data. How many patients have COVID? Where do they live? Are they considered recovered? Are they considered still active or have they deceased? Have they transitioned to another location? Do we know where they are at all times? Do we know any facilities we go to? Do we know if there are positive patients there that are not our patients? And we started tracking a giant spreadsheet, again, to communicate and disseminate information very timely. And then how do you address any barriers that come up? For us, one of the biggest barriers was lab action. We didn't historically have really strong lab testing before this. And so now, we just kind of use our local labs around here. We didn't have the direct contract. And so we had to go and get a direct contract with a group out of Kentucky. And we're one of their last entries in to be able to run all of these COVID tests. We saw it as an immediate barrier. And then how do you adjust as information changes? So again, how do you change your meetings? How do you change your authority makers? How do you change your actions, whether that's your PPE, etc? So I always say leaders, again, solo practice, multiple person practice, very large practice. Leaders are in charge of thinking of tomorrow. The management team and the decisions you make today, you just execute today. And especially in a crisis situation, we all get used to execution today and forward thinking because you got to think what's the next thing that's going to hit. Slide. So some workflows to make people more efficient and timelier during a crisis, you know, delegate authority for speed. We don't always have infrastructures that are built for great for delegation. So who do you put in charge and for what? You know, understand all reigning federal and state and regulatory guidelines. Put someone in charge just of doing that. Work closely with the clinical partners and staff to reduce red tape. Having a higher touch point for how often you meet will help with that. And then, again, you continue to create this culture that where anybody could bring ideas forward. And then set expectations on family members and education for patients of what that's going to look like. For us, right away, and many of you, right, and we have 1,500 patients in assisted living. For us, when a, and we do long term care. So we figured out that around five patients who are COVID positive tips the system of the building into chaos. Now people, now staff start showing up, don't show up. They quit or they're positive or they're in quarantine. And so now we have a situation where they really find it, you know, they're unable to manage family and patient relationships the way they did and update on a regular basis. So we would send in nursing and our providers to help support on the floor just for communication purposes. And so, you know, what is the expectation of us of a provider group of how we're going to keep people up to date on information? And how do we communicate that to everyone? And so we do that on a successful, on a consistent and successful, you know, marker slide. And then how do you put together your COVID task force? And so many of these things you probably have already done. Some, you may be even eight, nine months into it, we're still kind of chasing our tail. So, you know, again, this PPE stock, how do you assess it and how do you keep up with it? There has been a lot that has changed and that we have personally changed, I can say, from our practice around PPE and protocols. And so as we've gotten more information, you know, do we take the N95? Do we put it in a bag? How long is it in a bag? You know, how often can you reuse things? There was some new information from the CDC in the last couple of weeks, or excuse me, from our health systems around if they're wearing surgical masks over N95s. And that that could help or that could cause a little bit of a rub and would shorten the life cycle of an N95. So, like, how do you take all those things and make sure you have all that information, again, put together and disseminated in an easy to understand way? And then when do you require what level of PPE? What are you going to wear if you have a positive patient, if you have a suspected positive patient with the level of asymptomatic spread and with the community exposure right now? A lot of our teams are operating as if everyone's positive, you know, but that's a change of system from the summer. Staffing evaluation. Who do we need and where? Where are people going at all times? Do we know where they are? And do we need to consider any labor laws to get them there? Testing capacity resources. You know, we have all had our struggle working with some sort of testing capacity. But, you know, I would say we need to keep in front of what the expectations are. I have told our teams going into this month and maybe even next month, especially with the holiday, with the testing overload, you know, what we were seeing as a, you know, 12, 24, 36 hour turnaround could be a five day turnaround now. Some of the places that were already mixing, you know, two day or five day turnaround, they could be even longer with unknown information. So what do we do with the lack of positive results if we have symptoms or if we don't have symptoms, but we have suspected positive exposure? How do you keep up with a compliance plan? How do you keep up with all of your workplace safety and your HR and everything coming out of the federal government? Again, put these things together, assign again to delegate the authority, but put decision makers on a team. And so when you build a team traditionally for getting buy in, you build it in a different way than you might build a crisis team. These are people who have authority, who understand and can report back quickly. We talked about PPE training and Department of Health considerations. So any other kind of things for me? Think about them and we'll keep going through our slides and talk more about what you guys did that was successful and not successful too in building your structure. I'll turn it over to. Yeah, OK, so so I'm just going to show you and you can do the next slide of, you know, just I think, you know, we're what, how many months into this COVID thing. So I think many of us already have protocols in place about screening for COVID before we go out to see patients. So just, you know, as a quick review, I think we're we kind of all know the COVID symptoms of, you know, sore throat, fever, loss of smell and taste. You know, has a person had COVID exposure? Anyone in the family have COVID exposure? People who they're living with had COVID exposure? Have they been tested? That's very important because so many of our patients do live with other people. You know, has there been travel, right? So right now during the holidays, people are moving around. So did a college aged kid or grandchild recently come back into the home? So that's that's could be a potential exposure. So we need to ask about stuff like that. Have they had recent hospitalization or a long term care facility stay, you know, possible exposure in those settings? And and we talked about the travel. So so right. So I think we're we're all kind of dialed in about all the ways that COVID could, you know, be carried into the home into and in our patients could be exposed. OK, so next slide. So I'm just going to go over, you know, so I'm just going to show you. Oh, is it going to come up? Oh, so I guess it doesn't come up. Huh. OK, is it in your slide deck? Is it in your folder with the flowchart is hopefully you guys can see at least a hard copy print of it. If not, that's OK. I think we did include that in the in the workbook, but we'll get it in there. We'll get we'll get it in their resources. OK, so if you guys have in your workbook, you know, you just refer to that. This is this is actually copied from our own health system, home health, their their kind of flowchart. And it just basically does a really nice flowchart of, you know, all the questions that I just talked about, but really kind of, you know, spell it out nicely. You know, if they if you are positive with one, any of the screening questions, you know, you basically go into like another section where then you have to, you know, really reminds you of what you need to do to protect yourself going into the home. So, you know, talking about your PPEs, you know, if eyeglasses that really wraps around your eye, not just, you know, glasses, but really has a wrap around your eyes, your masking and N95 masking, gloves, gowns really kind of just, you know, kind of like signals to you that you have to do this kind of stuff. And if you're not, you know, did not come up positive with a screening tool, then, you know, just basically mask and eye protection and gloves when you touch the patient. But if you, you know, again, if you have a housemate or a caregiver that's also positive, you really also need to kind of think of it as just like a positive COVID home at this point, you know, until that housemate has been cleared. So, so it's just a nice little flow sheet where you can really kind of organize your thoughts about, you know, what you should be doing based on how they're answering the screening questions. All right, so the next slide. Yeah, and this is just, again, another way of, you know, maybe not so complicated with the one that, you know, was just shown or in your book, and this might just be a more simple screen. We do screen everyone before we go out. I think this is very important. I'm sure you guys are doing that. But you definitely need to screen everyone, even if you're like, yeah, no, they're fine. No, no, no, you don't know that. You don't know what's going on in their home. So you need to screen everyone before your providers go out. So, for instance, I'll just give you my example. In my office, my assistant, you know, does the scheduling for us. So she calls all the patients the day before or that morning before I'm going out and runs through the screening questions. And if there's anything positive, she actually tells the patient, she's like, you know, I need to get back to you. I have to talk to the provider, whether we're definitely going to come out today or not. So I will get a text or a call from my assistant, and she'll be like, look, patient had a fever and she's coughing. What do you want to do? And, you know, usually sometimes I'm like, okay, you know, like, you know, cough, fever, like, right. And I think the thing right now is like, we don't know if this is a common cold. We don't know if this is flu. We don't know if this is like, you know, allergies, you know, although fevers tends to not be allergic, or if it's a common cold. Or is this COVID, right? Right now, that's the thing. I think that's the anxiety is like, we just don't know. So I will tell you personally that if I hear a fever, a cough, you know, I usually will go out, will actually have my nurse or myself, we will go and grab a COVID test on the patient. So we're testing definitely more, just because you don't know, you can't tell by symptoms, if it's a flu or cold or COVID. So we are erring on like, let's rule out COVID. And we are testing. So usually we test that first, we wait for the results to come back. And then if it's negative, you know, we'll go out. And if it's positive, you know, we usually then, you know, actually put them kind of on a daily symptom kind of plan, where we basically check in with them daily, to make sure they're not decompensating. Okay. And we do this really for the telephone visit, or televideo visit. So we're really kind of leveraging the telehealth part for COVID positive patients, because, you know, in some ways, we also want to protect our workforce, in the sense that we don't want them getting sick, be exposed to COVID. And, you know, and, you know, and obviously be taken out of our daily work, daily work. So, so there's, you know, protecting them and protecting the patient at the same time. Okay, so, okay, next slide. And then this, this is also from my home health program. And this is basically just, you know, when you discontinue COVID precautions, this really follows the CDC guidelines. So this is really not like, you know, I know there's like a lot of boxes, you're like, Oh, my God, it just really kind of breaks it down into all the categories. But really, if you look through the categories, is just basically, you know, looking at the CDC, you know, recovery guidelines, and just following that. And CV just means COVID note, that's just our kind of abbreviation for a COVID note. And we have a template for that. So that is basically, you know, I'll let you read through it, but it's just kind of breaking everything down. But really, at the heart of it is just following the CDC guidelines. All right. And, and I think that was my last slide. Okay, so I mean, I think we basically talked about this screening, screening, screening, everyone needs to be screened. Every time you go out, doesn't matter if you just went to see the person yesterday. If you're seeing them again tomorrow, screen them again. Okay, there's, I just can't say there's not enough screening that can happen. And then the supplies. Oh, you know, we didn't talk about that. So let me go over that. So, you know, you really should absolutely be wiping down all your Equipment with a PDI, you know, with it. And then, you know, really bring your bag, especially for the patients who are COVID positive, you really should, you know, carry your bag kind of in a like a like a trash bag or some type of, you know, plastic bag. You know, don't put it down on their surface, you know, put it down on, you know, plastic, but like keep everything as contained. I mean, basically, just, just contain it as much as possible, you know, your stuff needs to be contained or sanitized, you know, immediately afterwards. Lots and lots of, you know, Purell. I feel like my hands are constantly dry at this point because I'm constantly Purelling myself. Just, you know, hand sanitizing a lot. Remember, you can't just hand, you know, hand sanitizing is fine, but you should absolutely do that. But then when you can actually wash your hands, you do need to, you know, actually wash your hands with soap and water. All right. And I think we pretty much went through all that. Okay, good. All right. So that gives us some time to for discussion and we really want to hear from everyone. You know, as many people who wants to join in about what their COVID experience has been, what they're noticing, what has worked, you know, frustrations. I mean, this is a time for you to vent too. We're good with that. If you just want to vent and be like, this is just really a stressful time. And I think, you know, I don't know about you guys, but it's, you know, turning on the news is very demoralizing. Knowing every day the cases are going up, you know, our hospitals are getting stressed capacity. And, you know, one of the things I hear, you know, where I, you know, we maybe we can talk a little bit about is about how, you know, how it's really affecting our homebound population, you know, how being cut off from families and loved ones is really just, you know, mental health really has been affecting them. And it's just, it's just sad. And they, you know, common thing people ask me is like, when is this going to be over? You know, and I'm like, I don't know. I mean, vaccines are coming, right? So I think there's a lot of press about vaccines. And that's a whole nother talk. But, you know, vaccines are coming. So I do see the light at the end of the tunnel. But it's, you know, the distribution, you know, when people are going to get it. I mean, that's all has to be worked out. I mean, I know our own state is ramping up for vaccine distribution, but it's not like we're getting a million of them, you know, at a time. You know, what I was told in Delaware that we're going to get like 14,000 vaccine, you know, in the first shipment, I was like 14,000. That's not a lot. It's not a lot. You know, I mean, Delaware is not a big state, but 14,000, this is really not a lot of people, not a lot of coverage. I, we also have to, you know, we've been struggling to talk with the families too. And we had to create some infrastructure and maybe you guys are the same with us around. Every time, every time something would come out about a treatment, you know, and so it'd get a big splashy news coverage, but like the details of treatments, or a tweet about treatments, you know, we had to learn everything that we could about it to relay that information. And, you know, it's been kind of difficult because at times, because, you know, I guess our practice, you know, I'm not clinical, but I would say our practice and me, I just don't think treatments have not come where I thought they'd be in the last eight to nine months and what we can do with that. And so setting those expectations with family members was a big, was a big area of learning that we didn't predict for us too. There was one question around labs and how people get connected with labs. And I see a little bit, like, how do they get COVID tests? For, for Genevieve, there's some pieces in here too. For Genevieve, we, we did end up contracting with a private lab, specifically just around COVID tests to be able to do those very quickly. And so we have a whole system and infrastructure just for COVID testing for labs. But other ideas outside of, you know, private, privately connect with a lab that people are doing? I do know there's some, you know, even our state is starting to promote point of care antigen testing to, you know, for our primary care offices to use to screen people. So, you know, so those type of test kits are also out there. And, you know, our, our Department of Public Health thought it was actually pretty, pretty sensitive to pick up, to pick up COVID. So that might be something that's a little bit easier to, you know, get testing to the people, to your patients. And for us on the antigen side in the state of Minnesota, we can't, we have a little bit different opinion, I think. Maybe that they're not, they're not as good as the PCR, but we, we can't get test strips. So you can get the test, but you can't get the test strips right now. So it's, you know, it's, and there's always a supply issue. So, say there's a question of people doing their own specimen collection for COVID tests. We are in some situations and in some we're not. So when we, we, we also, we do all of our employees and their family members as well. And then it depends. We have a couple of contracts to do, to do our own. And then some in some facilities we, we don't. So it just depends on our sites. Yeah. I have to say we do our own. Yeah. I mean, I think we do our own because we are able to, you know, part of Christian and care health system. So, you know, we are, we go grab it and we drop it off at our own internal health system lab. Turnaround is pretty fast. You know, if you're in the health system, it's usually within like 36 hours, you know, so it's faster than anything we will get in like lab core or quest. So that's why we're, we're motivated to go grab it ourselves. But I know not everyone has that luxury. And Mary posts here that they have to get tested every month and sniff providers every week in California. It isn't that funny, like athletes get tested every day. Some people have great access to testing, don't they? Yeah, our long term facilities are going through that too. They're testing. I think all everyone has to get tested. I actually now with a ramp up. They were getting up everyone all staff is getting tested at least every other week every two weeks and the patients were getting tested once a month. But I think that has recently changed because of the COVID activity spiking again. Am I heard? Can you hear me? Yeah. Yeah. I wasn't sure if I was on. I just want to also just let you guys know, you know, one of the things that, you know, I'm not sure if it was brought up earlier is, you know, we are facing an eight to 10% cut in fee for service payments come January one. Because when CMS increased payments to office primary care and cut everyone else, they didn't realize they were cutting home based primary care because we weren't on their radar. And one of the things that HCCI did this week is we reached out to the CDC as they announced that the first immunizations are going to health care workers and then doctors. And we got a very positive response yesterday from them that they are going to look into that and how home based primary care providers could be a distribution network for the vaccine. Just let you guys know. Oh, that's great. I know. Did you see the question from Jennifer or do you want me to read it to you? I can read it to the group. No, it's okay. Can we It's for you, though. Can we address how to escalate care for patients screened out by COVID questionnaire who need more than a television other than sending them to the emergency department. Jennifer's employer has a policy. They don't see patients in person. Those patients in person. That's a great question. And I think, you know, I think I have learned from my home health colleagues, quite honestly, because, you know, we're our home. We have a huge home health department at Christiana You know, they go out, you know, they go out and they have a huge workforce and they're coming across as even more than we are. You know, they go out, you know, they have a huge workforce and they're coming across as even more than we are. So I often like ask them, like, what are you doing, because, you know, they've obviously, you know, have a huge workforce and they're coming across as even more than we are. You know, they go out, you know, they go out. And so I see that your employer, your employer has a policy. We do not see these patients in person. So that that's that's hard. You know, if your employer says you can't go out, then absolutely. You're going to be strapped to do it. So we, you know, for instance, I just had a patient Who was on hospice pretty sure she had coded, you know, and but she was declining, most likely also because of coded, you know, family opted not to test for coded because, you know, like There are hospice like what, you know, what are we going to do. Right. So, but we're all pretty sure she had coded Because there was a risk of exposure through a home health aide that was coded positive that enter the house. So we're all like, yeah, 99% sure she got she's having coded. That's why she's declining. You know, family was really, you know, didn't want to go to the hospital, you know, but was like stressed out, you know, and, you know, you know, the dynamics dying is hard on the family. And they really needed some handholding. We couldn't get the television thing to work just wasn't working. So I went out, you know, I went out. I gowned up, you know, and I try to do socially distancing thing, you know, and and really try to, you know, Hold their hand without really holding like physically holding him as much as I can. And it was, you know, I think beneficial for the family and for me to do that. So, so yeah, we still go out even They need more than television, but I, I think that's hard when your employer says you can't go. I don't, I honestly then don't know what else to say, except that then you got to send them to the emergency room, which sucks. Sorry, Jennifer. No, it's not a very satisfying answer. I'm sorry. I could, I could just add a few things to that. So my background is in emergency medicine and then I've been doing Community paramedicine programs and now in home primary care for a little bit, but there's a couple of things that you can do in the interim. If you can't get to the patient. We've relied heavily on on home monitoring equipment. So getting it pulse ox is out to the out to folks equipping caregivers and patients with some of the I mean, it's just the basic OTC kind of medications, you know, making sure you're taking your Tylenol and your ibuprofen, whichever you can do constantly, regardless of how you're feeling, you know, you get them on a decongestion early Steroids for folks that have new oxygen requirements are sort of borderline with with their oxygen. Or breathing. So there's some things that you can do to sort of tee up the patient as best you can give them some of the tools in the home to help you help them. And that's, that's been relatively successful for us. We also have the luxury of having community paramedics that we can send out as well that have been very helpful, but just like most of you, we continue to see these folks in the home, regardless Right. Yeah. And I think, Charlie, that brings up a really great point when you put out that you can have them. You know, this family. I did tell them to get a pulse oximeter. I'm like, you can go get a Walgreens, you know, go, go get it. So I monitor O2 stats blood pressure monitors are automatic now. Right. Yeah. So there are things you can, you know, it gives it gave the daughter's a little bit sense of control, you know, that she's monitoring mom, you know, she's not just watching her like without data, she and then she can then you're right. Next day, she was like, Oh, too sad was like 90%, you know, I was like, I'll push up the oxygen, you know, that kind of thing. And I gave her like, okay, that's great. Like, you know, she didn't feel like she was giving up like we were all giving up on mom, you know, Yeah, I'm always surprised that like, you know, there's there's like the fundamentals don't get done for so many of these folks like the basic things just aren't They just for whatever reason, folks just do don't don't do those. And so trying to tee them up with those things. Remind them here the fundamentals that you can do To help. And these are the things you should be aggressive about put on a schedule and whatnot. It's just, it's little stuff that you can do to nudge. I think it has a huge impact. Absolutely. And I thank you for bringing that forward. That's excellent. Yes. So I know we're, we're at time I had before I know wraps this up. I had one question that maybe at the afternoon or the end of the day, folks might Be able to help us with. We've had a lot of conversations with families pushing back on how we fill out the death certificates. So have you guys had any of those conversations or death certificate discussions and where did you guys land on that would be one that I could use some help with is, you know, for COVID to Yeah, I would like to know. I'll let you wrap it up. Yeah, no, I like to hear that conversation to about that. So, um, no, I don't think there's a lot of wrap up. I think this is, you know, this is a very, this is a current like Situation we're all going through is constantly evolving, you know, the vaccine is going to throw another wrinkle into this whole thing. And so, you know, it's just more and more to come on this. So we're all learning together. It really very feel like that we're all learning together. So, okay. And thank you. Thank you. Thank you. Amanda and I know we are. It was a great, great job. We'll be moving on to our next session with Michael on wound care. Okay. We're going to go on to wound care. First we're going to go through the slides and then I'll quickly move across the room, my multipurpose room here, and do some demonstration. Next slide. So our objectives today are really to focus our talk on pressure ulcer, think about what are the wound care goals for homebound patients that we treat with serious illnesses, discuss interventions and the management of pressure ulcers, and review primary prevention of wound development. Next slide. So the first thing to think about is the skin is a complex organ, largest organ in the body, and there's actually several discrete layers of the skin that are listed here. I'm not going to go through them all. But the one thing I'd like to point out about wounds is they're often classified as partial thickness or full thickness. And a partial thickness wound lies in the skin layer, so the epidermis and the dermis. Anything below the dermis would be considered full thickness, extending down to the subcutaneous layer or lower, whichever wound type that is. Keep in mind that the skin layers are, you know, a handful of cell layers thick and get thinner as adults age. Next slide. The functions of the skin are obviously protection. They keep