Advanced Applications of Home-Based Primary Care-Virtual Workshop-Zoom Recordings Day 1 Part 1

Zoom Recordings Day 1 Part 1
Video Transcription
Okay. All right. So here's our day today. We do have a full one. You'll see that there are some breaks, both in the morning and afternoon, as well as a lunch break. All times listed  here are central. So between 12, 15, and 1, we'll break away for lunch. But you'll see the rest of the agenda there concluding at 445 Central Time. Next slide. And the workshop  objectives. So we're going to build on the experience from Essential Elements, for those of you who were part of that. Again, bring in case studies. We're going to get to meet  Minerva and spend quite a bit of time today exploring her particular case, and looking at it at a little bit of a higher level than maybe we did with Essential Elements. And  then tomorrow, we have the opportunity to discuss and see demonstrated and learn from experts on several procedures that are commonly done in home-based primary care. And I know  appreciate that. So I won't read through all of these, but hopefully, we're going to give you what you have come to this workshop for today. Next slide. Okay, we can move forward.  All right. So we do ask that you tell us a little bit about yourself. And you can use the chat box.  If you could please introduce yourself, again, by name, and what your role is  at your organization, and name that organization, if possible. And then if you would also include just one or two things that you're really hoping to get out of the workshop today,  that will help our faculty to make sure that we're tailoring the next two days to your specific  needs. So everybody can take a look at that. And yeah, so thank you, Renee. That's wonderful.  We'll give everybody kind of a minute to look at this. Hi, Josh.  And I know it's always so interesting to try to do these virtual introductions, and how we so wish we were in person. That is coming, you know. So if you have appreciated  your virtual experience here with us, and there are others in your practice or on your network that would like to go through these workshops, we're offering them in person. Again,  you know, COVID dependent, you know, that everything continues on the trajectory that we're on. Those are coming in December. We'll be in Orlando, Florida, December 2nd and 3rd.  And then in Schaumburg, I'm sorry, we're in Orlando for Essential Elements of Home-Based  Primary Care, December 2nd and 3rd. And then in Schaumburg, Illinois, which is HCCI's headquarters  outside of Chicago, on December 9th and 10th for Advanced Applications. So I'm seeing the  introductions come in. And I know our faculty will be reviewing those. And we really appreciate you sharing that. And would love to learn more about coding. Renee, that's coming.  So just wait. We can go to the next slide. All right. And I'm pleased to introduce our faculty.  So Dr. Thomas Cornwell is going to be here tomorrow with us. And just a shout out for him because he's HCCI's founder and Executive Chairman. He's also currently Senior Medical  Director at Village Medical at Home. And I know you'll appreciate his expertise when he is with  us tomorrow. And Dr. Paul Chang is Senior Medical and Practice Advisor at HCCI and Medical Director  of Northwestern Medicine's Home Care Physicians. And you see that little blurb there. Dr. Chang  recently made his 35,000th house call. And you can read his bio in the workbook. It'll tell you  about how he was House Call Physician of the Year a couple years ago, named by the American Academy  of Home Care Medicine and many other wonderful things about him. But I know he wants me to say  that at the end of the day, he is a happy house call doc. And I know you're just going to  really appreciate hearing from him. Michael Kingin is a Geriatric Nurse Practitioner at Johns Hopkins  Medical House Call Program, known as J-Home. And Michael's been a nurse for over 20 years.  He's been a faculty for us since the inception of these workshops. And he's worked in acute and  subacute and community care settings. He was Director in the Quality, Safety, and Education Division at the largest hospital in Washington, D.C. And he has numerous memberships and  accreditations, certifications rather, and is an expert in one care, which he's going to cover  tomorrow, but so many other things. And so we welcome Michael to the faculty. Brianna Plentsner  is the Senior Consultant and Manager of Practice Development at Home Centered Care Institute.  And Brianna is a Certified Professional Coder and Medical Auditor. And many of you have heard her speak before. She's been a member of our faculty from almost the beginning as well.  And is a great resource for coding and all things practice management. And then finally, Amanda Tufano is the CEO of Genevieve. And there she leads a team of over 180 people,  including physicians, nurse practitioners, nurses, and social workers. And they're deployed throughout  the Minneapolis-St. Paul area and greater Minnesota. And, you know, she's just been phenomenal. A longtime faculty member for HCCI as well. And so I'm really excited about what  you all are going to get to learn over the next couple of days. So I think with that,  oh here I'm going to, I want to let you know that our activities are all supported through a grant  from the John A. Hartford Foundation. And we are tremendously grateful for that. And then next  slide. All right. I'm going to get to turn it over to Amanda. Good morning. Thanks for the very  generous introduction as well. I was taking copious amounts of notes of where you're all from,  but it looks like a smattering of all over the United States. This is a really fun opportunity to  certainly learn from the course, learn from the faculty members, all of whom are smarter than I am,  and learn from each other. So, you know, how you use the chat and how you get to know each other  and our time together for two days. What I've seen since COVID has happened is I think we've  made the very best of virtual interactions. And so as much as you can interact when you're feeling  the moment to turn on your camera, certainly do. We're happy to have you here.  