everything on the inside, on the inside. It provides thermoregulation with perspiration when you're too hot. Sensation, again, a form of excretion. You can lose up to a liter of fluid through your skin. This is why we always talk about air conditioning in the state of Maryland in the summer for our patients. Synthesis of vitamin D, and it gives us all our own unique image that we put forth toward the world. Next slide. As the skin ages, it takes longer for the epidermal layer to turn over. So a younger adult takes about 20 days to regenerate the epidermal layer of the skin. Those cells actually all move up from the lower levels of the skin and then they're outward. This is why exfoliating is so good, why cosmetic companies bestow the benefits of exfoliating because you're trying to get rid of the dead skin layers on the outermost surface. After the age of 21, it takes twice as long for the epidermal layer to turn over. So you're talking about 30 to 40 days after the age of 20, and it takes longer as we all age. The collagen bundles shrink, and this is what causes the sprinkling. Sebaceous and sweat glands start to dry up. Sensory receptors are impaired. The subcutaneous layer of protection thins. The immunosuppressive cells on the skin tend to weaken. There's reduced blood flow to the skin cells. Cellular senescence is occurring, which means that cells don't regenerate as well as they used to as we age. There's less of an inflammatory response and there's capillary fragility, which can lead to bleeding under the skin and bruising, which we see in a lot of our patients that are on antiplatelet therapy or anticoagulants. Next slide. So thinking about how to assess a wound, first thing, I know that we're talking about pressure ulcers today, but every wound is not a pressure ulcer. And part of your assessment is to try to determine what the etiology of the wound is. And when you're doing that, you should kind of keep in mind the sort of the multiple choice answers of what the most common types of wounds would be, which would be a pressure ulcer, arterial, neuropathic, or trauma are the five categories that I most often recommend keeping in mind. The most common traumatic injury in our population is probably skin tear. In your assessment, you want to note the location of the wound. If and only if it's a pressure ulcer, you're going to stage it. And as Paul and Brianna mentioned, the accuracy and staging is going to impact your complexity, your HCC score. So it is important. Then dimensions. We'll talk about this a little more with the model. Length by width by depth. Length is head to toe in fashion with the side to side depth at the deepest point of the wound. And then is there any undermining or tunneling? You want to describe the exudate. That's also important because exudate is a common requirement for Medicare to pay for various dressing types. And then the description of the wound base and the surrounding skin. Next slide. So a pressure ulcer is any lesion that's caused by chronic unrelenting pressure over a bony area. There is often several other forces that are contributing to the development of the wound. If the wound is round in appearance over a bony prominence, the most most impacting force is pressure and pressure alone. If it's more oval in appearance or has more of a linear appearance, friction and shear also come into play. The fragile capillaries tear with the cell, the skin layers moving against one another. And then that helps to contribute to the formation of pressure injury along with the pressure alone itself. I should point out, I meant to mention this earlier on, there's several terms, people use these old terms interchangeably. The cubitus ulcer, bed sore, pressure ulcer, the most current terminology is pressure injury. So it also, pressure injury can also be caused by pressure injury can also be caused by medical necessary equipment. This could be a tracheostomy, a gastrostomy tube, indwelling urinary catheter. If someone was, had a pulse ox on their finger for a long time, I mean, that would be more common in a hospital, but those are also considered pressure injuries. The only other contributing factors that I didn't talk about are, but our most common pressure, friction, shear are heat and moisture. Next slide. So the cartoon here shows you the most common areas of pressure and that in prevalence rates across the country, the number one most common location is the sacrum and the number two most common and always avoidable are the heels. Heels are always avoidable by simply offloading heels, which means they're not touching the surface of the bed. Next slide. I think next slide must be, keep going and maybe one more. Okay. Yeah. So I, so the national pressure injury advisory panel, npiep.org, you can get the definitions and images most current full definition for the stages of pressure ulcer at that site. A stage one, I'm going to use sort of an abbreviated definition as I speak and kind of use the same terms throughout the staging. Stage one, the epidermal layer remains intact. The area in which the epidermal layer remains intact. The area is maybe red and in color and is dependent on the patient's normal pigmented skin. It's often missed in darker pigmented individuals because the redness is difficult to see. Shining a flashlight may help. In darker pigmented individuals, it can appear darker than their normal pigment or lighter than their normal pigment. There may be heat or warmth in the area. Also may feel firm or boggy and the patient may complain of pain or itching. If the pressure is relieved, the stage one will resolve all on its own. That redness is really the initiation of what I call cellular CPR, where those cells will attempt to quickly repair themselves and avoid any opening in the skin. Next slide. Next. Next. And one more. Back one. Thank you. So stage two, there's a break in the epidermal layer or there's a serum filled blister which may be intact. We've all had a blister. So if you think about a ruptured blister, it gives you an idea of the depth of a stage two. The blister is formed typically at the epidermal and dermal junction. So thinking about those cellular layers. So a stage two pressure injury is a partial thickness wound. The wound bed is pink, typically moist. Next slide. Next slide. I think one more. Maybe one more. So a stage three is now a full thickness injury that extends through the cell layers down into the subcutaneous tissue, which you see here, the yellow fatty tissue below the skin surfaces. Depth is not a hallmark sign in a stage three because it's dependent on the area of the body. If there's not much subcutaneous tissue, it can easily be a stage three but appear shallow in nature. There may be slough or eschar present. That's the avascular unhealthy tissue in the wound bed. There may be tunneling or undermining but it's not typically common. Next slide. Next slide. I think one more. Stage four is also a full thickness wound that extends below the subcutaneous layer and exposes the underlying structures. That would be ligament, tendon, and bone. And here you see the visible bone here. There often is tunneling and undermining present and there's often slough and eschar present in the wound bed. This image here, if you see sort of the cross section there where the wound extends beyond the outer presentation of the wound, if you ran your finger through that gully, that's called undermining. Next slide. I think I said that. Deep tissue injury is one of the newer terms, newer stages of pressure injuries. Deep tissue injuries are commonly caused by intense pressure over a short period of time or lesser pressure over a long period of time. So a common scenario might be a patient falls and is trapped between the tub and the toilet on a hard floor and a deep tissue injury can develop very quickly when laying on the floor like that. On presentation, the epidermis may be intact and the outer appearance may appear to be a hematoma or a dark red purple. Again, in older, darker pigmented adults, it may be difficult to identify. It is possible for these deep tissue injuries to heal from the inside without creating an open wound, but it's more common that this would evolve in one to three days to a full thickness wound. In the hospital setting, if these aren't caught early, they can be categorized as a hospital-acquired pressure ulcer, which we know is a reportable event. Next slide. Unstageable. Unstageable is a stage of pressure ulcer where we can't determine the stage. And that's because the wound bed is obscured, greater than 60% of the wound bed is obscured with eschar or slough. If you think about the words I've used in describing the stages, you'll remember that eschar and slough is not present in a stage one or stage two. So typically, this wound would have to be a stage three or stage four. It is a diagnosis code of unstageable, but you can't stage it accurately until that avascular eschar or slough is removed. If you're not able to accurately stage a wound, if people are often unsure between a two and a three, a four when there's underlining bone, folks generally can stage that properly. If you're stuck between a stage two and a stage three, you can't ask a friend for help. I would probably recommend to stage it at the higher stage, especially considering the medical complexity. Before we move on from staging, a sort of a drawback about pressure ulcer staging and when the NPUAP first came together to sort of have the experts define and update the terms, the staging leads the provider to believe that a stage four had to have been a stage one and then progress through the stages. One becomes a two, becomes a three. That's not true if the etiology or the reason why the wound formed is removed. The layers of the skin and underlying structures, the ones that are most impaired by lack of blood flow caused from pressure are the underlying tissues like muscle. Muscle is the most highly vascularized and most dependent on an adequate blood supply. That's why intense pressure is considered to start in the innermost layers and then project outward and not the other way around, like an inverse iceberg. Next slide. So, the NPUAP is a very common type of wound. It's a very common type of wound. It's a very common type of wound. It's a very common type of wound. Next slide. Okay. So, thinking about Minerva, she has a stage four sacral coccygeal pressure injury. We know that's a full thickness wound. It's four by four centimeters by two and a half centimeters deep. There's no undermining or tunneling. Serous drainage with 75% of the dressing is saturated. There's no order. So, how do we assess order? We actually should be assessing order after the wound, the old dressing is removed and the wound is cleaned because new technology with dressings, they can remain in the wound bed for several days. And if you think about wearing an undershirt for several days, it's likely going to have an odor. She has 25% adherence slough, 75% granulation tissue. So, this is a fairly good documentation of a wound assessment. The one thing that is missing, let's see, is the appearance of the outer skin, the periwound skin. Is that intact or is it macerated from a great degree of drainage? I would include that. I'd also talk about the wound edges. If you're not sure about slough versus granulation versus eschar, another thing that you can do is describe what you see in the wound bed in color. Next slide. So, the margins are defined. So, the wound margins are the outermost appearance of the wound bed. So, this is the wound edges. It's what you see on the outermost appearance of the wound. And those are considered well-defined when they're beefy red, usually more red in appearance than the rest of the wound. If the wound margins aren't well-defined, once the void is filled with granulation tissue, the epithelial cells won't march across to close the wound. So, you want to try to keep those open whenever possible. Surrounding tissue has no maceration or induration. And what that tells me is that the drainage of the wound is being well-controlled by the dressing products. There's no sign or symptoms of infection. So, infection is difficult in chronic wounds. And I just caution you about regularly culturing wound beds because you're going to take yourself sort of down a rabbit hole. If a wound is not progressing and through the stages of healing, you may think that there may be some bacterial burden on the wound bed. And at that point, think about switching to a bacteriostatic dressing if you're not using one already. No complaints of pain or discomfort. This is another sort of curious indicator. If the pain isn't in alignment with the degree of the wound, you should be somewhat worried that something else is going on. And in that case, infection could be causing pain. Incontinence, the daughter's doing dressing changes daily and checking for wetness throughout the day. With incontinence, we worry about maceration of the skin. Keep in mind that incontinence-associated dermatitis is its own category of wound and not a pressure injury. Commonly, you'll see them over the buttocks, not over an area of bony prominence. Next slide. So assessment. The one thing I say about developing a topical plan of care is there's really no wrong answer. The only wrong answer is to continually doing something that the patient's not benefiting from. So if you're not noticing continual improvement in the wound, you need to kind of go back to your wheel here and figure out what you're going to change. Next slide. That's, of course, if the plan that you've put in place is being followed accurately. So goals for Minerva. If the goal is to heal a wound, which it's not always the goal, especially in folks that are near the end of life, or maybe the pain is too great, or it's a heal wound with dry adherent eschar that's considered protective that we would want to keep intact. So if the goal is to heal the wound, we always need to remove any debris that's in the wound bed, whatever it is, whether it's avascular tissue or gravel from a traumatic fall or something like that, motor vehicle accident. So this wound is obviously a stage four sacral coccygeal. It's not, it's not round in nature, solely round in nature. So it leads me to believe that there's other or other forces contributing to development of this wound. We see that there's bone present here. That's the indication that it's a stage four with bone. We worry about osteomyelitis whenever there's bone present. Here we see eschar, yellow eschar, or yellow slough, black eschar present in the wound bed. This is the pink granular tissue that we're seeing here that's trying to heal this wound. So we always want to maintain a moist wound surface. If a wound's not kept adequately moist, it'll heal downward to the layer of moisture. So if you've ever seen a scar that's like got a negative divot, you know that that wound wasn't, didn't have enough moisture. Whenever you can minimize the dressing chain's frequency, that's best. It speeds wound healing time. Every time a dressing is, a wound is opened, cleansed, it decreases the wound healing rate by 50%. We want to prevent and manage infection, and there's lots of bacteriostatic dressings that we can use now to do that. Manage drainage, manage odor, largely contributing to patient comfort, but managing the drainage will also help to heal the wound and prevent pain whenever possible, especially if it's an end stage patient. You want to try to minimize the number of dressing changes, especially if they're painful. Next slide. So some considerations. I already talked about end of life. If the patient has an impaired inflammatory process, it'll likely impact the wound's ability to heal. I've listed some of the medicines here that can also impact wound healing. If the wound gets, the wound often gets delayed and may get delayed in the inflammatory stage. Here you'll see delayed wound healing again, reoccurring of slough, redness, exudate, and swelling. The older the adult is, we talked about how long cell turnover, so age can impact wound healing. The medications are listed above. We talked about infection a little bit. It's not wrong to consider a course of antibiotics if the wound's not healing. Generally, I recommend changing the dressing type before that, unless there's obviously a systemic infection going on that forces your hand. Nutritional compromise will also delay wound healing. Next slide. So for Minerva, we want to make sure that she is getting adequate nutrition. We may think about checking her A1c, her albumin to give us more information, her glucose level, her HNH. Also, we may consider prealbumin total protein. Mostly, we just use albumin now. She doesn't have any sign of obvious sign of infection based on her wound. She's doesn't have any significant medication contribution to delay healing. She definitely has comorbid conditions that may delay her healing. And then what is her goal? What's the goal of her care? And is wound healing included in that goal and what matters most? Next slide. So for Minerva, we would try to go to a daily dressing change, probably mostly because she's got a fair amount of exudate on the dressing. 75% on the outer dressing is noticed. So anytime that you notice more than three quarters of exudate strike through drainage on the outermost dressing, that the dressing should be changed. That means that the products are overwhelmed with moisture. That's about their maximal capacity. You should cleanse with the wound cleanser whenever there's debris present in the wound. And most wound cleansers come in a bottle like this. There's surfactants in the wound cleanser that help break down the bond that exists, that protein bond that exists with slough and eschar on the underlying granular layer. The spray also gives a positive pressure, 12 to 16 PSI, that when you spray on the wound bed, it also helps to lift any debris that's in the wound bed. You want to let the wound cleanser sit on the wound bed for a good three to five minutes, again, to help break down those enzymes. Deciding on how to cleanse the wound is really sort of your first step in the topical plan of care. If there's no debris in the wound bed, you can soap and water in the home is fine. If you prefer sterile water or normal saline, that's OK, too. To protect the wound edges, the wound margins that I talked about, so here's a picture So here's another wound. The wound edges are the wound margins. To protect those, you can apply Vaseline or A&D ointment. The goal is to keep those wound edges open so that when the void is filled, that wound will close, will re-epithelialize. Another technique to keep those wound edges is to just gently abrade the wound edges with a dry gauze dressing to kind of keep that area open and then apply the A&D ointment. I'm going to talk a little bit about dressings, but the next thing when you're developing a topical plan of care is you have to decide if you need a filler dressing. So anytime there's depth to the wound, the void needs to be filled. And for Minerva, I would recommend filling that wound with an alginate rope. And the rope, you go around until the void is full. If you don't fill the wound bed, the body is going to replace the void with slough or eschar, and then you're going to have something else to deal with. The next step is to cover. You need a cover dressing. And in this case, we cover with gauze and secure with a border gauze dressing. I generally always recommend an as-needed dressing change for greater than 75% strikethrough and a defined frequency. So every other day or with soiling or greater than 75% strikethrough. Here on the right, we have a list of common wound products that you'll see. Next slide. So I already mentioned that covering wounds, they'll heal twice as fast. This has been documented for a long time way back in 1962. So wet to dry dressings are really out of favor because you have to typically do those at least twice or three or four times a day. They're not wrong if you had a highly exudative wound that you're going through costly surgery or going through costly dressings, dressing supplies multiple times a day. But generally, you want at least a daily dressing. And ideally, every other day, every three days, there's products up to five to seven days. So a little bit about prevention. We always want to redistribute pressure whenever possible, turning schedules, incontinence care, adequate hydration and nutrition. If there's a full thickness wound or even a skin tear, I would recommend referring to nursing. They can also help you pick products that'll help heal the wound and give closer monitoring. Then you're able to go out and see the patient. We want to try to identify pressure ulcers early, especially in darker pigmented individuals. Those folks, based on research, have been proven to have to deal with fuller thickness pressure injuries because they're not detected early enough. Always educate your patients and your caregivers on prevention interventions. And if you're not sure about what forces you need to address, you can always refer to the Braden scale, which assesses all the areas that put an individual at risk for pressure ulcer. Next slide. So things to remember. Remember that your topical plan should always be within the patient's goals of care. You should always manage pain if that's necessary. If you're going to do a dressing change or assess the wound, when you call ahead, have the patient pre-medicate before you get there. Prevention is always key, although all wounds are not preventable, even in the hospital. Think about a terminal injury, a terminal pressure injury. Those typically occur over the full area of the buttocks. They'll have a butterfly appearance. It's a sign of skin failure and impending death. I already mentioned the goal to reduce the number of dressing change because covered wounds heal faster. So I still have to deal with leaving it open. I left it open to air so the air could get at it. That's actually not the best idea anymore. And then when you're coming up with your topical plan of care, you want to think about cleaning, filling if appropriate, debriding if appropriate, protect the margins, and cover the cover dressing. Next slide. So I'm going to go over. I think I went over the stage four pretty well. This would be an example of a partial thickness wound. It could be a shearing injury from a skin tear. If it's from pressure, which I suppose this is the ischium, if it's from pressure, this would be a stage two. Remember, a stage two still lies on the skin layers. This area of bruising over the trochanter would be what we would consider a deep tissue injury. Remember, that's intense pressure over a short period of time or pressure over a long period of time. It does primarily look round in nature, which also tells us that pressure is the most common force. This is a dehysturgical wound. We don't stage that. Next slide. I'm going to say that this is likely meant to be unstageable. It's a little difficult to tell, but it looks like so we have black eschar here, and it looks like we have yellow slough or biofilm here. This may be biofilm. Biofilm is sort of slimy slough that may or may not come off with cleansing. But considering all of those, greater than 60% of this wound is obscured by avascular tissue. So this is unstageable. And this one would be a stage three. So this is not bone. I don't believe that's a ligament or a tendon. So you see my finger here. This is really undermining. I wouldn't consider this a tunnel. But when you just, so undermining is that gully-like projection of the wound beyond the outermost dimension. And when you describe that, you want to describe it in the form of a clock. So 12 o'clock is the head. And it extends to, I'd say, two. So undermining, and then you describe how far it undermines. So I'd say undermining 3 centimeters from 12 to 2. And that's pretty much it for undermining. Tunneling is a fingerling-like projection that extends beyond the outer dimension under the skin. This stage four also has undermining You can see where I can run my finger from about 11 to 2. And sometimes I use a cotton applicator. I often use my gloved finger because you can feel things better, like bone, that you may not be able to appreciate with a cotton-tipped applicator. So some common dressings. I have several of the most common dressings. This is what we call a duoderm, or a hydrocolloid dressing is the generic name. There's several manufacturers. This is sort of a rubberized dressing. And it's OK for a stage two or a protective layer. They generally don't adhere well to the perineal area. And you have to apply, take off, reapply, or partially take off. And that frequent partial removal and reapplication can further break down the wound with the removal of the adhesive in the perineal area. So I generally don't recommend them. For those types of partial thickness wounds, I would really recommend a zinc petrolatum-based barrier cream. They're occlusive in nature, mostly occlusive in nature. They do allow some moisture to evaporate from the wound bed. They do provide a small amount of absorption. The duoderm kind of gets slimy if it absorbs moisture from the wound. I would only use this, as I said, for a stage two for protection. And it would be a primary cover dressing. You wouldn't be using this with a filler dressing. For protection, it can stay on until it falls off. You really want a duoderm to stay on for two or three days, if possible. I generally don't recommend them every day. Using skin prep may help them stick. That's true for any wound products that you use. This is a transparent film dressing. In the hospital, you might call them tegaderm. It's what we usually use to cover an IV. They all work a little different. I think most everyone's familiar with these. This is not the treatment plan anymore for a skin tear. So a tegaderm is occlusive in nature. It's going to trap moisture against the skin. It doesn't provide any absorption. If you use this for a skin tear, it's going to likely collect serous fluid that's going to encourage slough overgrowth. So we don't generally use these for skin tear. And then the removal can cause additional damage to the skin layers. This can be used for a cover dressing. In some cases, if you wanted to, you could use this as a cover dressing for a deep wound that you're using a filler dressing along with. Let's see. This is an absorptive gauze dressing with an adhesive border. So that's how I would refer to this without using a brand name. It's partially occlusive. So there are several products that you can get. This is sort of a gauze-backed dressing. There's others that you can get, like Aleven would be a trade name, where they are occlusive in nature. There's sort of a plastic backing to the dressing. This will provide absorption with the gauze pad. It also provides a cover layer. So this could be used for a shallow wound as the primary dressing, where you don't need a filler dressing. Or it could be used as a cover dressing, especially for a deep exudative wound, like Minerva's, where there's a lot of strikethrough drainage on the outermost dressing. So we said that Minerva's outermost dressing, there was greater than 75% strikethrough drainage on the outer dressing. So you would see the moisture here on the gauze. Greater than 75% means it's time to change. And depending on the day that the dressing was last changed, if it was that morning or one day ago, that may be a considerable amount of drainage. Regarding exudate, you generally say stent, mild, moderate, or heavy exudate. For some of the more advanced products, Medicare goes on the amount of exudate to approve the products. Those are usually things like hydrofibers or hydrofiber with silver. This is a roller gauze dressing. We sometimes call it a Curlex. It comes in several forms. It's cheap, which is good. It's easy to come by. And this you can use as a filler dressing. You could also use this to secure the primary dressing in a skin tear. When you put it in the wound bed, you want to always take it out moist. So wet to dry is totally out of favor, because when you take it out dry, you're going to cause pain. It's also a non-selective form of debridement. You're going to remove any debris that's in the wound bed, as well as healthy tissue. And you can cause significant pain and possible bleeding when you do that. So if you're removing gauze or any filler or wound layer dressing, you want to take it out with moisture. You can use the wound cleanser or normal saline to do that. This, let me see. I think I have it open. This is a hydrofiber dressing with silver. The way we can tell is that it's silver in nature. Now, whoever makes this one, it's only silver on this side. I've actually never seen that before. But the silver side would go against the patient on the wound. The silver is what's bacteriostatic. You can use it in a wound that you're worried about colonization, or as prevention if someone's at high risk for wound infection. I don't know if you can see the difference. But this side is silver clearly does not run through this dressing. Hydrofiber dressing, whether it's silver or not, you can put in the wound bed dry. To absorb excess moisture, you can also, if you don't, if the void is significant, like this wound that's probably 3, 4, 5 centimeters deep, you can put the silver layer down first against the wound bed. And then I would fluff the roller gauze to fill this void. So that would give you more moisture absorption in this wound bed. So in this case, we're using a layer dressing, then a filler dressing, then a cover dressing. If the wound bed's dry, you can put this in moist to donate moisture to the wound bed. In that case, I would recommend using normal saline. Silver can stay in the wound bed for three to seven days as long as the moisture is managed. I generally don't go more than three days because then I find that the dressing change is forgotten. When you take the hydrofiber out, whether there is silver in there or not, it's going to feel slimy. Just so you know, that's fairly normal. There can be some color change to the tissues with the silver leaking out. It's not absorbed systemically. So anyone that's worried about that, the silver is not absorbed systemically. Sorry. Oh, here it is. This is a silicone dressing. I'm trying to think of generic terms. Non-adherent silicone dressing. And there's SafeTech technology, which is, I guess, they allow other vendors to use SafeTech technology. But a common trade name would be Mepitel. And this is a sticky dressing that won't adhere to the wound bed, that comes off easily. This is an option that's more costly than oil emulsion gauze or Vaseline gauze that I would recommend for a skin tear. This is the primary layer, or the oil emulsion gauze is the primary layer, and then secure it with the Curlex. Change every day, generally. I generally don't recommend Mepitel because it's more expensive. With the Medicare changes in home nursing and their reimbursement, I've definitely noticed their product, they watch their products much, they're much tighter on their products than they used to be. The last dressing I have is Manuka Honey, or the trade name would be Meta Honey. There's several other manufacturers now. But there's actual medical grade honey on this dressing. It's bacteriostatic in nature, and again, can stay on the wound bed for several days. The bacteriostatic dressings, they cost more money, so you want to try to keep them on as long as you can. This dressing has an adhesive border, which you can see, extends beyond the honey. So this is actually, it's a primary cover dressing. You could only use this on a shallow wound because you can't, you wouldn't be able to lay this on the wound bed. It also comes in sheets, so you know, I can't lay this on this wound bed because of the adhesive border that you can see. I actually had a patient that bought Manuka, edible Manuka Honey in a jar, and he kept it next to his recliner with the lid off and was trying to use it to treat his wound. You cannot do that. I had to tell him that I had no idea how much bacteria was growing in that jar of honey that he kept open in his home. That was one of those homes we don't really like to go to sometimes. So you can't use edible honey for your wounds. I think that's it. Any questions? I'm going to look at the chat real quick. Yeah, Michael, there was a question about, what about wounds associated with lymphedema? Oh, so lymphedema, like a venous wound where there's edema, if you don't address the edema, the wounds are going to reoccur. Reopening of lymph-associated wounds or venous stasis ulcers is very common, and I am always careful to tell patients that because they'll say, you know, I don't understand why I keep getting a wound. Addressing the edema with compression is the best answer if it's not contraindicated, If it's, it can be pressure, actually, from lymphedema. If the lymphedema is so bad that the skin is actually hanging over, and I've seen it dragging, literally dragging on the floor. So you have to kind of determine the etiology of what's the primary factor of the wound, and then how you're going to address it. So if you don't address the edema with compression, the wound is going to reoccur. What's the primary factor of the wound, and then address that? Lymphedema, venous ulcers are very difficult to treat and often become chronic wounds, and in some cases, I tell patients that the wound is unlikely to ever heal. OK, great. I didn't see any other questions in the chat, but I know we are a few minutes over for our lunch break. We will give you the full time, but any final questions from our learners? All right. I think, I'm sorry, put them in the chat, and we can grab them for the afternoon as well. I just, thank you, Michael. And before we go into lunch, we want to remind you to stay logged into Zoom during the lunch break. After lunch, we are going into our procedure breakouts, but we are also offering a non-clinical breakout on practice management with Amanda and Brianna. And if you want to attend that one, could you please type your name in the chat now, and we will assign you over lunch. The handouts that go with the breakouts are located in session 14 in your workbook, beginning on page 69. So we will now have a 30-minute lunch break, and we will start promptly at 1255. So thank you, everyone, and have a great lunch. And those will be in zoom breakouts. There's just a couple slides. I think with just objectives before we do that. We'll just do a quick check. Do we have Paul and Michael and Tom? I'm here. I'm here. Okay. I'm here. All right. If it's okay, I'll just answer a couple of questions in the chat. Okay. All the products I bought at CVS, you can often find them at a decent supply, you know, larger drugstore. I think they each had about three to five dressings in them and they were all about 15 bucks each. So just for price consideration. Yes, you should generally be able to get Medicare to cover them. Partnering with a DME or pharmacy or combined agency that has really good customer service to help you get those things paid for is really what I would recommend. We have a couple really good partners in Baltimore city that help make sure that we document accurately to get them paid for. Exuderm is a hydrocolloid dressing like duoderm. So it can be, I would recommend using it on a shallow wound that's minimally exudative. Keeping in mind that all of the manufacturers of all of these products are always going to try to tell you why their product is best and how often you can use it. So that's just my recommendation. Someone might say something different. Thank you. I think that's all of the, most of the common questions. Thank you. All right. Well, we're just going to quickly go through the objectives and let you know what's going to be happening. So the first objective is that we're going to discuss and demonstrate common procedures, including tracheostomy, tube exchange, gastrostomy, tube removal and replacement and knee joint aspiration and injection. And then we are going to have Brianna cover applying the appropriate coding and documentation practices for performing procedures, including wound care. Next slide. So basically this is how it's going to work. We're going to have everyone attend three breakout sessions. Each session is about 30 minutes. We've addressed that because we're running a little late. So we've adjusted it just a bit. You're going to watch a 10 minute procedural video that was recorded by our physicians. We're going to have a little bit of time to review and discuss with our group. And then we're going to transition from breakout to breakout. So you will all stay in your room. The faculty and staff team will be moving around. You also, if you would like, go to the practice management. It's an open discussion room. So you can at any time leave a Zoom room and go to that as well. And then at the conclusion of those three breakouts, we're going to come back to the main room and we're going to actually talk about coding for these procedures. Okay. Next slide. So those are our breakouts. And I think we're going now. Yeah, I think just real quick, if you, you know, you should get to go to all three of the procedure breakouts without any problem, unless you've told us you prefer to be in the practice management breakout. But if for some reason you find yourself in a breakout and you're in the wrong place because you've been there already or some other need change, you can go back to the main room and Danielle can direct you to the right place. Okay. All right. So if everybody's ready, Danielle, I guess. Amanda, are you here with me? You're muted, but I see you. In my mind, I started the video and sound and I was just crushing it. You were giving us a whole intro before this. Hello, welcome. Sorry, sorry. I was playing. We have three kids now. We've adopted two children during COVID. And I line them all up on the floor and I play the drums on them. And my five-year-old thinks it's hilarious and my eight and a half month old starting to think it's funny, but my one month old does not enjoy it. So I was doing that at lunch and lost track of time. Before we get started, is everyone that's here right now want to be in the non-clinical practice management breakout? Otherwise, if you don't, please turn your video on and speak now and Danielle can send you to one of the other clinical breakouts. Good. Okay. You guys are welcome to that. You don't have to, but we'd love to see faces if you want to turn video on. And this is going to be very informal. Amanda and I have done this a couple other times and what we've done is just kind of gone around one by one and asked you, like, what are your burning questions? And I'll just keep it informal list and then we'll just talk about it and share ideas. Does that sound good? All right. And Danielle, you can be monitoring if people, you know, jump in and out. But Leilana, do you mind if I pick on you first? Is there anything in particular you just have to unmute yourself, like any burning questions or any topic at some point you want us to talk about? Yes. Let's see. So I've never been part of an ACO or anything like that. I did recently join one for 2021. So, so I'll be looking forward to that. But I've recently partnered with, it's called Doc ACO in our area and it's for like Manatee County mostly. And it's been great because I've gotten referrals, but these referrals are, so it's almost like the physician's office is kind of like data dumping all of these patients who are the most, you know, high risk in their practice. And so I really need to kind of figure out the partnership that I have, you know, a partnership is when both people are winning and I feel like we're spending a lot of time and they're just, oh, you have all these new patients, here they are, and they're throwing them at us. And, you know, some are in ALF, some of them are in ILFs and it seems, you know, so we appreciate the work, but they're so high complex and, you know, and then sometimes they'll send us a referral and they haven't done their homework and the patient has already established a new primary. So I don't know, has anybody else had anything like that happen? Getting referrals from other ACOs, knowing that we can handle, um, we're equipped with, um, pulling all of the rabbits out of the basket and we just, we can keep them out of the hospital. We have great outcomes. So, um, I don't know if anybody else has that kind of a situation. Katie, I saw you nodding your head. Yeah, I do. And sorry, I just now finally getting to eat. That's why I keep taking myself off of video. You guys don't need to see me eating. No, no judgment. If for whatever reason, you want to keep your video off, you know, we're not going to frown on you, but thank you. Um, yeah, we've gotten some referrals from some ACOs in some of our areas and the only thing I can think, they really need to do a better job screening before they send us those referrals. Cause we've gotten some that aren't homebound that don't even qualify for our services. They're just maybe noncompliant with going to their doctor. So they're like, oh, well, you know, we haven't seen this patient, so they must be really sick. Give it to them. And that's not the case. They're actually healthy and that's why they haven't gone to the doctor. So that's been a huge challenge and we like their complex ones. Those ones that, you know, really need more than 15 minutes of their time in the office. Um, you know, I always say, give us those patients. Let us, you know, we only see five or six patients a day because they're that complex. So let us take those off of your caseload so that they can fill their schedules with the walkie talkies. And it's just educating. Um, I'm finding that me, myself being able to speak to these different doctors within the ACO and having myself explain to them exactly what to look for or whatnot has helped, um, somewhat, but it's still a learning curve. It really is. It's all new. I mean, we formulated together like a quick e-facts, you know, with the information we thought, and we're always kind of updating it, but it still doesn't. And at first it almost felt like we were soliciting or like your doctor said, and they're like, well, we love our doctor. We're like, well, I mean, so we've kind of, you know, worked through all of that. So I just, if you have an intake form, if you, if you want to share it or whatever, I can show you what we're using. Um, you know, that would help, but we do give it to our clinical nurse management manager and she'll go through it and she'll kind of give it a complexity of, you know, cause ours have a rationale on them, like five days, 72 hours and within 24 hours. And we're like, oh my gosh, we don't even, you know, have anything. So, um, it's been, uh, pretty cool to see it come together cause it's a new process, but it's been pretty taxing on us. I mean, one of the physicians in our area is giving us 60 patients and you know, our new patient intake coordinators, like, hold on when I call these patients, like they've, they've already established. And so, yeah, it's been kind of interesting. So just to clarify your question, yeah, no, no, no. Um, so you're signed up with an ACO, you formed a new relationship and they've told all primary care and now some of them are just really turning on that hose. Do you feel as though, is that, is that all true? What I've said so far? Yes. Yes. Right. Okay. Okay. Um, and then do you, but do you feel as though there's just a significant volume piece or are they missing on your intake form? They're missing some of the key things, which means they're either not reading it or they're just trying to give you, or are they really probably applicable? It's just a high volume. Yeah. See, I'm not very familiar with ACOs, but we were contacted by the ACO and the ACO has hired these different reps. Um, I think they're looking at these physician panels are like, okay, well these are the patients that are frequently going to the hospital. These is who you're not seeing. The reps are going into the office. They're getting all of that information and they're saying, this is going to go to Florida mobile because we know, you know, they have good outcomes. We've chosen them in our area to work with them. And so that's, I don't know, it's all kind of new to me. So, um, yeah. And for me, I'm wondering, I'm sorry, I didn't mean to interrupt you. I'm wondering when I, you know, give, when the ACO gives my panel to Medicare, are those patients, you know, going to be part of, cause I'm billing for them now. Are they no longer? And are you billing as primary care? Yeah. Yeah. And they're great. They're letting us take the TCM. They're letting us take TCM. They don't really care. They're just, just like keep them out of the hospital. Yeah. Well, and once you join the ACO, I mean, you're in their network. So when they file with Medicare, like you're, you're in their structure and they're, but they're still ultimately attributed to kind of their ACO. And so I think your assessment is, is probably right. They're going through and they're trying to clean house for everybody. They lost money on last year and figure out, you know, how you can wrap your hands around them. I don't know if you've tried, you probably have, but you know, can you meet with these reps to try to organize the referrals, either the volume and the system or it just won't, it's not helping. So we have an Excel program that we present to them every Friday. And then we have a meeting every Monday. And basically I've just made a huge you know, a shared file and it has, you know, all the patients, what's the status with them, who we were not able to contact, how they signed consents. And so then we do that, you know, every Monday and we kind of go through everything together, but you know people, a lot of different people involved. And so that's been quite difficult. So I think I'm just going to have to just meet with them and just kind of like lay it out, you know, just, I'm not going to help you. One thing you could say is, well, and you know, you know, we attempted at one point to kind of try a consultation like business, if you will. So one thing you can say is, look, like you guys fill out the assessments, you know, you, you take a look. We just need the space when we find out it's because of just med non-compliance, but they're perfectly able to come into the office. We need the space to return them, do an assessment and then say, okay, here's, we're going to return them to primary care. They're better fit there. So that's another option is you can say, hey, we still want, we'll take a look at people because my guess is these reps are non-clinical, you know, they're just sorting through data. Yeah. And so you say, look, like we'll find people that just aren't good fits and we just need to make sure we put them in a referral path. And then we track why they weren't good fits. And then maybe that highlights the program we need to spend more time on like med compliance or a home health or something that we need to utilize instead of us. Yeah. I don't know if that would help. A solution for their problem. Yeah. I appreciate that. Thank you for the feedback. The other thing that. Go ahead, Katie. The other thing that we did when we started working with the ACOs is that we made it very clear we were not joining the ACO. We were not, we were strictly just a referral, you know, for the, the patients, I don't want to say the patients they didn't want, but for their complex patients that they were losing money on, it was just a straight referral. I become their primary care. I will be billing Medicare and TCM and everything else. And, you know, essentially they're discharging those patients from the ACO and we are becoming their primary care, which has alleviated a lot of the potential confusions with the ACOs. Yeah. So my guess with that one, but yeah. My guess with that, Katie, though, is they're happy to see these patients go. And, you know, whereas, you know, whereas, you know, am I saying Lelaina? Lelaina. Whereas Lelaina's problem is they still like the ACO still has skin in the game on these patients. Right. And they're trying to share that at some level with you. And, and that's why I'm saying, you know, you know, that clean break is sometimes nice because then, hey, I don't ever have to deal with you guys again. But then if you're going to, if you're going to be in it, you just got to keep bringing solutions to the problems they're trying to, you know, they're trying to solve because they still, they want to control costs. They want, you know, meds or visits or whatever. And home-based medical practice, now that it no longer has the guidelines that you have to be strictly homebound, there are still some like, kind of gray guidelines of when you want to use this tactic, because it's a limited resource that you can offer. And so you want to, you want to get the patients you can make the most impact on, not just necessarily the ones that have one issue, you know, one issue that's maybe not as good of a fit, or, you know, heavy psychosocial or behavioral health stuff, you know, and it's like, you know, we really need a social worker intervention is, and we need to get that under control before we start talking about primary care. And so I think, if you start making a list and kind of can articulate here, the top three people we really, that you keep sending me that aren't good fits, but let's track that data and jointly come up with maybe a solution to take care of those. Are we allowed to request, I mean, obviously, they're going to get paid for our hard work. So, you know, you know what I mean? So, I mean, are you able to say, you know, after a year, you know, for them to share the cost with us, even though we're not part of that ACO? Or no? Oh, yeah, I would certainly I would certainly ask for it. I'd certainly ask. I would, I would say, even I'd say right away, ask for it now. You know, you start seeing patients in January say, hey, I want to meet quarterly on our patient roster. And, you know, probably by June, they would have first quarter data on those patients and start to get, you know, some of the expense and revenue and say, I just want, you know, when we come out and you meet again with us bring bring the financials around these patients and compare it to your total population. And the thing about when anybody skims off the top, the most expensive patients, you're not you're saving the system overall money, but you're not taking a patient who is going to spend 25,000 that year. And, you know, and spend, you know, like 10,000, you're taking a patient who might spend 500,000 and spend 200,000. And so what you're trying to prove, when you when you kind of siphon off the or, you know, skim off the top 1% of high cost patients. It doesn't like it, the ship that it's turning is the total cost of care for all other patients. So if they have 40,000 patients, you technically, for success purposes, you you want to say you gave me last year, the 25 25% of your cost patients, and this was what your performance was. And this year, you know, this is what your performance is. So you need eyes both to your patient data, and to the total population, because that's what they're asking you to turn the boat on. Does that make sense? Yes, thank you. Sometimes people go in and yeah, they go in and they're like, well, just give me my own patient data. And it's like, well, when you take care of the sick of patients, you're you're turning a much bigger pool than that. And, and you don't like you start to see expense. And they're like, Oh, well, we're still spending, you know, a million dollars on your program. And it's like, yeah, well, you were going to spend 5 million. And this difference between what you were going to spend and what you actually spend with the high cost patients. People like to bury and not pay people for they do, they do. It's hard to prove it's hard to prove what didn't happen. You know, that's right. I appreciate that. Thank you so much. And before we move on, sorry, Danielle, I see you are here in the main room now. Um, are we? Is it okay if I pause and just do a pulse on anyone that's trying to move? Or do you want to chime in with an update? I thought Fran was trying to move. Did she? Fran, Kim and Karen were I think the problem is once the video starts playing, they can't like because there's a 10 minute video they're doing in the breakouts. They can't do it till the video is over. So they're working on it behind the scenes. I'm texting and chatting as fast as I can for you guys. So sorry, if you're stuck here and not wanting to be but we do have the videos recorded. So we will be sure to share those with you guys if for whatever reason you you know, moved, weren't moved to the correct breakout. They should be able to correct it when we're not. We'll work with you one on one even if we have to schedule like a call with Dr. Chang or something. After this, we'll we'll get you taken care of as best we can here. Just make sure if you're putting in the chat put it into everyone and I'll make sure that I don't have the rights to move people. Sorry, guys. I know I'm staff but I don't have the power. All right. So Katie, Katie, did you I'm just going in order of names here. Did you have something in particular you want to talk about? Thank you for sharing your insight too. I know I've had the pleasure of working with Jeff on our practice advisory group and I was excited that you're going to be part of this project. Yes, good old Jeff. No, I I can't really think of anything right now to I'll just keep chiming in. No, I love it. That's awesome. Thank you. I do have a question. A lot of just different people that come into the practice all the time, referral sources and stuff. A lot of them use Gmail's and, you know, I always question, you know, different physicians and things like that that have just Gmail accounts. So, I mean, I I don't know, do you guys ever run into a lot of, you know, just different colleagues in the community and things like that. So don't spend the money on the, you know, HIPAA compliant, you know, email accounts. It's it's a lot here. It's a lot here. There's a lot around here. So, I mean, mine are encrypted, you know, and I spend all the extra money. But it seems like a small question. But, you know, throughout the day, you know, a lot of people are requesting information, especially, you know, smaller groups in the area. And they most of them have Gmail accounts. And so I don't know. Yeah. I don't I don't I don't have that problem. I can't say that's as common here. I would I would certainly open it up. I mean, HIPAA from a from a HIPAA standpoint is really on the sender. So you are protecting yourself appropriately. You know, from from a cost perspective, you know, even we just moved our entire group to Office 365. And it is not inexpensive to do a lot of these, you know, more enterprise focused systems, as you know, because you do something to that effect, too. But, you know, so it's it's such a great question that I've never been asked before. And it makes a lot of sense that people are doing that. Okay. Yeah, I'd love to learn from others. Yeah. You said that Gmail is coming to you like with patient information from the ACO? Or who is it coming from? Well, it's just coming from all different resources, just in in the area of in our area in general, whether it's, you know, a different physician's office, you'd be surprised at one of the physicians that we deal with on a, you know, common basis has a Gmail, sometimes, you know, mobile physicians, they do. So I just, you know, it's difficult, because when you encrypt something, then they can't open it. And it's just been this, like, it's been a problem that we're having here, dealing with so many different people who have Gmails that are professionals. So and now, you don't mean me mobile positions, do you? When you said mobile position? Like, we all have NPS. Okay. You don't know what I'm talking about. I don't know. Oh, absolutely. The adult family care homes and the smaller ALFs are the probably biggest offenders for that. And I always just write secure in my subject line before the subject, I make sure the patient's name is not in the subject. And then they call and complain that they can't open the email. I don't know what else. Yeah. You know, I mean, you can't, they can open it, they just can't open it on their phone. So I, you know, you just have to explain to them that, you know, sorry, it's worth more to me to protect, you know, HIPAA than it is to get in trouble because I sent an email to you. Right. Oh, yeah, absolutely. I mean, we do that all the time. But it's just beginning to be where it's just like, really, throughout the days, a couple of stopgaps are like, well, let's put it in the mail. And you're like, I don't want to have to pay for postage all the time. So but anyways, and that greatly delays the process to buy mail mailing it. Yeah. Very frustrating. I didn't realize that with you couldn't open it on your your phone. So that I mean, that's also limiting for the receiver. You'd think maybe they'd want to not, you know, to not to eventually not have that be the case and spend the money on the system or something. I'm so sorry to Can you hear me? We can hear you. So this is the practice management. Yeah. Is this where you want to be? This is why I just we're having a couple of people that Danielle is trying to help on the fly. So we're just doing very informal. And actually, I can open it up to you next. Is there a certain topic or burning question that you want to talk about or pitch to the group? So I was interested and this is kind of where a lot of the motivation for me was also to join this is kind of the practice structure, right? The home based care is such such a complex field to navigate. So I'm a freestanding practice. It's me I have, you know, a full time nurse practitioner, I'm currently recruiting another one. And we have about maybe 330 patients or so. And 300 of those 40 of those are homebound. The other two 50 to 70 are assisted living settings. And then the other 30 are sub acute settings. So we go to over probably like 1012 buildings or so, you know, and so different, very different settings. And because I am trying to structure this really independently as the practice owner, right, it always revolves around how am I going to be most efficient? How do I do this? And yesterday, there was a lot of talk, um, how do I integrate other ancillary staff in this? How do I utilize, you know, manpower, or, in my case, all woman power, right, most efficiently. So I have about 10 employees or so, and I'm actually planning to further expand. So I'm kind of interested to see what other models other people use, I kind of want to have a T model, where each facility has an assigned MA nurse and provider, because I think we struggle a lot with continuity within the facilities. We round on the schedule, we do a lot of the things that you mentioned, we have like a daily reminder and huddle text, so everyone knows where they are. But it's also very, right, very disconnected. There are people in the office, there are people in the field. And in regards to the messaging, we use Microsoft Teams, and I did invest into the secured system. So this way, we don't find ourselves texting each other anymore. But we use all the secure teams messaging system and our emails are encrypted. So we can send regular emails, even if we send it to a Gmail address, our email, you know, so we added those components on over the last couple of years, but I'd be interested to see how other practice owners, independent or not, know and how their procedures are to make them more efficient. Yeah, I mean, there's lots of different I can start and then Katie, you know, or anyone, Amanda, feel free to jump on. But there's lots of different practice models. And honestly, every staffing model that I've seen is slightly a little bit different. But I do think there is value in having like, I usually hear them referred to as pods, or you know, if you have, if you have that staff available, where you can, you know, there's a practice that we work closely with, I might even have some slides, I can send you where that really is their model, they have, they call it a patient care coordinator, and then their RN clinical manager, that's assigned to the same provider who works with the same panel of patients. And they, you know, they monitor ideal panel sizes for patients, as well as, you know, caseload and things like that. And they work as a pod or as a team, you know, and they care for the same patients in the same areas or the same buildings. And that works, you know, fairly well for them, as far as to your point of continuation of care. You know, that's definitely something you can look at. I mean, do you monitor, you know, panel sizes, or what kind of other, you know, support staff outside of your providers do you have right now? So I have medical assistants. And of course, with COVID, everything is different. What to me was the most valuable tool is actually take medical assistants on site with me to the assisted living setting, because if you have, you know, 30, 40, 50 patients in the building, 25 people, right? So they would come on site, pull charts, get the data, get the vitals. Now, keeping the medical assistants, you know, in the office, because exposure risks, right? Some of them are type one diabetics, so I don't want to put them at risk and not further expose residents. So that is a current obstacle. But I hired nurses, which I didn't have before who do come out into the field, you know. So I have medical assistants, and then some of them are really designated MAs to the buildings that go to versus the ones who basically handle just the ins and outs of the daily office flow. So the other MAs can focus on updating charts, calling families, and keep some continuity there as well. And the nurses then handle the more advanced clinical discussions, you know, advance directives and that complete call over there. Do they really want to feel cold? So I try to kind of, I feel us as providers are most efficient when we can see patients, generate productivity, right, by doing visits, but not be held up with the administrative load. And I do think that a lot of that can be done. I was hesitant about adding on that overhead, you know, for nurses, but I find it actually makes it more productive and actually more financially viable. They basically pay for themselves with the work that they do. So, but it's just so much work, right? And I don't think that 300 patients is a huge patient panel, you know, and, but it feels like it's just never ending, right? The preventive here, the acute issues. And, you know, so, yeah. So just so I understand your, your model one more time. So there's nurse practitioners, you, you're the only physician and then CMAs. And so, right. CMAs. Okay. Okay. Got it. And you're using your nurses, or you do have nurses. One LP and one RN. Okay. And you're using your, well, your, at least your RN for an assessment component. So to be your eyes and ears out there, is that what you're, or to be triage or how are you using? Okay. Yeah. So the RNs have a mixed, so I use them, they are designated for the buildings that they're in, but they also, let's say today, there was a home visit patient who needed to be seen, no provider available. I'm here, right. Then he has seen other patients. So she actually went to go see them and we did a tele-visit that way, you know, and I was able to speak to them. So we use them very, you know, clinically as well as taking care of, again, the advanced, right. The more involved clinical conversations. So that's how we're utilizing the nurses. And, and for us, that's been really, you know, so we're similar, we don't have really, and so in our assisted living practice, we really don't have CMAs that, that, I don't know why this is, but in Minnesota CMAs traditionally stick to primary care and bricks and mortar, but LPNs are the ones who do all of the really like the nursing functions and, you know, kind of entry level supports for nursing homes or for any facility living. So, you know, I've posted before numerous times CMAs to get into this, to get into this work and I've never, never been able to hire one. So I, but I think for all intents and purposes that we're doing essentially the same thing is we really use, you know, LPNs slash CMAs to do clinical data gathering onsite, you know, support some of, some of the paperwork needs, the moving things around, the things where you need, you know, a general understanding of nursing. But what we use nurses for in our model is that higher level of assessment and to really be the outreach for acutes. So it allows us to build up a physician schedule and physician nurse practitioner schedule fully. And then when we get the call that day, we can, you know, and it's like, oh, someone needs to be seen. We can deploy a nurse to do the full assessment. And now, you know, now that we are doing a lot more telehealth can also just do a quick virtual visit then. And so we rely pretty heavily in our model. If that's the base of the question is how do people kind of build their models? We rely pretty heavily on our ends and their assessment abilities to be able to do that work. And then anything kind of below that, you know, if it's faxes or, you know, delivery, you know, that goes then to more of a more of an LPN. So can you just explain really quick the healthcare model that you or, you know, the healthcare system that you're part of? Do you own the assisted livings? Or are you healthcare providers that go into outside companies buildings? Oh, ladder. Yep. We go into other other buildings. We don't own the buildings. Are you are you part owner in some of these buildings? No, same thing. So we are outside providers. And I find that the trick is to really not give the staff there any additional workload, right? And this is when I first decided to bring MAs and even just pulling the charts getting med lists ready, right? Yeah, I feel especially in the aisle side. Oh, we don't have no one outside. Exactly. Yeah, there's no one else there. So you have to have someone to do all that, like, you know, the CBs, the first people to land in the Marines, you need the group to get all the important data, data gathering together, it's just, I eventually run into a, like, once they're built, and it's you kind of have like your established patients and your existing patients. But once they're built, there seems to be in my mind, kind of two potential tracks for type of licensure work nurses. And one is kind of the ongoing maintenance and collection to get you ready as a provider that really can be done by a CMA and an LPN. But I think the second is almost thinking about nurses, RNs, as, you know, we call advanced practitioner nurses, you know, they call, you know, sometimes physician extenders or whatever. I really think that nursing could be that, you know, for not not trying to give an exact title, but could be an extension, we say extension of the provider. And so if you think about an RN who has that assessment ability, you know, it can really do in the field triaging for you, as things come up. I see that's a future of healthcare that we have not been utilizing RNs well enough in that space. That's a good point. Very good point. Yeah. But you can't bill for RN services. And I think this is where I'm trying to recoup some of that overhead by generating the televisits, because as an independent practice, you can't bill for the, even if they, I used to, you know, just have them go out and give the vaccines and you can't bill for it. Now we can with the televisit components. I'm trying to really recoup some of that overhead there. But that's, I think, an obstacle is you use this fairly high overhead in RN versus an MA to go out there and do the initial assessments and paper shuffling, right? So I think you need to recoup some of that. Yeah. I think we're just going to get a minute before they split back and then we'll keep talking. Our practice manager, hang on. They might need to, HCCI team, you need any housekeeping to make the next transition go smoother? Well, we have some tech issues. We wanted to check in. First of all, Katie, we see you want to stay in the practice management room. Anyone else who wants to stay in practice management, please, you know, go ahead and put your name in the chat. That's fine. Where are we going? Where am I going to next? To be determined, Nicole. Oh, okay. Nicole, if you go into a room and you already know that procedure and don't want to stay, you can just hit click room and it will take you back to this main room, which is where practice management is happening. I know this room is hot, but I want to learn some things. I'll check on it. Hi, this is Tom. Am I in the main room or am I in a breakout room? You're in the main room. We're just giving everyone, I think, a couple minutes to come back and then we'll go off again. Okay. I'm reassigning the rooms and then everybody will go back to their room and I have hopefully solved our slight tech issue. Thanks, everyone, for hanging with us and giving us our couple minutes. This is a trial, more of a trial than anything that we've done lots of breakout rooms before, but moving a big group like this to three separate rooms is a little bit new for us. So we're working the best we can. I'm sure everyone has plenty of emails to check and messages in the room. Yeah, I'm sure everyone has plenty of emails to check and messages in the room. I'm sure everyone has plenty of emails to check and messages in the room. Thank you for your time, for being here. So I'm actually, I rented an extra space because of COVID, right? Because I'm separating the providers from the staff because of the exposure stuff. And they know I'm here, but I was like, you need to pretend I'm not here. I like covered the window with a poster. So they're all getting the message. It's the funniest thing. I'm right next to my staff. Can we message you something? I guess it's okay. I love that. Okay, I will be sending everybody back to their breakout rooms. And once you get into your room, just it does take a few moments for everybody to get situated. And I just want to make sure, if you want to switch rooms, please come back to this main room and let me know. And I can reassign you to a different room. And do they know how to do that, Danielle? Sorry, is there I'm typing it in the chat, and I already announced it. All right, perfect. Okay, I'm ready to go. I think I need to go with Paul. Did Odessa split out too? Shoot. Oh, no, we lost Odessa. She said she wanted to, oh, wait, hang on. Oh, Danielle, I need to go with Paul. And we're missing Odessa. Well, she can do it herself. Let's worry about Melissa first. I have like a two sentence response to the question. And I like have some clue that we'll find her eventually. She's out. She's out somewhere. All right, I think Melissa's gone, which is good, because she's supposed to be running the video for Paul. So that's why I said let's get her sent first. Odessa's back. Yay, we have Odessa back. Okay. You're on mute. Okay, so while we, well, maybe, well, maybe a few more people come in. I said I had maybe two sentences for you on this. So I think from a nurse standpoint, like now with the new relaxed telehealth, I mean, I completely agree. When they're doing an assessment, even if they're just calling you to verify it and you're laying eyes virtually, now that's available. So I think that's great. And hopefully some components of the virtual will continue going forward. I think, though, in the future for RNs, I think this is a, like value-driven care is a perfect spot for RNs. So as you expand and get more opportunity for paying for something, for us, the number one thing I put money towards is RNs. And so, and now I'm at the point where I'd like to start getting some specialty focus. I really think, you know, and there's some practices that do this really well. There's a huge opportunity for us to start really specially focusing on behavioral health, both from a social worker and a nursing perspective. But, you know, when you're going in to think about, okay, I have value and I want to, you know, ask for something, think about, I think, the cost of an RN, because their ability to make you more efficient by doing a lot of the assessments, I think is, I think it would be great. I think that's actually the future of healthcare. I, nobody ever asked me my opinion on that, but I have a whole thought of what's going to happen in the next 10 years and how really licensure is going to have to change. And I do believe in the future that I think we're going to need to start being able to bill for RN work. Yeah, we have our RN do our CCM care plan for us. So that's, yeah. I'd like to see them like billable providers. Yeah. Oh, that would be great. I think basically, I'm in the, I'm in the boat of, I think all the work or all the stuff you go to Target for that an RN could, you know, you go in and they're like, you know, that an RN could, you know, you go and that an RN could do that. We should be able to self-sustain there. So it's nothing against people's current licensure and what they do. It's, it's a capacity issue for where healthcare is taking us is we need to start redefining, you know, how we teach and deploy resources. So one possible, no, it's fine. Please go on. I always love hearing your, where healthcare should be going talks. I think we could make that a whole talk in itself. But one, I'm going to share this information. Oops. Sorry, Melissa. Do you need help again? Danielle? Can you help her? Can you make me a co-host? I'm not sure if that's the issue, but I can't I'm disabled from screen sharing. You are a co-host Okay, right now yes, I'm looking at it and it says co-host Okay Can you? You're Yes, you're in room. Which one two With I'm with Drake So you are in room three. I will be right there All right Sorry guys. Thanks for banding in on the the chatter while we get them set. But yeah one I'm so I'm gonna share this with you guys cautiously because With medicine we you still have you know, there needs I think this potential flexibility I'm concerned for some fraud and abuse with but one of the flexibilities that Medicare is looking at making permanent is the ability for direct supervision To be satisfied by telehealth So when we're thinking about our end visits, you know If you were thinking about your RN being your extender for an incident to scenario But you were connected and were able to do a physical assessment over video Technically that would satisfy the requirements for direct supervision in an incident too, but there's a lot still pending I have to dig through the final rule and and see what's gonna happen with that policy So I'm not saying that's a solution right now However, it's worth mentioning because I think it could be an opportunity in the future There's a lot of unknowns with depending on what happens with policy in December But I do know especially with you know using people to Top of scope similar to Odessa and Amanda like you just described where you can utilize that RN to be the person that's in The home and connecting with the provider who's doing that tell you know The visit virtually back in the office or wherever they are So I do think that that might be a greater opportunity that alone just the direct supervision being satisfied via telehealth Meaning it has to be video and audio connection the entire time to be you know Doing the assessment doing your evaluation still documenting your assessment and plan all of that is Appropriate right now They've hinted that that's staying but still working through some things there But something to keep an eye on if that's part of your model where you're using the RNs in that kind of way And I would say this is a huge time to plug the HCCI You know newsletters because you know what we always are like, how do we get resources? You know of all the spam kind of emails we get I always read the one from HCCI because you know I can digest it. It's so much faster and earlier than anything else for my team can get information So, you know, this is one of those especially with the telehealth with kovat that you know You know as they you know digest all this information. We're gonna get it, you know frontline here So, you know and be able to use it quick Well, thank you for that why I say to like use us to do the research for you like I Providers say that they have like click fatigue in EHRs I sometimes feel like I have CMS fatigue through all the updates that I read but I do it for you guys Because I don't know how you all do what you do and manage your practice and your patients with trying to keep up I feel like this is a full-time job in itself on top of The other hats that I wear sometimes for HCCI. So like do not hesitate to reach out to us with questions You know, we really do our best I can't say I have the answers all the time and I'm very thankful that the team I have behind me that helps a lot And I can bounce ideas off of great faculty like Amanda and things like that when I when I feel stumped But I mean use us as a resource we want to be a community we want you know We do our best to stay up on the updates We usually have a resource for that as my response Because I've probably gotten the question enough time that I felt like it was important enough to put in a tip sheet or put In a tool or something like that Odessa the only other thing before we move on maybe to Rita's share a topic you might want to chat about A lot of times what I see too is just simple breakdowns when teams grow, right? Because workflows change a little bit and you don't realize the task Duplication and you really do want to make sure your CMAs are doing CMA work and your RNs are doing RNs work And I know we talked about this little a little from our previously But like when I evaluate workflows, I literally just start with interviews Like I see what you could do yourself like sit down with your team Like tell me what your day is about. Like what are you doing? Let's talk about your roles and responsibilities Let's talk about your challenges I even know one team that in a staff meeting had their RNs and CMAs use sticky notes and they're like, all right Every task that you do everything you do put it up on the board and then they looked for duplication and overlap I'm a big, you know, like process improvement person. So sometimes even just taking tactical steps like that Or I love observations to like go sit with your clinical team for a couple hours and see you know What happens, you know, I did that once in a previous practice and that was how we figured out Lover to death but we had a nurse that had been there for 20 years and she somehow still had like her own line that like when she wasn't there people Would literally have to like jump up from their chairs to go answer and I was like, what what is this? Like why no, we haven't one main nurse line. Why is this phone over here ringing? So it's like sometimes just sitting with people or going out with a provider that's struggling with efficiency on house calls and you know Seeing what insight they just might not be aware of and really making sure you define team rules and responsibilities People don't like to do all that workflow documentation and mapping but it really does make a difference sometimes if you're struggling with efficiency From my perspective sometimes that's where I start to like I need to understand what your team's currently doing and I can you know Help you kind of work through it from there, but there's things you can do, you know yourself to that respect as well And you have to be just as wary on the people part You have to be just as you have to be more worried about the people who are super Overperformers and easygoing about everything because what they do is they just add on all the stuff They don't want to bother anybody with and then you find out 25 of their work is wildly inefficient um, you know, and they just didn't want to make a scene or whatever and so I always I always look at the people i'm like Okay, you know we gotta you're you're one that's too pleasant about all this Agreed I I have them write down Every little thing I said, you know from picking up the phones to Checking the supplies. I want to know exactly what you did. So we do a lot of those flow stuff I think right now it's more the restructuring Adding on the new nursing component, you know, and also I think it's easy to develop bad habits, right? So I do always invite everyone to be like doesn't mean we need to you know, do it the same way Maybe your role is different. Now. You used to be in the field now you're in the office How does that change what you're doing, right? So I think there's a lot of that, you know with the current um Health care environment and then you don't know what is short-term Intermediate term and what is here to stay and to hire with that in mind is a bit nerve-wracking, you know To commit to an employment. I don't want to end it in a year just because then the pandemic may be better You know, so all of those components make it challenging, too Yeah, you know just as we think about transitioning out of the pandemic, um You know i'd be curious as time goes on We've talked a lot with our staff around how do we take the learnings that we like and didn't like? And translate them to you know, the things we should do or not do in the future And i've actually been thinking a lot about you know, so if anybody sees any resources I think my information will go out but certainly you can always filter it through brianna for everybody's benefit of you know How do we actually reintegrate our work lives? And how do we actually sort through those things because I think you know We kind of need a little bit of a formal process to think through You know keeping the stuff that worked Well that we never thought of before So just just a note there if you guys could help me in the future And I that's going to be a big area for us to focus on Yeah, I think there's gonna be a lot of opportunity, you know I mean we were talking yesterday too about how do you take the little wins and the little positives that you know? This this pandemic has given us. I mean, I don't think any Most people attending this meeting would probably even be using telehealth or even think of virtual visits, you know without a solution So, I mean and maybe that's not something that stays we have to obviously see the reimbursement But like from an efficiency standpoint too, you know, like what have you learned? You know how you can use different people in different ways or even just those virtual check-ins for social isolation and things like that um that you know Sometimes there's things that are going to be part of your model that you're not always going to get directly paid for but it might Save you or prevent a readmission or something in the long run for the benefit of the patient that makes it worth it Um and odessa, you know last comment on you that rn, you know We're going to talk in the last session today about chronic care management. I mean there are options for billable time, you know Yeah, I utilize them for that as well. I think The lanya mentioned that yeah, I I do that as well, you know to um Yeah, I this is the part that I I think everyone hates like the most about this, right? and the whole lecture was so great about the you know, hcc and I it's it doesn't appeal to me and one thing and I put that down my plan is that I find I need this I need a person who really You know, we're all we're all into the care But I need a person who is ready to like take on the nitty-gritty of the coding and the billing and the numbers and the data So and invest in your people for that like if you have a good practice manager or someone like I you know There's lots of people I put it in the chat I didn't want to take up any more time because you're running a little late in the session But I mean the american academy of professional coder coders a pc is who holds all the coding certifications, right? And so we have to do a continuing education But they have like training like they have a new credential called the crc which is fairly new that certified risk adjustment coder You could send some of your staff to just that training without purchasing the exam Like if they don't want to become certified and have to deal with the ceus and all of that But they want to benefit your practice I know a lot of practices that i've recommended that to or they've said like hey We sent our practice manager to you know the boot camp for cpc like a certified physicians coder or there's one for hcc2 and like wow has that helped our practice like I would hope this isn't all on you as the provider that you at least have you know Some sort of external billing company or someone helping you but You do have to have that line of sight to it, you know, but but have a specialized person in that role I mean there's training that they can go to whether they want to be certified or not just to help your practice And it's like only a few hundred like it's not crazy Um, I mean, it's like a few hundred dollars for for that kind of training without the exam What's the time involvement or time commitment for that? Yeah, um, it depends on so I would say at least I think it varies from like so it's all on demand So you can certainly like do it at your own pace um depending on like how like how your your pace is a learner to I would say probably anywhere from like 10 to 20 10 hours that About on average probably about 10 hours Um, but you know, you can take it in chunks Like i'm constantly, you know purchasing new training bundles that I just kind of keep and you know If there's a topic i'll go back to I want to expand further on Um, you know, you can't you can take it in chunks, but I would say generally probably about 10 hours It's you know, not not suit if it's one specific area, right? Like you can always go more um, but if you really know This, you know general coding or hcc is your specific area need that will enhance your practice then focus on on that training option And you know you guys read it ask oh go ahead no, go ahead Rita asked me a question Rita asked me a question that kind of built it or built on odessa's question around How do you pay the rns and care coordinators and all the other workers? It seems to me like a lot of money, but maybe due to the small size of my practice. I really want to grow so how um, you know rita maybe you want to outline kind of what you do today and we could all kind of talk about talk about it because You know that that That growth the the growth piece when you're trying to grow. Um, certainly like are they full-time? Are they part-time? Are they contracted they have incentive bonuses? Like what are the bases and you know? What are you mapping all that that pay component off or maybe i'm misreading your question. So i'll let you okay, so um Let me see, let me start I have an office manager And he's paid by salary and then I have a receptionist in quotation marks and She's paid by salary too. And then the nurse practitioner she gets paid by how many by The codes she submits to medicare um, I give her right now 50 percent of the payment because she Just got out of school. So I can't pay her a lot and so Any percent i'm sorry, I just didn't get the number 50 of what she bills medicare. Mm-hmm and then um I was thinking that It would be great if I had an a nurse and lpn or rn uh, because then I don't have to be calling back so many people because uh, i'm kind of like a control freak And uh, every time I get a call from a patient i'm the one that answers them Uh, the nurse practitioner doesn't do any of that. So of course i'm getting kind of overwhelmed and now I'm noticing that the patients are getting more and more and more complicated and it's driving me crazy and um, of course since you have more complicated patients you have more of them that are um Stubborn and don't listen to what you tell them and um So that's that's my my issue if I had a lpn or rn uh, would I uh hire her as a salaried or as uh, By the hour or what? Will I be ever her expenses Well Kind of two questions. So from an flsa standpoint, uh someone correct me if i'm wrong Lpns have to be hourly. So, um from an rn standpoint Um, typically I see them You could kind of go either right like often triage will be hourly is if you go the hourly rate You know, you certainly have to be willing to to pay over time Considering they're they're going to be not really true contract workers. You probably are looking to hire um You know them as as employees really because they're not really doing contract type work um You know they have they're very different pay scales for the two of them between an lpn and an rn And they're very different skill sets. So like when I try to think of a new role You know, I always start by writing down everything I want them to do and then for this one You know check with the board of nursing and and kind of what each licensure is approved to do check with brianna You know and say, you know who kind of fits the role that I need best here Um as you try to to build it out and then you know And you can also start to say, you know, can I hire someone part-time that moves into full-time? I have had You know middle of the road luck trying to hire someone part-time or full-time like typically I find it employees Know today if they want a part-time or full-time, they're not available to move full-time in two months if it works out for you um, but you know, um, so from an flsa standpoint, I think we've done a lot of work because we actually had a bunch of lpns who were Salaried because of some old hr rule and we were like, oh, that's that's really bad. We can't can't do that. Um so Yeah, I mean so from a financial standpoint We're going to talk a lot about like chronic care management in the next session Um, and that's a way that you can get reimbursement for that nurse um, you definitely I think you could go either way I know some practices like when they're kind of Trying out that new position that i'll hire them on like a part-time hourly basis too and just make sure it works out Because people in turnover are expensive but um, you know, you really want to be thinking about what do you not all encounters hopefully, um, And you know some of this might just be like a mindset change too are going to require a like your discussion to call back Right. So I mean using a nurse you can use your ehr to have a new nurse pool And if it's fairly straightforward advice or calling back with lab results or updates is something that doesn't need to be an in-depth conversation Use your team for that and those are all conversations and minutes That that rn could count towards something like chronic care management if you're under fee-for-service, which i'm sorry I should have asked that first. Are you rita? Yeah, okay Um, you know you want to we were talking earlier too about using rns for like in-home assessments for acutes rather than you know The provider having to go out and you know mess up their day Um, or maybe connect with the rn who's in the home doing a telehealth visit or something like that Um, so as far as pay structure like amanda said you could probably go either way but definitely, you know Define their roles and responsibilities with a clear job description and then think about how you know What's gonna what kind of tasks are going to relieve your daily burden and what can she help with and then what kind of triage Protocols like what are you going to empower her to act on without that message having to be routed to you for you to tell her what to do So from Just from a to back up. So, um flsa is fair labor standards act and they define In that they define a couple of things around general Role functions and it just it will say if they can be salaried or out hourly My understanding is and we've had numerous attorneys look into it and because it's a national flsa piece That lp ends because they don't do uh, um They don't have to find they don't do Assessments or some function that that really treats them more like hourly workers and so they have under flsa like you know administrative work and Professional level work and so like You know like managers is an above you wouldn't see necessarily a full-time employed manager Who's hourly and it's really under flsa. It's access to overtime pay And so you just want to check when you build out your job description and you figure out You know what your role is that you're hiring that you meet flsa guidelines because there's a steep penalty If you don't pay overtime essentially, it's like, you know, they go back they look at all the period you didn't pay It's like 3x if you don't if you screw up over time. So as far as I know, it's Lp ends just due to their licensure qualify more as like administrative staff than they do nursing professional staff Which would be a nursing would be under the professional bucket um From a from a workflow efficiency. I would just jump on and so hopefully that helps I think it's that could vary by state too, right amanda. I mean, I know sometimes it's Flsa is federal. Okay. I was gonna say because I know like usually when i'm checking like an rn scope of practice thing I always you know, look at the state level regs and board of nursing and stuff like that, too. But um now that's helpful Yeah, I mean you certainly have state labor laws and you might have county Laws like for example, we just had you know, the city of minneapolis put into place a sick time law And if you spend x period of time every week, you know in the city working at all in the city of minneapolis Which includes your drive time through the city of minneapolis you are given access to sick time So that's a nightmare um, but no flsa is federal, um, right so Uh from a from an roi standpoint, you know one other way Just to say it is when you start mapping out and putting on paper Um, you know just do a back a napkin if you don't want to spend a ton of time But do back a napkin on what you think freeing up that administrative time from your schedule and your np schedule Will mean in terms of visits more visits you can do and so find that breakeven cost Is it if we all do two more visits a day or two more visits a week? And now i'm paying for someone and then keep track of that and to Brianna's point you can hire someone on a temporary basis and wait and see if those numbers pan themselves out If they don't then they don't Well, we do have a 90-day period That you test the employee probationary period. I always recommend that especially in this space in the state of florida that little Bit yeah, so that's actually that's one of those funny Yeah, it's that's one of those funny things and it's specific to states and if you are a union state or a right-to-work state And so even you know, like minnesota conceptually puts that in it still It still falls under a lot of the kind of union Conceptual rules of how our state, you know works versus some other states So, you know, um what I like to say is if you know, you you have a general When you hire them if you hire them under the guise You hire them under the guise of you know, an ongoing relationship and Then you you you look to use that clause You know, make sure you check with an attorney because the practicality of just putting it on there and using it um, you you know, you you start to run into eeoc potentially, um, you know, so so you just you want to in flsa you run into a couple things So you want to take some some care of but if you start at the beginning and outline them as a temporary employee From the beginning with the opportunity full-time if these things work out and that's in writing you might you might be in a slightly better position, but again a lot of that state state dependent and some of that stuff technically Technically you look at um The legal, you know, the legal lawsuits that have been won or lost by employers and and that will dictate some of your hiring practices Not all of that is encouraging. Sorry No, I mean you bring up a good point too as far as like, you know, obviously from a legal standpoint in in hiring and the contracting the hr needs to be set up too, but I mean even actually having I just kind of was working with a practice who unfortunately went through a nightmare because they never Formed formal job descriptions. It was just them They were all partners in the business and their kind of administrative lead person really wasn't working out But they had no documentation of like what her roles and responsibilities were like what was the job and it's Changed because their needs had changed in their infrastructure. So I mean like Especially for independent practices. It's like sometimes that's just like oh, that's the last thing I want to spend time doing But I will tell you and i'm sure amanda will jump on my bandwagon here. It really does help I mean if you don't have those clear job descriptions and roles and responsibilities And on top of all the hr and the legal aspects of hiring figured out from the beginning And you're not documenting like, you know, good worst case scenario, you know Hope that you don't but if you had to let someone go and you're not Documenting corrective action plans and you know those kinds of conversations and meetings where you've provided support and are trying to work through things It gets a nightmare. Um trying to get rid of people, um, which is always really hard Do you have no? I just i'll do 15 seconds on. Um, brianna just emailed me I don't know what a couple a month ago and asked me, you know Is there an hr tool that I use and I sent I don't I got it for free from our benefit broker um, but there's a there's you know, hr 360 that essentially you can go in for um state so for state Your own specific state laws and federal laws and you can search things like time off or whatever This policy is and it comes up with sample policies or any rulings around it So I don't know what the cost is. I don't know if it's prohibitive But I certainly know when we were early in ours We got it free and I referenced it constantly like I don't I don't know anything about flsa or I don't know anything about You know this specific part of eoc. What do I what do I do there? So and then and then i'll I know a lot of that's not this specific to home-based primary care so I can I can stop It may not be specific to home-based care, but I think it's specific to like running a business or practice And I think I I think a lot of providers and I don't know, you know, how many here are no practice owners But as a physician I can tell you I had zero training in any form of management running a business Uh, and I think a lot of people, you know, and I think rita seems to be starting with the same thing We don't know how to structure business yet medicine here in the states is very much a business, right? Everyone can put up their shingles. There's a marketing component. So this is super helpful I was actually just going to ask about the hr resources. I use a payroll company that offered hr services when I bought the practice And my account was like that's so expensive. It was the best investment that I did I still use their paperwork their handbook templates, you know that I and once in a while I have them come back on for a couple of months just to see am I still up to date with everything? So I think it's an investment that's worth it Yeah, it's yeah, especially from a payroll component alone to have to have someone else and what so in You know like the 70s when all this stuff starts getting um, you know created and you know We're building on infrastructure. Essentially. You have groups like adp or paycom. You guys may or excuse me, um Paychecks you guys may have worked at some of those or facilities that had those types of things Yeah, and what they what they do is they take it at that time they built it all Disintegrated and then they brought a bunch of systems together. And so when you're trying to navigate it, it's incredibly complicated Well in the 90s the payroll systems started building from the ground up like newer structures on you know Basically not in the cloud, but essentially in the cloud on a server and they started building more of a horizontal integration So paycom paylocity. There are a bunch now that exist within your payroll system within your price point And that have really seamless integration and can offer modules that you can turn on or off depending what you need and your growth So, I mean many of you it sounds like are in the growth stage. And as you're looking at your entire infrastructure the What you'd like to start thinking about is, you know, how do I have a finance system even if it's quickbooks, right? Can you know what finance payroll? What are the the? underpinnings of analysis, um data Analytics where it's it's not that expensive today, but I can maybe grow with it. Um grow with it in time. So um I agree on that one other thing that I recently learned in the last five years was You know for those of you who buy independent malpractice policies, you know for us in minnesota I assume this is everywhere. They do them as full-time or slot position policies And so and I never think to tell the malpractice how many hours a week they work but we have you know a couple of contracted physicians that we use and They all add up these six people add up to a full-time provider A full-time physician and we buy a slot policy for them So we only pay for one physician policy doesn't matter who comes on or off of it And then they're all under one structure. And so, you know when you are working with your malpractice groups and talking to them And you can again you can go directly to them. I don't use a broker for that You uh, you tell them they work 20 hours a week and you get a cheaper half-time policy or I got three people who work You know only half-time great. Then they're on one policy. You don't need a separate policy for them In terms of the payment what we discussed before and rita so rita Are you a nurse practitioner who is now opening her own practice or am I seeing am I? No, i've been doing this since 1998 Oh, okay, so I thought but is the home base new to you what did you say was or no you're just growing No, i've been doing this since 1998 and then slowly and surely I started getting I got the office manager and I then got the Receptionist, but I understand that I need more help because how many patients do you have? I have like It's hard to tell it about 300 That's insane. I mean I have like 10. I wow, you must and it's Yes, and then I finally read an article that each one of our patients counts as seven to eight patients. So i'm totally full Yeah, and I have a nurse practitioner, but it's I need more help. Actually. I know I do So when I hire, you know, the first question I ask myself is why am I hiring right? And then sometimes the answer is to increase revenue And sometimes the answer right now to me is to offload myself because I feel the same way, right? And it sounds like that's what you need also So I think Amanda mentioned before so I found it's helpful to really take the salary of what I was going to pay Basically calculate how many visits that translates into And how would that person generate that visit just so it breaks down at least even if I know my goal is not to make money But to just offload myself, then I would take the same Okay Yes, I was gonna warn people but I didn't want to interrupt they're gonna everyone's gonna get sucked back out hopefully, um, we all got Back quickly here. I think Odessa will be able to come right back. It just it's that's okay I saw right as you were typing in that Nicole was asking. How does she stay? um, I don't know if you want to Nicole Eversley hall she might want to be in here. You might want to check Or have them or she can do it herself if she's in the wrong place, right? She can come back to the main room herself. Yes All right, let's Give a Rita. Um, we've used that 90-day Policy or you know the 90-day like temporary employee In a lot of situations where we've hired either a new medical assistant for the office or or you know whatever position and There's been on more than one occasion where we're on day 89 and we're like, sorry And we're like, sorry, it's not working out and we've knock on wood we've never had any problems, but just don't ever let it hit day 91 because then you start getting problems, so um, it definitely works I don't know if it would work if it if it would be enough time to try out a new position like an rn But it definitely works in florida anyway I'm sorry. I was put in the tracheostomy room before I was put in the knee room. So same thing happened to him back I was gonna say I think sometimes they're like I was gonna like say I was like, I didn't want to interrupt you But I was like, hey, non, you might get cut off like you'll come back. I think So, uh, well you're back now, sorry odessa, what did where you did you want to finish? No, I think that was my you know I I really relate to that struggle of thinking about you know, what am I gonna add on and to me? it's such a simple question, but I think the question of Why you're hiring and then determining what you need is so crucial to it because then you're fine if they don't make money, right? You're fine If they see only six people a week if that's enough to offload you and that's what you need and it breaks Even and that was your intent with a hire to begin with Because I think sometimes you break our head over that versus I want to grow I have so many patients and i'm not making the money to sustain what I have. That's a different motivation behind hiring, right? so but um So I relate to that, you know constant you know reeling and uh wheels turning but So that helped me to really break it down in units What are our units that we paid and really the visits the codes and now we have all the ancillary codes being familiar with TCM CCM prolonged provider services codes really utilizing that and maximizing it And I think now that many of us have a lesser um patient volume I I say we're kind of changing our concept to be more like a lean and mean concept, you know Versus having this high volume of very complex patients So we added on things like ear clinics that we do every few weeks, right? Because the patients are now on the phone all the time so they can hear We added the surveillance swabbing as a layer to our practice to recoup some of that patient loss And now my goal is actually to not have more patients but just be able to provide more comprehensive care on the patients Okay And you can I mean, I don't know how other people use this. Um But you know as long as their salary there's always the range and it's probably you know public like in minnesota the you know the state of minnesota publishes You know the average cost for lots of different positions through their labor department. Um, so you could take You could take the low end of the range and say we're going to pay you salaried We're going to pay you 25 and to get up to the you know, 50th percentile You need to hit these metrics So you can start tying it to goals and maybe it is you do this many visits, you know You just may telehealth visits or whatever. Um, so, uh, you know, just just an idea there Absolutely Um, so mara we've kind of just been going around this is a very informal group discussion But I know we have connected via email Did you have a specific topic or question that you wanted to open up to the group to talk about? Okay, uh, no, not really i'm, you know, kind of just interested in in in all of the the topics we're looking to start um home-based primary care Um, so it's it's really um interesting hearing everybody's perspective and you know those have been in practice for a really long time and So, thank you Are you um An independent group. Are you within a health system like so? Yeah, we we're part of um, our it's our parent organization's a hospice organization um, and then we expanded into palliative care Um, you know mostly hospital-based and now we're growing into the community. Um, you know, because there's definitely that need for office and home-based palliative care and we're our next step is Home-based primary care so those, you know Seriously ill patients that really need that coordination that because we're seeing them in the hospital, you know we're seeing them bounce back and forth and Um, unfortunately, they they don't get good care once, you know, they don't they don't have a good source of of primary care That's able to manage them in their homes um And keep them out of the hospital in the first place and help, you know, get palliative their palliative needs taken care of Um as they go through the treatments for their serious illness, so that's sort of our next step So it's a hospice organization, um, but really wanting to move upstream Um in the services that we're providing for our patients That's super cool. Um, you know and I could totally see the continuum there you know one thought and why it makes sense to have those co-linked to is You know as you think about getting into value and all the HUC and risk adjustment that we do um They because hospice is a separate benefit and it's actually paid on the per diem, which you know, uh it um Just so you know, you fall you fall out of the value contract when they're in hospice. They're in hospice. So Let's say you decide, you know, you're taking risk on your population When they go on the per diem, they come out of the pool And so in in many ways your organization is capturing revenue both ways Uh and and getting that continuity So that's that's kind of that's kind of a slick benefit too as you you may already be in value or thinking about value for your Actually, I mean, that's a great point because we we've started talking with um, you know some local um groups that are that are doing dce the direct contracting um And some acos that was that was my question is when they come on hospice um Does does that still count towards their total cost of care, you know, so it reflects positively on the total cost of care for those patients um Or when you mean they drop out of the pool meaning they're no longer counted. Um For the or the yeah, so Go ahead amanda No, no, no, I think we're gonna say the same thing. Go ahead. Go ahead. You start it. I'll add on if I say something Right Yeah, okay good. Um, you know, i'm a little less familiar with direct contracting. However, because it's part of the original medicare um, my guess is I feel like I have an educated guess here that they'll fall out so you no longer get the revenue and the expense association So essentially like if you have a patient who is alive for 12 months They you know in the last two months of the year They're on hospice You would get all the revenue and expense associated with that patient the first 10 months of the year and then the last two Two months you're getting the per diem So they don't medicare won't double count your and won't double pay you for these patients So and I think I mean, you know at the per diem rate that they pay I mean hospice, you know quickly becomes You know the more cost effective payment as long as you're you know, capturing it you will be am I saying anything? No, you're right. I was gonna essentially say the same thing. I mean, they you know Obviously the the dc and all of these like a medicare beneficiaries, right? Unless you're contracting with a payer Um, if they go into the hospice benefit, they should fall off that attribution list as a dce participant Is is how it should work ideally again these I think there's going to be a lot of learnings from these new models i'm kind of excited to see I know a lot of the practices that are Working with them and I think they have some tweaks to to flush out like I still The sip population that they think they're going to outreach to them by like a anonymous call from cms I'm, like they're all going to think this is fraud I I still have asked so many times on the cms contractor calls like and how do you expect to identify these patients? but um, but I it's great I still I am interested to see some of the learnings from it because I I think it's good. These patients already get enough calls. Uh, but it'll be interesting to see how it works out, but they should Technically no longer be attributed as a dce participant for you if they're on hospice. Um, that should be one of the things that excludes them Thank you. And hypothetically if you see them in that bucket Don't spend that money yet because medicare always comes back for their money. So You'll get you're definitely going to keep the hospice payment But if you're reconciling your member list, and you see any issues, you know, bring it up because you don't want, you want the hospice money more than you want that capitated money is my guess. Yeah, and Amara, to me, I mean, I think I've shared this with you too, but you're really kind of on the cutting edge of what I think is, I'm starting to see as the new innovation is all of a sudden, even hospice and palliative entities, you know, who care for a lot of the same patients, you know, from a risk standpoint are wanting to really become a continuum of care solution and offer all stages of care, which, you know, takes a lot of work you can do, but I can say, you know, even just the past year, I think I've worked with more hospice and palliative organizations, you know, and we support palliative care, community palliative care. There's a lot of overwrap as far as infrastructure and things like that anyway. So, you know, they're doing home-based care too. We have a workforce shortage. We need everyone we can get. You just have to know what kind of patients and what kind of care you're providing and what your model is. But I mean, I've seen a huge interest just in the past year of hospice and palliative care organizations wanting to expand mostly because of the SIPP, you know, that was their way to kind of get in the model, but it's interesting to see what will happen. Yeah, no, between PACE and SIPP, that was, you know, I think brought to the forefront for a lot of the other organizations, the importance of SIPP. Absolutely. Thanks again. Thank you. Let's see, Kim, are you, hopefully you want to be here and you're not stuck with us. Was there anything else? Oh, I think I asked you already, or was there anything else as we were talking that spurred? I'm just trying to make sure we don't leave anyone out and everyone gets to kind of voice a topic or a point you want to discuss. I appreciate that. Just really, you know, when I listened to you talk and the wealth of knowledge that you and Amanda both have, and this whole world is new to me. I come from home and community-based services. So we're skilled in providing case management services. And about a year ago, I came across this great idea. Let's build a home-based care to go with the home and community-based services that we already offer our participants. And then while we're at it, let's go ahead and just become a SIPP plan. So we're actually working towards becoming, yeah, our own plan. And so we're doing this as a method of doing our own model of care. So it's just a huge, huge learning curve. This is not my ballywig. And so it's just, it's really helpful to listen to everything. So tell me more about your SNP program. Are you partnering with like American Health Plan or Ally Align to do the backend office and you're building the network and the model of care all yourself? So we have some consultants and we're working with them and looking for a partner. We've kind of established a partner at this point in Michigan. So they're a skilled agent or an agency that's been providing or an insurance agency. Yes, that's been providing insurance for 40 years in Michigan. They recently got into the Medicare Advantage Plan side, but this will be their first SNP adventure with us. But being that we already provide all the home and community-based services, we felt like we could really control costs for our patients. And so then just adding this model of care onto it, again, just to reduce costs. And when are you looking to launch? We've already started seeing patients just for fee-for-service. And we started doing that in July and I just hired another physician so that we can continue to build. So I have two nurse practitioners. So in January? No, we actually started in July. Oh, launch the plan. The plan won't launch until 2023. Yeah, 2023 is our goal. So, you know, it's an interesting, we did basically the same thing, except we came at it from a medical practice standpoint and working with the duals for so long because while Minnesota has not had a great Medicare Advantage track record, they've had a long history through demonstration projects with CMS for the last 30 years around Medicare, Medicaid. And so we have one of the best, 5D SNP, fully integrated duals, 5D SNP, fully integrated dual eligible special needs plans in the country. And so when Medicare Advantage showed up, we said, let's go to some of our payer partners here and pitch the iSNP. And so we did the same thing. They filed the H number, you know, we helped build it. We helped to build the network, but they kept the contract, the network contract going. We took our patients. We defined it for us as, you know, memory care, assisted living, and long-term care. And so we, that was kind of our first track at these patients. And we took our 1,500 assisted living patients. I was like, okay, we're gonna go in and try to get those patients. And I, you know, I am not at the end of my journey, so I don't have a lot necessarily to share, except, you know, except that the switching patients from fee for service to iSNP has been really hard when we already take care of them. And so it's like, we're already there. We're already taking care of you. And people are like, why do I have to change my health insurance plan? Like, you know, I'm fine. Like, what are you gonna do differently? You're just gonna keep coming to see me, you know? And so we're trying to push this model of care that's really nurse-centered, but it's, that has proven way more challenging, and especially during the pandemic. We built one with one of the health plans all of last year. We launched at one one this year, and then we've spent since Christmas of last year building a second one and launching it in January. And I can say I'm exhausted, and, you know, and I'm still, again, reeling on what I'm learning, but the flipping of the patients has not gone the way I thought it was gonna go. So I wish you good luck and keep in touch. Keep, you know, keep everybody posted on how it goes. Yeah, that's really interesting to hear. That's one of my concerns too. I mean, with the way that we integrate with our current participants, we have a nurse and social worker that goes to the home, sees them every six months, and is calling them monthly. So they have a really close connection with our participants already. So our hope is, hope, is that we would be able to flip those. But yeah. Yeah, but the hard part is around some of the CMS marketing rules is basically it's like, you know, unless you restrict, and this is where we may have to get to, unless you say, you know, in a building we're only gonna take, I don't know, Humana, our Humana iSNAP, otherwise we're not taking any other payers. Then you've built this infrastructure where people are like, yeah, I like you, you know, but like, you're gonna keep coming to see me no matter who, you know, and why would I pay that money to see you when you're already giving me it for free? So I'm not at the end of that journey. In the next three years, we'll see how that goes. But, you know, for us, we have essentially held one thing back, which is our highly integrated nurse. We call them a clinical nurse coordinator that is supposed to be the carrot. So if you can think about that in your rollout strategy and start by reading the marketing guidelines from CMS, they publish it all in their big CMS manual. Start by reading those now because you'll be surprised how little you can actually say sometimes about this, but because of firewalls, but yeah, see if you can hold a couple things back that you're like, this is why you guys want it. You're not gonna get all this stuff for free. Kim, you said you're in Michigan, right? And you're starting with doing some fee for service home care right now or home-based primary care. I know, obviously, you have your community-based services anyways, but that's great. Nice. Let's see. Fran, hopefully you want to be in this practice management breakout right now. Is there anything you'd like to particularly talk about if you're by your computer? Nothing much. I wanna be here. It's fun listening to all this. I'm really learning a lot from everybody, but I don't have anything right now. That's okay. You started your, or are trying to start your own practice, if I recall correctly as well, right? I already started. I started in April this year. And what state are you from, Fran? And what state are you from, Fran? Texas. Texas. Oh, Amanda loves Texas. I was waiting for that. I'm from Texas. Okay. So it's like in my blood. I see you, Fran. All right. Any, well, no, I think I at least formally called on anyone. So anyone else that wants to chime in with, or Katie, I mean, you obviously, your practice has a wealth of knowledge and experience too. Anything you wanted to add, you know, feel free to just start a conversation of anything we've talked about so far. No, I think I've chimed in when I, when I wanted to. Yeah. Can't think of anything at the moment. Don't have to, that's okay. I'm curious. I have a question real quick. Has anybody run into signing a death certificate? Many times. How do you deal with that? Because that kind of was a problem for me because that was the first time. Well, if you know the patient, you know, you most probably know what the patient passed away from. Because here in Texas, here in Texas as nurse practitioners, we're not allowed to sign them. Okay. I was wondering, because here in the state of Florida, nurse practitioners can't sign it, but since I'm an MD, so I can. Could you have, or Amanda, go ahead. You probably have a better answer on this. No, I mean, you know what, some of those licensure things are really, really behind the times, you guys. It just is infuriating. We take every opportunity, and HCCI pushes those out too to send letters. So, but you know, I hear, you know, I hear from other groups, and I'm trying to think about death certs. I think we just got the ability for APRNs to sign those in Minnesota in the last two years, but we still can't order diabetic shoes. And so I, one day I'm Googling diabetic shoes because I thought they had to be something that like Marty McFly wore. You know, I'm like, what the heck is it? These must be the most amazing shoes on the face of the planet. If someone can't attest to these, and I send them around to the MPs, we got like 40 of them. I'm like, what the heck is this? This is ridiculous. You can't sign for these little guys. So anyway, that's an aside. But yeah, we hear a lot that people, you know, they pay a physician just a couple bucks a month to do any of the physician level signing stuff that needs to be done, so. Yeah, I mean, other than using your collaborative doc, which would still be hard, you know, but at least you have that collaborative relationship. It's still a patient within your practice. I don't know that I have a good answer, but yes, I mean, HCCI has been very supportive of any time we, you know, with the regulations, we commented on support of the nurse practitioners and physician's assistants signing from home health. I know in the next big policy barrier is trying to get them to be able to certify and order hospice, you know, so little chunks at a time, you know, we're fortunate to have advocacy organizations that we partner with in that work. And I serve on a couple of the regulatory task force for the American Academy of Home Care Medicine and the Coalition for Transforming Advanced Illness Care. And they both do great work in that respect as well and trying to, you know, little barriers like that, like the diapers. I know that always caught me up too, or, you know, the DME or things like that. They are making permanent some, like the diagnostic orders and some of the testing in the hospital that used to have to come from a physician too, that just got made permanent as well for nurse practitioners to have the authority. Great. Sorry, Fran, that's not as hopeful. I know you're less than a year into it. Oh, thank you. Well, and congratulations on starting a practice. Yes. Especially during COVID. Awesome. Katie, I have a question for you. Are you guys credentialed with Medicaid? So if it's a secondary to Medicare, then absolutely. We all, all of our providers have Florida Medicaid or Ohio, you know, depending on what state, have the Medicaid ID numbers. We do not take patients that are primary Medicaid, you know, if they've got stay well or whatnot, but we do with those plans, we do single case agreements with them all the time. So the case managers within the Medicaid plans will reach out to us, typically with very complex patients, your quads, your vents, your trachs, TBIs. And that's an outside of Medicare contract that we do a PM, PM rate with them. Oh, okay. Very good. Yeah, it's been something I've been considering, but, you know, our coders like, don't do it, it's so complicated. So that's what is the cost and benefit of it. So, yeah. At one point we decided we weren't gonna do it. And there's just such a huge population of Medicare and Medicaid patients that it didn't make sense for us not to do it. Now, Ohio is such a different beast when it comes, like up there, all their Medicaid, Medicare and Medicaid, they're all dual eligible plans. Where like in Florida, you have so many traditional Medicare and like Medicaid QMB. Very, very different programs and it can be a nightmare in the billing. Yes, it really can. Okay, thank you. Thank you. Mm-hmm. Oh, I have another question. Oh, I was gonna say, otherwise I could just throw out a random topic. I have like a to be prepared list if we need it, but I'd love for this to just keep going. So if you guys have questions, please go ahead. I just wrote them down when we've been talking the last couple of days, but. So is there like a standard that you have found with all of the mobile practices that you work with, like percentage wise, like, you know, how many private homes should you have? How many ALFs? How many ILFs? I mean, it seems like our private homes are growing. The need is just so great, you know, and you don't wanna turn them away, you know, because they need the care too. Is it much easier in ALFs? Well, yeah, of course, you know, but I had a physician tell me many, many years ago, you know, Lilenia, home-based care, going to the homes is really the heart of mobile visits. And, you know, that's always been, you know, we do some of our best work in the private homes. So, you know, well, that's sort of where I'm at right now. It's, you know, it's growing so much. It does take a burden on the driving, you know, with the providers and things like that. So not to say that we don't have, you know, a lot of ALFs and I, well, we also have like community buildings like ILFs too, which is nice, but I don't know when we should cut it off. Yeah, I don't wanna do that because, you know, it's the need is so great. Yeah, I mean, everyone on this call would be interested in your experience because you all have practices of both too. I have not, I don't have a magic number, but I very much am on the agree with you. I think the patients that need it the most or that have the lack the access sometimes are in that traditional home setting. So I really hate to ever discourage a practice from not wanting to care for that population because I think it's just the right thing to do and it's a need. If you're gonna do that though, I think you just need to be very strategic with territories or if you start to have those patients that are a little bit farther or that are really friendly, can you hire a provider that even lives in that area? And then they only see those patients or something like that. Like you just have to be really thoughtful of your service area territory because there's always gonna be a sob story. You know, that's why it's nice, all of you Florida practices, I hope you exchange numbers. You'll get, we're gonna have more conversations with just you guys, you know, too, but, you know, refer to each other if they're outside of area or things like that. You know, you can reach out to HCCI too if there's something you're looking to. I don't, it's, we don't have like a formal director or anything like the academy has on their website, but obviously, you know, from connecting to a lot of providers, if it's for like a referral basis, I try and be the middleman when I can. I sometimes miss like the normal like daily practice coordinations. I feel like I like throw my hat in the ring anytime I can like connect to people. Like, sure, I miss doing that. Like, happy to help how I can, but not, this is not like a formal thing we do, but if you're looking for someone in an area and I happen to know someone, I connect people pretty frequently too, but. Yeah, I refer people all the time to Katie, yeah. Yeah, I don't know what like a magic number. Obviously, the ALFs are a better business plan as far as just maximizing your time and your revenue and your expense, but, you know, Odessa, do you have a magic number you strive for in your practice? Cause I know you. It's not magic at all. I only added on really residential home visits maybe three years ago. I've had the practice now for eight years and we started really basically exclusively ALFs and SNFs. And now I'm counting, I'm really cutting down on the SNF settings and then added on the home visit layer. So, and I think of it, and my NP does really most of the home visits. I do the ones when, you know, they really are need like a physician involvement. So I think of it as, I find almost everyone needs basically monthly visits, maybe quarterly, right? So I try to figure out what the complexity is and how much can my NP really manage within the month. She has one dedicated home visit day. So if I think about it in eight hours, I count maybe one home visit per hour that I would expect to be seen, you know? So how many, I like to think in numbers. So how many visits does that equate to in months? So do you have enough provider to carry that? So if you just keep adding on, you're not gonna provide the care, you're not gonna have enough providers. So I try to do it by that. Right now we're cutting off at 40 patients, but 10 of them are probably patients that we only see quarterly, you know, that are co-managed by hospice and then 30 more active patients. And sometimes they need weekly visits, right? For their CHF and stuff like that. So, but between 30 and 40, which is about 10 plus percent of the overall practice right now. But since I'm hiring, I do want to expand specifically in that area. Oh, okay. Yeah, and we literally have a map. We have pins in the map where we have patients. Okay. And they do Google map. When the new patient, there's a screening process. Where do you live? Oh, it's a 12 minute drive from the one patient, you know, that's the- Great. So it takes a lot of coordination. The most gratifying part of the practice, but I do think it takes the most coordination and it's the most complex. So I'm grateful, you know, as to who I accept and who I don't. Right. And I reserve the right to say, hey, they sound like they, you know, I also, our first visit is basically advertised as a screening visit. We're going to come and we're going to determine if we can even meet your needs in the home visits as you know, a small practice like this. So I don't want them to think, oh, they've been there, now they'll take care of everything. We're going to send a provider out, but we're going to see if we can continue being your primary care provider. So I kind of reserve that right to say, this is too much for us to handle. You know, we don't- Yeah. And stuff like that. Yeah, no, that's very helpful. Like, it's on my dream board for the company as we think about expanding around our assisted livings is to kind of take a three mile radius around the building and go to the residential areas in that area. I could say we have, you know, quite a history of overextending ourselves in our home-based primary care because we were paid under different contracting. And so as we kind of look, you know, forward and think about, you know, what our future is, you know, just that slight extension. And the idea, I mean, conceptually, it depends per neighborhood, how it works, but the idea would be in a couple of select neighborhoods that as people age from their independent dwelling house, they might enter that independent living, assisted living, long-term care, and we could kind of continue that continuity. So, you know, if you're like, hey, we really, we need the money for the ALF, you know, you can start to draw maybe a little service area around, you know, on your way home, on your way there, you know, or is it just the house down the block? So. It makes you very uncertain to think about that. ALS makes you marketable, right? Because they want referrals from the community. So I think as a practice, to be able to say, I have a base of 40, 50 patients that may have potential to either go to your subacute, to your AL is a good market value. So I don't look at it just as income for the practice, but also just to, you know, kind of make you just, again, more marketable. Right, yeah. Want to work with. Right, that's one of the agreements that we have with Brookdale, some of their buildings. Their marketers are always in touch with our providers and talking about our patients that live in private homes. So here we go. All right, we're gonna give everyone a couple of seconds for them to send everyone to the last breakout. Okay. We're done with the breakouts, Brianna. Sorry, I lost time in our changing that. You're on deck now. Well, I'm here and I'm ready. That's fine. We can move on. You're all coming back. All right. So. Okay. All right. I'm sorry, did someone ask a question? Is this for the practice management? No, so we are, I guess we're done with all three breakouts now. So now we are back as a big group. I'm gonna spend a few minutes talking to us about coding for procedures. Can you all hear me okay? I'm starting to echo. Right now, there's some feedback. How about now? Yes, good. Good? Okay. It's being very testy today. Sorry, I'm hoping it won't act up. All right, so I'm gonna talk to you about the G-tube and the trach and the joint injections and a little bit about wound care and the coding for procedures. Now, I'm gonna start this with a little bit of a disclaimer is coding for procedures on top of E&M services can always be a little bit of a slippery slope, right? You need to make sure that the work is separate and distinct and that you're, you know, and I'm talking from a fee-for-service standpoint. I know we have some value-based here, but it really needs to be separate and distinct and that you can show that you independently, you know, treated their chronic conditions or addressed, you know, an acute problem and you also did the procedure because procedures generally include some pre and post work. So if you just went to the home, you added them on, you're on your way home because the G-tube fell out and you're just doing that replacement, you know, that's not supportive of both. But generally, especially as home-based traveling providers, you're not gonna be, you know, making that time and effort and trip without addressing the whole patient and these patients are complex. There's also a little bit of what I would call gray area with some of these procedures. So I'm gonna tell you what I know and my professional opinion and then we're gonna go from there. So if we go to the next slide. So G-tube, not that there wasn't a code for it before, but just a reason to have some sort of revenue cycle management or billing support because this was a replacement code as of 2019. So if you started seeing denials, I think the old code was just different by like a digit. Like I think it was six zero, but you know, you need to make sure that you're staying on top of those coding updates. This one is still a straightforward procedure. However, I, last year there was a lot of questions around practices receiving some denials and some of these new codes. And I did reach out to an auditing association for an opinion and they were the ones that were really stressing the importance of, you know, if you're not being able to show that, you know, it was more than just a straightforward G-tube train, like you were changing it because the patient had a concern or a clog or a problem, they would want to see some sort of other documentation to support it. But it is very straightforward. The code is 43762. If we go to the next slide, there's a lot of text in here just because I wanted you guys to have the correct information. First step of denial, if you're getting a denial for this code, what diagnosis code are you using? Is it separate from the E&M service? That would be one, you know, potential area that I would look at. Also as much as you can, you know, it should be almost like a little separate section in your progress note of going over the risks and benefits, going over the routine care, make sure there's some separate documentation to support that procedure work so that you can, if the payer comes back and asks you for an audit or wants to see your documentation, you're able to really support that extra work of the procedure on top of whatever service you're billing. And if you are billing it with a E&M service, you're going to need modifier 25 on the E&M to support it. You can always check with your local MAC as well. I have heard a couple of practices that told me that with certain payers, if we go to the next slide, they had received, you know, a denial because they were concerned that the home was not an appropriate setting. So I don't have a perfect answer. It's just something that you have to watch. With G-tubes too, a non-billing consideration, but just always make sure your patients have replacement tubes in the home. You know, we used to run into issues a lot in our old practice where they would call us to come out. You know, they'd want that visit scheduled, but they don't actually have the equipment. So just make sure you're being proactive if you're taking care of G-tube patients, that they have those and they understand their coverage and their DME vendors are working with you. Next slide. The reason I'm putting enteral nutrition in here too, and this was another just kind of DME headache, is we used to have issues with patients that for whatever reason, got their internal feeding supplies and their G-tube from different vendors. And then the G-tube itself was not covered. And we had to, you know, order it for a while and go back and forth. It usually happened when, you know, the hospital placed an order that was not their internal feeding company. So this is more just informational. Again, you know, someone, if you have a DME specialist or your clinical support staff that is on top of that, make sure you have customer service reps with the major areas in that area so that your patients are getting the supplies that they need. Next slide. And there are things Medicare won't cover. You know, I know we shared some other challenges earlier with certain wound care supplies and things like that not being covered from professional service. So again, more information. So again, more information. Next slide. Next slide. Can you guys still hear me okay? I might have to, okay. Next slide, please. For the sake of time, I'm gonna move us on. So this is the controversy procedure because I'm gonna tell you that based on the code description, I do not believe you can, this is a billable code for a trach tube replacement. And this is why, if we go to the next slide. So 31502, this was a code definition that changed. This is the only code that exists for trach replacement, only one in CPT. The problem is the language that says prior to the establishment of fistula trach, right? Those aren't the kinds of changes that we're doing in the home. Again, the CPT assistant, that's typically a paid subscription. So that's why I put this in here, more informational. That doesn't mean that you shouldn't find a way to try and get paid for the extra time and effort. If you're doing a procedure in the home, that added complexity to your visit. So if you're billing, are you choosing the appropriate level of service? Or because you did a procedure, and we'll talk a little bit about prolonged services in the next section here. Did that add extra time and effort? You should always be billing at the, usually you should easily probably be able to get to the highest level of service if you're doing that kind of complex care in the home. So this is what the code definition does. I would still encourage you, if you do a lot of trach changes, you can always reach out to your local Medicare administrative contractor, explain the situation, maybe even provide them an example of documentation. And if they tell you they'll pay for it, then you can get paid for it. But all in all, if we go to the next slide, it only pays about $30. So can you get paid for that work by billing at a higher level of service based on documentation or complexity, or that added extra time that you had to spend with the patient while you were doing that? That would be my suggestion. Next slide. So knee injections, little bit more straightforward at least. Next slide. So 2610 is the major joint, which is the knee and the shoulder or the hip. Typically the knee is the most common that we've seen in the home. I'm not sure if you guys are all doing this. Maybe in the chat too, it might be kind of interesting to see who's doing these procedures in the home and who's not. You guys can share amongst yourselves. Important thing to keep in mind here, if you only did one, there's side, right or left side modifiers. If you're doing it bilaterally, you don't bill the code twice. You would just add modifier 50 to identify it as a bilateral procedure. And if you were doing multiple joints for whatever reason, you would need to use 59 to get it paid separately. So keep an eye on these things pretty closely. And if we can move to the next slide. Yeah, and someone's saying only a few practices. I know a lot of practices that do or don't do these procedures. It depends on what your practice model, what can your clinical model support? What kind of things do you wanna do for your patients? Again, don't forget that if you're billing an E&M service and anything, like procedures especially, but anything in addition, you need to be able to show that the work was separate and distinct and they were both medically necessary and you should get paid for both. So you should have a separate assessment and plan that's not, or I'm sorry, separate progress note. I don't wanna see in the chief complaint that you're seeing the patient for a knee injection and that your whole note is focused on that because that's gonna be a little bit of a red flag. Your note should be focused on the other chronic conditions and the things that you're assessing. And then as you mix in the arthritis or whatever was going on, I just don't want that as a primary focus of the E&M visit because I want that to show me later in the note why that was separate and distinct and why it was medically necessary for you to do both. Next slide. And this is just the reimbursement. Just a little caveat on this. I always just use the CMS National Fee Schedule Calculator. If you're ever wondering, they have a great tool. You can just search for it, the CMS Fee Schedule Calculator. You can check by your locality though because it might vary a little, it does vary a little region to region. Next slide. Any questions before we move on? Or comments? Okay. So wound care. You heard Michael talk about the clinical aspects of wound care. I just wanted to make sure that you all have the information for debridement. HCCI is actually working on a new online course that goes into much more detail about wound care too if this was a topic that interested you. The missing piece that I usually see though is from the documentation. What was the depth of tissue? What were the, are you taking wound measurements? I might have to switch my audio here, but make sure all of that is getting in your documentation. Next slide. So just a definition of what excisional debridement really is. Next slide. There's two different types of codes. The first two, the 11042 and 11045, these were really probably the only ones that you're using in the home. You're probably not doing debridement outside of the subcutaneous tissue. It's important to know when it comes to debridement, it's all about how much square centimeters was debrided. The add-on code is used for additional square centimeters. So if you're doing multiple wounds, but they're the same tissue depth, rather than reporting 11042 twice, you should be using the add-on code. That's usually the common error I see here. Next slide. So summarizing documentation, if there are multiple wounds, make sure they're numbered, that you have different observations and clinical information. You should be taking measurements before and after debridement, and that should be included in your documentation. Again, length, width, and depth, that's usually kind of that missing piece. And it's all about the total amount of tissue that's debrided, as I mentioned, and the type. So just make sure you're very specific in your documentation, and most importantly, that you're taking and documenting measurements. Next slide. So here's the reimbursement. I always like to give reimbursement and work RVUs. Again, these are based on the national and might vary slightly by locality. So there are complexities, but doing G-tube, trach, and joint injections are possible. You should get paid for the work that you're doing. It's just how you go about that. So even if it's not billing for the procedure, are you taking into consideration all of the extra added time and complexity to make sure you're really reporting the appropriate level of service to get paid for all of the work that you're doing? And being able to have confidence and confidence in performing of these procedures. We know that that's providing high quality care to our medically complex patients that without it wouldn't have that opportunity. And of course, we always wanna make sure we're getting paid for it. Even if it's just a blood jar or little simple things like that, yes, the reimbursement isn't enough, but make sure you're billing for everything you're doing in these encounters. And that is what I will leave you with before our break, unless anyone has any questions. You know, Brianne, I just thought of a little trick that I learned and some of these tricks you learn from patients, right? I mean, how many in this group have learned so much from patients that they've been able to then teach other patients? But one of my patients, they would tape down the G-tube to the skin in the past because, so it wasn't just like flopping all over the place, but it was causing irritation to the skin. So what they did was they put a piece of Duoderm next to the G-tube and then they would tape the G-tube to the Duoderm and the Duoderm would literally stay on for weeks because if it's not being used for a wound, and they would just change the Duoderm like every two, three weeks, but that way they were ripping the tape off of the Duoderm every time they did it rather than the skin. Does that make sense? And so just little things like that, that can help us do better care for our patients. Yeah, absolutely. And before, I'm sorry, I just noticed Michael is still here. Did anyone have any other questions or Michael, did you have anything to add as far as, how you go about documenting with your wounds? I know you have a, might be leaving us shortly here. So just wanted to open it up to you before we go to the break. No, I think you've covered everything beautifully as usual. I don't have anything exceptional to add. 20 centimeters squared of debrided tissue in the home is more than that, I should say, it would be quite a bit. I don't think I've ever coded greater than 20 squared centimeters. Good. I know I had to tap Michael, cause I was like, I'm not clinical, like Amanda and I have said, I'm like, I don't think that would be reasonable, but I don't know, maybe you do do that complex wound care in the home. So I was like, I'm going to put them all on here, but I had to have Michael kind of give me a reality check. I'm like, how much do you debride in the home? So thank you for that. Well, thank you everyone. And Paul, and thank you to Paul, Tom, Michael, Amanda and Brianna for our last session. That was excellent. Lots of great information. Please take a moment to complete your learning plan and we will break for 15 minutes. Please mute your mic and turn off the camera. We will see you back at 310. A few minutes before we start, Danielle will be showing everyone how to access the evaluation. So come back on a little early if you want to hear about that. And we have a quick announcement from Melissa and then we'll break. Well, it's really just tagging on to Brianna's message. Michael needs to leave us, but if there's any final questions for him, you can feel free to put them in the chat. We'll have him email you directly about that. Yeah, if anybody has any questions, you can either email me or HCCI team will get the chat question to me. Thank you everybody so much. You've been a great dynamic group. So fortunate to have been able to meet you all today. Enjoy your break. Thank you, we'll take a 15 minute break. We'll take a 15 minute break and come back at about just a few minutes before 315 Central. Hi everyone. I'm going to pop on to show you how to complete your evaluation. So I'm going to share my screen. The first thing that you want to do is go to the HCCI Learning Hub and you will be prompted to enter in your username and password. It's the same one that you used to create your account here. And we definitely want to encourage you to complete your evaluation. The reason is your opinion counts. It helps us to be able to take the good, the bad, the improvements, the challenges, everything, and really tailor our future teachings to what it is our learners are looking for. Once you go into there, you will look at your specific course, Advanced Applications of Home-Based Primary Care Workshop. Inside your course, you will see where it says Evaluations. It's 18 questions. It seems like a lot, but it is something that we really want to be able to get as much information from you as possible. It will be listed under your My Resources section. Additionally, if there was something from the course that you wanted to get and could not access, under Course Materials, if you click Access, you'll be able to find those. For the evaluation, go all the way to the right where it says Start. Once you click on Start, here, you'll go through and you'll answer all of the questions on the evaluation. And it's pretty quick. Once you've completed that and you can click Submit, you will then be able to claim your CME credit as well. If you have any problems claiming your CME credit, please send an email to education at hccinstitute.org, and we will work to assist you to get that corrected. Thanks so much, everyone. Great. Thank you so much, Danielle. Welcome back, everyone. We hope you enjoyed your break, and we are now going to move into advanced coding with Brianna. All right. Thank you. So, hopefully, everyone is still awake and with us. I know we've had a great couple of days, and sometimes I think they do this to me on purpose to challenge to see if I can keep your engagement for coding as the last talk of the day. So, if anyone wants to turn their videos on, I'd love to see your faces. You don't have to. You know, please feel free to share in the chat. You know, I'm billing for this. I'm doing this. Your video will help me make sure your eyes aren't glazed over. So, I'll try and make this as fun of a coding talk as we can. How about that? So, before we get started, I just wanted to start by acknowledging something that I know Dr. Cornwell mentioned, but really, all of these opportunities, these are fee-for-service traditional Medicare opportunities. They're never going to be more important than they are in 2021 if you're under fee-for-service, and really maximizing everything. Because of the CMS proposed or now final rule, the Medicare Physician Fee Schedule final rule, although I'm an optimist and there still is hope that we could possibly get some legislation to postpone budget neutrality in 2021, but if we don't, then unfortunately, for calendar year 2021, your home and your domiciliary E&M visit codes are going to see a pay decrease, on average about 8%. And the reason that is, is because any of you that maybe work in different settings might have heard of all the office visit changes. It's the first time they're changing documentation guidelines and they're increasing the payment for what they assumed was majority of primary care services, but unfortunately, forgot the home. I just want to reassure you that HCCI, along with our advocacy partners, the American Academy of Home Care Medicine, so many of you, we had a joint comment letter signed by individual practices. The academy also sent in a joint comment letter with AFP, AGS, AMDA, all of these really powerful organizations. Our voices are being heard. The comments were addressed. They just pretty much said, you know, we want the AMA work group to really consider revaluing SNF and home services separately because we don't consider them too similar to office visit and we need more time to think about that. But if we don't get legislation within this next month, unfortunately, we will see that cut. So that's going to be making all of these opportunities that much more important for your practice to be sustainable. Secondly, I know we have a handful of folks, you know, either from Oak Street or those that may be in value-based contracts. Many of these care management services may be bundled in your care management fee. So what I would encourage or challenge you to try and take away from this talk is CMS pushes out systematic processes that they think are going to improve care, right? So what can you take as far as the concepts and how you're delivering care and how your care plans are developed and are there any things that you might want to take away in that respect? Or, you know, is remote patient monitoring or virtual services something you can negotiate into your contract? So just think about it through that lens if you're in value-based care already. I know the majority of us are in fee-for-service. If you attended Essential Elements, you heard me talk about, you know, the core documentation, basic elements of E&M. If you weren't in that talk and that's something you want resources on, we have a great online course or reach out to me and I'll share some information. All right. But with that being said, let's jump into advanced coding. So I'm going to talk about, again, opportunities beyond your E&M. How do you get paid for all the extra effort and work that you have to do taking care of these complex patients? And what impact does that have on your practice's bottom line? We're going to talk about a lot more, but we're going to talk specifically about transitional care management and some care management opportunities as well. If we can move on. So chronic care management, you can go to the next slide. Start by what it's not, right? Because many of you, and maybe just put in the chat or raise your hand if you're using and billing chronic care management already in your practice, it's more than just, it is a time-based service, but it's more than just you spending the 20 minutes per month. And I'll share with you a couple of pitfalls that I've seen just this past year when I've done some auditing of some CCM programs for some practices for you to keep in mind. Pitfall number one, which we'll talk more in detail about, you have to have a separate informal comprehensive care plan, right? And that, not only have it, it also needs to be provided to the patient and caregiver upon implementation. So if you're not doing that, that's going to be problem number one. Also, you know, it's the clinical activity, how that time is spent, all those individual minutes throughout the month, you need to be able to support exactly what was done. I had a practice that for whatever reason was using Excel spreadsheet that their poor clinical supervisor had to tally. So I had minutes with general bucket categories, but it didn't tell me what specifically was done. That would not stand up in an audit. So another thing to keep in mind. And then, you know, again, if it's just a minute and, you know, there's very vague descriptions, like you're trying to say, I spent 20 minutes reviewing labs. What labs? Did you talk to the patient? You know what? Be as specific as possible when you're documenting your minutes and supporting your time. And all of these findings that I've found personally for CCM, it also matches up with there's an annual audit report called the CERT or the Comprehensive Error Rate Testing Report. It's worth looking at because it'll tell you where the most improper payments are. And if there are things that you're billing for, you're going to want to be aware of those pitfalls. But that's what they talked about for CCM is they found, you know, not care plans or not supporting documentation or not provider signatures on the care plan. So if you're using your clinical staff to develop those care plans for you, your provider should still be reviewing and signing off on them. Next slide. And Rita, we'll get to your question about the 15 minutes. I'm glad you answered. You're going to cue me up for what we'll talk about. So again, it's a time-based service from a patient eligibility standpoint, they have to have at least two or more chronic conditions that put them at significant risk. You know, I think we know of that. Yes, the traditional CCM code 99490 assumes 15 minutes of billing practitioner time. However, your clinical staff is going to be working under you as incident too. What I would say to support that is especially if you're using like RN care managers who are doing a lot of that, just make sure there's collaboration and oversight, right? Even if they're spending time with the patient, are you getting that information routed to you? Are you acknowledging it? Are you being involved in their care throughout the month to show your involvement as a physician? That's what they want to see. It's a partnership because CCM is built under the billing practitioner, right? Either the nurse practitioner, physician assistant, or MD is the one billing for it. So it should really be your oversight of the total amount of time, whether it's you or your clinical staff. And if we move on, I'll talk to you specifically about what that means and what it looks like. Next slide, please. So just a common question. I think you guys are probably familiar with this. There's not like certain conditions, right? We can't say that this condition doesn't qualify. Just know they have to have at least two or more and you need to be the primary provider providing their medical oversight for their chronic conditions. CCM has to be one billing practitioner per patient. Just make sure you're the primary management. Next slide. Next slide, please. So I mentioned it's not just time-based and this is why. So new patients or patients that you have not seen within the past 12 months, that conversation and that obtaining consent needs to happen during a face-to-face visit by the billing practitioner. So if your physician is going to be the billing practitioner, they should be the one doing the initiating visit and enrolling the patient in CCM. The consent can be written or it can be verbal. You have to have it before billing for services. A best practice would be just including that in your new patient paperwork so you get that written consent on file and then your provider can still talk with the patient, maybe give them some supplemental information about the CCM program during that first visit. You also have to be using a certified EHR. I really see just using certified EHRs as a necessity of the future. It's a clause in a lot of the value-based payment models and things like that. So if you're not, it's something to think about investing in in the future. When they say 24-7 access, they're not expecting you to be a concierge practice that's going to run out, you know, two in the morning and go see your patient, but you need to have after-hour support. Can they reach you to get medical advice? A designated relationship with the care team member. Again, they need to have a designated primary provider that's following their care. The comprehensive care plan, we'll talk more about that. It does have to be a separate informal care plan document. It's not just your assessment and plan. They assume you're managing patients' transitions, coordinating with home and community-based services, offering enhanced communication opportunities such as a patient portal or a digital platform where they can communicate with you. All of those are participation requirements with CCM. Next slide. And Odessa, to answer your question, yeah, so she said, best to document time with any time spent on care, phone, refills, med reconciliation, and then document separately. So no, don't, yes, I think the biggest pitfall I see is like, oh, I can only count phone call time with the patient. No, it's any and all medical management time. That's why I love CCM. But explore your EHRs. Almost all of them have CCM modules where if you turn it on, they'll actually be like a little time tracker in almost any type of encounter. So real time as your clinical staff is documenting whatever they're doing, you can just add your minutes. I do have some practices that will choose like one type of encounter and they just keep like a running total because it's easier for them, you know, while they're still building up. That's okay as long as you can show me separate dates and times and minutes and then the clinical details. But I'd really encourage you to work with your technology. If your EHR isn't an option too, there are other vendors and platforms and things like that that can really make the time tracking easy for you. That's really going to be important for CCM. So these next two slides too, you know, I created this particular one. What do I want to see in the provider's face-to-face note that initiating visit that you talk to them and are explaining the CCM program, they understand they can revoke, they're getting that comprehensive care plan. I'm not going to read through this. This is more for your benefit to compare to what you're doing. The next slide is just an alternate example. I always kind of like to give two. This is a little bit more formal, really showing that the patient, you know, meets the eligibility participation and all of the information. Next slide. So in your appendix, I've created, you have a couple different resources. We have a resource explaining the CCM care plan in more detail and then an actual sample form. Again, this should be in your EHR. Work with them. See what you can tailor. The bullets on the right-hand side of the screen. A lot of people don't realize CMS does have very specific recommended care plan elements. This is what they recommend. So they didn't say required, they said recommend. So you want to think about that. But anytime the government is recommending something, I recommend using it. So if you're not using all of these elements in that care plan, I would consider doing it. You know, I do know some providers too that, you know, they take a standard approach. There's certain conditions like hypertension and things like that, where you're going to have somewhat standard treatment goals, right? So you can build templates for things like that to save you time when you're actually doing the care plan. But again, remember it has to be a separate formal electronic care plan document. You have to make sure the patient and caregiver have access to it. So if your practice has a patient portal, but they don't, they're not active with it, that's, you know, often a problem that I see that that's not meeting the requirement. You're going to have to put a process in place to mail a copy of the care plan to them if they're not active on that patient portal. You also need to have a date for periodic review. At least once annually, you know, put it as a flag or an alert in your EHR, make it part of your annual wellness visit process. You know, it is a really, it's the initial development of that comprehensive care plan is done when you're enrolling the patient. I wouldn't expect every little change, you'd be go back in there and updating their care plan because that documentation is going to be elsewhere in the medical record. But you do at least have to review it and update it annually as appropriate. Next slide. So here are the actual codes. So you do have options. And there's another one that we got in 2020, an add-on code. So what I refer to and what most people are familiar with is traditional CCM. That's your 99490. That can be combined clinical staff and your provider time. It has to be a minimum of 20 minutes throughout the whole calendar month. So you should be billing this at month end, have a process for that. There is a separate code, especially for many of you who are starting out on your own and are really the solo provider, it pays more. You can see 42 compared to $83 if it's 30 minutes per month of all qualified provider time. So if it's all your time and you're doing 30 minutes per month, you'd be better off reporting 99491. You can't do both any of these. You have to pick which type of CCM you're reporting for that calendar month. There also is what's called complex chronic care management, 99487 and 99489. I'm not a huge, there's options with this. They used to say there had to be a substantial change in the care plan. CMS took that language away. They just now said it has to support moderate to high medical decision-making, but that's by the billing provider. So sometimes in audits, those can get a little hazy and you can still bill if you're spending that much time, like 60 minutes per calendar month. If we go to the next slide here, there's an add-on code. We got this at the beginning of this year, G2058. So this can only be used for traditional CCM. So that's that 99490, 20 minutes of you and your clinical staff time. You can only bill this for up a maximum of two units. So it would be a total of 60 minutes per month. And all together, this would add up to about $118 if you did 60 minutes of traditional CCM time, which is actually a few dollars more than the complex CCM that I just mentioned. And that's why I wanted to reference this slide. But again, if you're an independent provider and it's all your work, consider the 99491 for you getting paid for your, it being a higher level of your time, or if you're using your clinical staff, which I recommend you do if you can, because it's a great way. We were talking in the practice management section about, you know, trying to get RN billable hours. This is the way that you count their time. Next slide. So the other option with CCM, and this would only be payable once per patient lifetime. So that is at the start of that initiating visit. So you can only use it for new patients or patients not seeing within the past 12 months. If you as the billing practitioner and provider are doing the initial, you're starting to develop that care plan, right? You go above and beyond just getting their consent. You're really talking about their chronic conditions. You can show that you're starting to create that care plan. GO506 pays $63. It's a one-time on enrollment for that patient. I was talking to an independent provider that owns her own practice in Indiana, and I said, you know, how do you make this reasonable for you? And she was like, well, you know, yeah, the care plan takes time, but this is why. Well, I know with new patients, I'm going to start their care plan, and I'm going to bill GO506, and then I'm going to transfer it to my nurse to finish it and things like that. It's a little bit of, it makes the extra work a little bit more worth it for me. So if that helps you think about it a little bit extra, you know, just wanted to share. Excuse me. Yeah. Ada, is that you? Yes, it's me. I'm taking up the whole screen, so I can't see you either. So you can do that in addition to the new patient code? Yep. This is in addition. So it can be in addition to your E&M visit. So we talked about trying to make more bang for your buck in 2021. Again, you know, this could only be for new patients or patients not seen within the past 12 months. It has to qualify as an initiating visit. So it could be an E&M. It could also be an annual wellness visit. I want to see a separate spot in your documentation that is really focused, you know, maybe towards the end of the assessment and plan on CCM. I discussed the risk and benefits. We are going to work on these treatment goals for at least two of their chronic conditions, and then be very specific. What was that discussion with the patient? What are their treatment goals specific to that condition? If you have that, then I would say this would support it, and you can build this in addition to the E&M. Do you need a modifier? You should not need a modifier for this particular code. No, I have not heard that. Brianna, Kim had asked, can the initiating visit be a telehealth visit during COVID? Thank you. Yeah. It should, yeah, because it's the same E&M code. You know, I've gotten that question. I've looked at the regs. I've looked at the FAQs. I don't really say anything that said it cannot be. Again, so right now, the telehealth visits are the face-to-face visits. As long as you're still doing a video visit, I would just say it can't be a phone encounter. But right now, you know, true Medicare telehealth services are face-to-face visits. They're just virtually. So you should be able to still get away with that. Going forward, after the public health emergency, if those telehealth regs change a little bit, that might be a problem. That might need to be an in-person encounter. But right now, I do know practices that are still enrolling. I haven't heard of any denial or issues if it's a telehealth visit, because they're still billing it the same E&M code. And one other question, does any of this apply to straight Medicaid patients? Straight Medicaid patients. So it would depend on the state, unfortunately, because Medicaid is such a state plan. If they're dual-eligible, yes, Medicaid should pick up the remaining coinsurance. It would depend. I would check with your local, you know, state, or if you have a rep or something like that. This is a Medicare service. So typically, it's going to be your traditional Medicare Part B or your Medicare Advantage or your Part B beneficiaries. I was actually looking at the – I have a link at the end to the resource page. If you go to CMS's care management website, I'm a big fan of that. They have a lot of great resources there. They have a frequently asked questions document that talks about that in a little bit more detail. They didn't give a great answer, though. I read it this morning, because that question usually comes up. And it was like, well, it depends on the state guidance and the plan participation. But for sure, duals, yes. So, how do you kind of take everything we talked about and tie it all together? If you're thinking about CCM implementation, it's definitely going to be helpful for you to have some support staff, right? Are you capturing extra added billable hours for your RNs or other times you also want to lean on them to help you develop those care plans, you know, do patient and caregiver education, maybe your practice decides systematically how often, based on kind of their level of risk they get checked in on, there's lots of things you can do with that. You also need to have a way to track your time. Again, I really encourage you to work with your EHR vendors, ask them if they have a time tracking, you know, mechanism within their EHR type of care management encounter or things like that. Make sure you're developing macros and templates. We talked about efficiency yesterday. How can you save your providers time and make this as easy as possible on them? If you're not familiar with the terminology of macros or smart phrases, they're essentially just taking standard pieces of documentation and building it in by a button or a click in your EHR. So work with your vendor on that. Do not forget about that care plan. It is really important. It does need to happen. It can also be as meaningful or as less meaningful as you want it to be. You know, I would challenge us to think about it a little bit more because, like, for example, HCCI was doing an initiative where we involved a caregiver. We wanted the caregiver's voice to be heard. And one of the things that she shared, which, you know, is, like, no, if I just had a central document in the house that told me who I was supposed to call for what, like, would it speed up efficiency if I'm having, you know, an issue with the oxygen to just call a home health or call the DME first or should I call my provider first? And these are probably all things that you talk through with your patients. But even just the time of her having to go dig up that number from that supplier, so even just giving them that care plan, that could be a real benefit to these patients. And spending the time to go over it with them and not just, oh, this is an added thing I have to do so I can bill for this. So it can be as meaningful as you want, that care plan. And then a month-end billing process. Providers, you know, this is where you really want to consider, do you have the help of an external billing company or is there someone on staff that can at least take care of tallying and capturing all this minutes month-end so that's not on you? Again, CCM is billed at the end of the calendar month and it's non-face-to-face time. And next slide. And, yeah, Rita shared Florida Medicaid won't pay for CCM. That would probably be my guess is most state Medicaid plans won't. But, again, it's kind of dual eligibles, yes. So this is just an example, again, showing you the reimbursement with the different types of codes. Think about your business model. Think about what makes sense for you. But it really does, the extra work that you can put in to implement something like this really does pay off. Next slide. So those of you who attended Essential Elements, this is going to be an either-or scenario, right? So, you know, I'm not saying there's one right type of care management service to provide. Care plan oversight is another option. Just know you can't do both, right? So you got to pick one service. But I'm going to talk to you a little bit about the CPO requirements. Next slide. So what is care plan oversight? So it's very similar, only this is for provider supervision of only patients that are actively on home health or hospice. They require, you know, complex multidisciplinary care, all of the things they're already doing. The difference, which we'll look at on the next slide, is there is a very specific list of what they consider billable activities and non-billable activities. My professional opinion, I think CCM is more flexible. You don't have to worry about if it's an improved billable activity. And also, the difference with care plan oversight is it has to be a minimum of 30 minutes, and it cannot be your clinical staff. It is all the billing practitioner's time. It has to be a nurse practitioner, physician assistant, or MD. Next slide. So here's that list of billable activities. So again, keeping in mind that this was really designed to reimburse providers for their non-face-to-face time caring for patients who are enrolled in home health or hospice services, they're thinking about the time you're reviewing care plans and talking with other healthcare professionals or those home health nurses and things like that. You'll notice what it does not count is that time with family, which I think that's, to me, a big kind of loss on using this code is because there's so much coordination that goes on with the patient and family. Next slide. Other considerations, you would have had to have seen the patient within the past six months before you can start billing for care plan oversight. Again, that established patient relationship. It should be the only service on the claim if you try and bill this with another patient on the claim. If you try and bill this with another service, it will be denied. Again, it's billed at the end of the calendar month, which that at least 30 minutes is obtained. Again, only one billing practitioner, and it cannot be additive over calendar days and months. It's all within the same calendar month. It's all within the same month. It has to be a total of 30 minutes. Again, all provider time, all of your billing practitioner time. And when I say billing practitioner, too, you can't add, if the physician is billing, you can't be adding the physician and the nurse practitioner's time, even though they're working together. This is specific to the billing practitioner's oversight on time if you're billing CPO. Next slide. So the reimbursement, if it's a home health care plan oversight, it does pay about $108. Again, these are all based on the national CMS fee schedule, and the hospice is $109. This isn't for physicians that are employed by the hospice or nurse practitioners. This is more of the professional outside attending provider. And so, Jennifer, I'm just looking at your question here. Yeah, so if it's only once per month separate from any other claim, yes, that's correct. So again, a strategy that you would think about with care plan oversight services is, how am I going to identify my home health and hospice patients? Can you flag that as an EPIC uses care episodes? I know many of you are on EPIC that you might be able to track that with. Can you do a patient list if you have to keep track of them separately? And then make sure you're capturing your time as you're doing it throughout the month, and that someone on the team is responsible at the end of the month for allocating and adding all those minutes and billing it out. Next slide. Let me know if that didn't answer your question. Yeah, so basically, if we have anyone on home health or hospice, we should be billing this. If this is the care management service that you choose, yes. This isn't formal. This is, you know, my kind of comparison of, you know, do I want CCM or do I want CPO? Here's what I think. If you're an independent practitioner that's just starting out, care plan oversight might not be a bad idea. Because you're using the home health care plans and revealing off on those orders. So if you don't have that support staff, and it's really all your time, and the payment is, you know, $100, make more sense to start with care plan oversight. The downside is, you know, with CCM, you're really capturing all of your patients. You know, what about the patients that aren't active with home health and hospice and all of that care management time? I would just encourage you, if you're not billing either of these, to think about the differences and think about really what makes the most sense for what your practice is doing. And that would make, you know, see what makes the most sense for you and then decide from there. Again, it's either CCM or CPO. You can't do both. Next slide. So separate from care plan oversight, although a lot of people that I talked to think this is care plan oversight, just another easy win, are the codes for actually signing the home health 485s, the certification and the recertification for patients that are on home health. This used to be only billable by MDs. Because of the CARES Act and the interim final rule from CMS, that finalized policy that nurse practitioners and physician's assistants can independently order and certify, you can now bill this as an advanced practice provider. Next slide. So these are the codes. Again, this is for actually signing the 485. So GO-180 is billed only once per care episode when the patient has not received any home health services in the past 60 days or starting a new plan of care and you're signing that initial 485. That's when you bill GO-180. GO-179 can only be billed once every 60 days for that recertification. So all those little in-between status reports, that's not what this is about. This is the actual plan of care that's being billed once at the start and then the recertification every 60 days if they're continuing skilled home health services. I'm looking at a question. Can you bill GO-180 and CCM? Yeah. So these particular codes, let me back up a second. The documentation to support these is that you're coordinating. Like within the medical records, you're going back and forth with the home health agency. You're involved in their care. The person who's billing it is the one that actually signed the 485. These particular two codes should be billed. You cannot bill the care plan oversight and CCM, but these two, I just checked before this conference, I don't see any bundling edits. So you should be able to bill these and CCM, just not the care plan oversight codes. The care plan oversight codes and CCM are bundled. The other headache that I've run into with these is, and it's more unfortunately on the home health agencies, if they are not getting you timely 485s or plans in a timely manner and then your signatures aren't matching up exactly every 60 days. Again, that GO-179 has to be exactly 60 days apart. So you do have to have some back-end billing. In the revenue cycle world, there's usually what we call charge review kind of rule that they can bill into your billing system that would flag those for review so you're not accidentally billing bundled services. And then, yeah, Moses, to your point, always bill these codes after you sign the plan of care, not before. The date of service on these claims is the date of your signature. Next slide. So we talked about a lot of care management services. Let me just take a pause. I know I've been at least trying to answer questions as they come in the chat. But any questions? Okay. So transitional care management, oh, go ahead. That's a great question. I just wanted to clarify. So you can bill the CCM and CPO together. You can either one or the other one. Right. You cannot bill them both. You have to choose, am I going to count my care management time and choose to bill chronic care management or do I want to do care plan oversight? One or the other. Okay, thanks. And then, so again, just a big plug for TCM. The good news is transitional care management is getting a pay increase in 2021. It got one in 2020. It's getting another one in 2021. So when we think about sustainability, if we don't postpone budget neutrality, TCM is never going to be more important for home-based providers under fee-for-service to actually start billing for it now. Because this is not getting a pay cut. It's getting a pay increase. So I'm going to talk, you heard Dr. Chang and Amanda talk yesterday about, you know, we do transitional care management, right? We're doing it regardless for these patients. But what is the Medicare definition of TCM and how do we bill for that? So first, you have to have a qualifying discharge. If the patient had an inpatient or observation hospital stay or they went from a SNF home or to an ALS, those all qualify. What does not qualify is if the patient was in the ER. Unfortunately, that's not an approved TCM episode. Or if they were in an assisted living and went home with a family member, that would also not qualify. The second piece, yeah, so discharge from an observation. As long as they were an observation-level hospital stay, that does qualify for TCM. And then interactive contact. So the second piece is once you get notified of that discharge, within two business days, your clinical staff has to make a phone call to that patient and caregiver. And we'll talk about what those requirements are, but that has to happen within two business days. So an implementation consideration is how are you getting promptly notified when your patients are discharged from the hospital? There are certain non-face-to-face services. Again, all things that you're doing and how you're going to support this documentation is going to be building templates. Then, what about, yeah, go ahead, Iraki. What about if you're getting a new patient on your service and you didn't know about this patient? You're not able to contact them within two business days. Can you still bill for the service? Yeah, that would be a hard one. The interactive contact call is required because TCM is actually a 30-day service period. So what I would encourage you to think, if you're getting a new patient that's discharged from the hospital, is that care coordinator calling you? Is there any way? If you're seeing them outside of that window, unfortunately, that is a requirement. It has to be done. We'll talk about a little caveat, but that is a big requirement, a big piece of the CCM. We'll get to one of the exceptions in the next slide. That face-to-face, so two business days for the phone call. You have to actually see the patient within seven to 14 calendar days of discharge, too. That's the other caveat. And this TCM code, which we'll talk about, is your face-to-face visit. That's when it gets billed. Next slide, please. So discharge from SNF is TCM, yeah. So if a patient comes home from a skilled nursing facility to a lower level of care, that would qualify as a qualifying discharge for transitional care management. That call, the difference with TCM and CCM is TCM requires licensed clinical staff. So unfortunately, a CMA is not licensed. So keep that in mind. Maybe you want to do that post-discharge call if you don't have RNs or LPNs. LPNs would at least be considered licensed. Again, two business days of discharge. Can you educate the patient and caregiver? Can you work with your local hospital if they're going to refer you a patient to be notified as prompt? I don't want to give you the reason I was pausing, but I still don't think this would be a solution for you. The caveat is if it's a patient that just never answers the phone, but you have at least documented in your medical record that your clinical staff or you has at least tried and failed to contact them at least two times, and all other TCM requirements are met. You still got out there and you saw them within 7 to 14 business days. You have all that other documentation, which we're going to talk about in the following slides. Then you can still bill for it. They don't want you just not being able to reach the patient to disqualify you, but the exact language is CMS expects attempts to reach the patient to continue until they're successful, and all other elements have to be met. But if you've had at least two failed documented attempts, you've still seen the patient for that post-discharge visit within 7 to 14 calendar days, and you satisfy all the other requirements, then you can still bill for it. So in a new patient scenario, go ahead. What if the family members contact you? They contacted you a couple of days or so after they were discharged. They're not on a SNF, for example. I'm sorry, not a SNF, an assisted living. Would that still count as a phone encounter? Yeah, so if the family member is the appropriate healthcare representative, like the patient has dementia, and so they're the power of attorney, like whoever is cognitively capable of having that phone call with you, but there are formal requirements. You know, it needs to be medical in nature. It's not just the family member calls you, yep, I'm going to get you set up. I'm going to come see you. You know, it needs to be, do you have your medications? You know, do you have everything you need? If we go to the next slide. Next slide, please. Here we go. So here's some example questions. Although in the resources that you have in your appendix, oops, go back one, sorry. What you want to make sure to call is medical in nature. It's not just, I'm coming to see you Tuesday. I know you were discharged. You know, it has to be by you as a provider or a licensed clinical staff member. You need to be addressing medical concerns. And there are, you know, I actually have a slightly different template, which we'll get to that I recommend, just showing that you've checked the boxes essentially on, you know, you got in, reviewed their discharge records, you're reviewing their medications and so on and so forth. Next slide. So all of this, again, thinking about that face-to-face visit, rather than billing your home or your E&M, kind of like chronic care management, you bill it at the end of the month. TCM is a 30-day period, but you bill the actual TCM code as your face-to-face visit when you see the patient. It needs to support moderate or high medical decision-making. You're doing that with these patients already. If they have two or more chronic conditions that you're, you know, assessing and you're reviewing labs or the discharge summary or talking with other people, your MDM will be supported. But you can't bill an E&M and a TCM visit. Although TCM, it sometimes gets a little confusing because it's a 30-day service period, these are the codes you're billing for that post-discharge visit. The other note, pitfall that I've seen with this is a requirement of TCM is comprehensive medication reconciliation. So this is where I'd want to see a little bit more expanded documentation, not just a checkbox that meds were reviewed. Did you review it for necessity and effectiveness? Did you do a bottle-by-bottle home review? Give me at least a sentence of something that proves you did a comprehensive medication reconciliation. Next slide. So why TCM was underutilized is because before 2020, it was bundled with chronic care management was the biggest barrier and some of these other care management services. Again, CMS is telling us they are encouraging providers, they feel TCM is a good care model for patients that reduces readmissions. And so they've actually unbundled it in last year's rule with a total of 16 care management services. And if you go to the next slide, they're unbundling it even more in 2021. And again, these codes are getting a pay increase. You know, they're going to pay substantially more than your home visit E&M or Dom's Delay of Visits are anyway. Next slide. And this is just the other ones that are being bundled to that G code for CCM that I talked about. They unbundled that in 2021 too, making it very clear that for traditional Medicare purposes. TCM and CCM can now be billed for the same patient within the same calendar month, as long as you're not double counting your time and activities. It was bundled prior to 2020, which was a big barrier with, you know, reporting this. Your Medicare Advantage plans, you know, should be following Medicare regulations, but this was a fairly recent change. So just watch your payers and make sure you don't need to do some education there. Next slide. So this is what I mean by increased reimbursement. And this is just 2020. They haven't updated their fee schedule yet, but this is going to go up even more in 2021. $187 is the first code. So that's if you would have seen the patient within 14 calendar days of discharge and moderate medical decision making. If you're going to use 99496, again, you're billing this for the post-discharge visit when you see the patient. And it can be for newer established patients. Adirondack, if you were able to reach the patient soon enough to do that interactive contact call, you could still bill this for new patients. But the difference with 99496 that I think a lot of people don't realize is your documentation needs to support a high medical decision making complexity. It's not just being a patient within seven days of discharge. You know, you can easily, you heard me if you attended essential elements talk about what MDM is, and if that's something that you need additional information on, we do have an online course I'd recommend, or you can reach out to me and we can talk more about MDM requirements. Next slide. So before I move on, let me just make sure I don't miss any other questions. It looks like people are putting in the links for me. Thank you. How many people either raise your thumbs up with a reaction or put in the chat if you're billing for advanced care planning? I'm seeing some thumbs. I'm happy. You should be because you're all having these conversations. Good. So I'm not going to spend too much time talking about it. But what I wanted to make a point of covering is advanced care planning. If you're not, it's okay. We're still going to talk about it. So, Jennifer, you can still bill for it. It is an active work plan item on OIG. So OIG's active work plan items means it's a service they plan to highly audit. I do not, I'm an auditor and I'm telling you that should not scare you as long as you know what these requirements are and you're doing it appropriately. One of the regulatory task force that I work on actually, Dr. Chang and I were able to give some feedback to them and they actually had a call with OIG explaining the importance of these conversations and some of the barriers that providers face. So they really are making an effort to understand these services. So I do think that there's hope for this to possibly get even easier. The big thing that we're working on from an advocacy standpoint is there is a co-pay associated with advanced care planning if it's furnished outside of an annual wellness visit. If you do it with an annual wellness visit, you can use modifier 33 and there will be no co-pay. The patient will be responsible for a small, you know, co-pay billing this in conjunction with an E&M service. So we're working on that from an advocacy standpoint. But again, if we go to the next slide here. What advanced care planning really is from a billing perspective, you heard Ina have a great talk yesterday and Dr. Chang about the importance of these conversations with your patients. From a fee-for-service billing perspective, it's time-based. So you have to meet the time threshold. 99497 is the first 30 minutes. So we have CPT time rules that say if it doesn't specify a minimum, the time is attained when the midpoint is passed. And so what that means is if you spend a minimum of 16 minutes, only on the advanced care planning conversation, you can bill 99497. And this can be billed in addition to your E&M. You're probably going to need a modifier 25 with most payers to get it covered. Next slide. So here's what I would build as your template. These things in bold, this is what the template would be. Just so your providers don't have to remember what to document. And then what I would want you to do as the provider is fill in the details. The date of the encounter and who the individuals that were involved in that discussion were. So thinking about if it was the son whose healthcare POA document, who is present. What were the actual patient preferences? Sometimes I see this billed and there's so much great documentation, but I'm like, did you really have a close-up care conversation? Which you most likely did, but it didn't make it in the documentation. So it's with or without the completion of an actual formal legal form and advanced directive. If you don't get that post form or that most form signed during that particular visit, it doesn't disqualify you from billing advanced care planning, but you should have a clearly documented goals of care conversation. And most importantly, that total time spent. From an audit perspective, we always recommend start and stop times. It's not necessarily required for this code, but it's just a best practice. I need you to tell me you spend at least 16 minutes with the requirement. It also does require consent. Now, the language for the consent is focused on the patient or caregiver expressing voluntary, they understand what this conversation is and they're agreeing to participate in the discussion. CMS encourages you to make them aware there could be possible cost sharing because they don't want beneficiaries being billed for services they don't understand. But the consent is really, one of the things that we do with our practice is have these advanced care planning conversations. I'd like to talk to you and, you know, mom about if she didn't have decision making capacity, what that would look like. Build in that consent and then work with your front office on how they handle, you know, making patients on intake aware of all the services you're going to be billing. Next slide. So, how often can this be billed? There's actually not a frequency limitation. This slide is actually a little out of order. So, if we can go back. So, one slide, so I don't confuse people. I caught this earlier. I don't know when we were putting this slide back together. I must have gotten messed up. There's no frequency limitation. What CMS said is this can be billed as often as there is a change in health status. So, if you have to have an additional goals of care conversation or that you're following up because there still hasn't been a decision made on, you know, if they're going to be DNR or not, then you can.

building relationships

partnerships

value-based care

value contracts

clinical readiness

home-based primary care

COVID-19 pandemic

managing patients

practice management

ACO partnerships

clear communication

workflow

virtual visits

billing opportunities

transitional care management