So some of you are coming off of Essential Elements, some of you are not. We're going to  jump right into some of the pieces of value-based care. So here are some of our learning objectives  in our short 30 minutes introduction to this. And we'll be touching on value-based care  in all of the conversations today in some way or another, but we'll have some more pointed than others. So, you know, one is how do we think about the shift from Medicare,  from other payers, from what we need to be successful in the United States as we shift into value-based care, and what does the business space look like? How do we think about  the quantifiable terms of a home-based medical practice and the demographics for the patient  populations that are best cared for in their home? We're going to talk a little bit about the IHI and the John A. Hartford Foundation, 4Ms of caring for older adults, as well as  the later introduced multi-complexity that makes it a 5thM. And then we'll start this introduction  of your HCCI learning plan. So for the whole two days, the staff will walk us through how to make  the most of the learning plan. And so what we see is those who really fill it out and use it can go  back to those notes later on and find a lot of value and cut through what were the most important things for them during our time together. So that's a good opportunity. Slide.  We're going to watch a video from the founder of HCCI, Dr. Tom Cornwell. And so it's about 15, 17 minutes long. Thank you.  My name is Dr. Tom Cornwell, and I'm the executive chairman of the Home Center Care Institute. I would like to welcome you to our presentation  on Home-Based Primary Care equals Value-Based Care.  Our learning objectives are to describe home-based primary care in the U.S. and explore the socioeconomic drivers and the business case for home-based primary care.  We also want to demonstrate in quantifiable terms the value of home-based primary care and assess the role of new supportive payment models. We also want to discuss the alignment of  home-based primary care with the geriatric five N's, which stands for what matters most,  mind, mobility, medications, and multi-complexity. So what is home-based primary care? Home-based  primary care brings providers as well as modern technology into the homes of mostly homebound  patients in order to improve their quality of life, the lives of their caregivers, while reducing  health care costs by enabling them to stay at home and avoid hospitals and nursing homes.  A perfect storm of forces is fanning the sails of the modern house call movement. Just some of these include the aging population, advancing technology, increased home and  community-based services being funded by the government, the value of house calls, and payment reform.  The first force is the aging of society and the cost of increased chronic disease burden.  The extremes on this graph are surprising. The least expensive 50 percent of the population  consumes only 3 percent of total costs, but conversely the top 5 percent consume 50 percent  of costs at over $50,000 per patient, and the top 1 percent consume an astounding 23 percent  of all the costs at an average cost of over $100,000 per patient. These high costs are caused  by our fragmented health care system that is not set up to care for the sickest patients who are  often homebound. Bringing home-based primary care to these patients has been shown to dramatically  improve their quality of life and, again, the lives of their caregivers while reducing these health care costs.  Advancing technology is another force. I like to say that house calls are principally high-touch  primary care in the home, but we also have the high-tech capability to provide quality care in the home. Just some examples are smartphones that can do rhythm strips in seconds.  They have numerous apps now that I can do vision testing, drug databases, decision support, and much  more. Portable x-rays and ultrasounds can be done in the home. Labs can be done in the home, including  point-of-care testing, as well as we can draw blood in the home and spit it down in the car in a  centrifuge that's plugged into the lighter. Modern technology has enabled me to do more in the home than most primary care practices can do in their offices.  The third force is increased funding of home and community-based services. Government funding of  long-term support and services are made up of institutional care, nursing home care, and home  and community-based services. This graph shows that back in 1983, 99% of all funding went to  nursing home care, so your only option if you needed help was to go to a nursing home. Over the  past two decades, there has been a remarkable shift in funding, where now over half of all  the dollars goes to home and community-based services, and this enables nursing home-eligible  individuals to remain in the community. These individuals create an increased demand for  home-based primary care. Recently, there was a study in the Journal of the American Geriatric  Society showing how integrating home-based primary care and home and community-based services delayed nursing home placement by 13 months.  A major force has been the data that has come out showing the value of house calls, but before getting to the data, I wanted to share a couple stories illustrating just how  valuable this care is. Our first story is about Amanda, who when I met her in June of 2017 was 34  years old, suffering from type 1 diabetes that she had had since she was a child. She had kidney  failure and was on renal dialysis. She also had coronary artery disease and already had had four  stents. She also suffered from chronic pain. In the four months before we saw her, she had been in  the hospital 30 percent of the days. We were able to dramatically reduce that over the following  seven months of 2017. In 2018, she was so much better that she did not spend one day in the  hospital and sent me this wonderful picture of her at an art festival in the fall. In 2019,  she did go back to the hospital because she'd gotten so much better that she now qualified for  a kidney transplant, and she had a kidney and pancreas transplant which cured her of her diabetes  and removed her need for dialysis. What a joy to be able to give someone their life back like this.  Elsa was born in Germany in 1921 and came to the United States after World War II.  I was called out to see her to fill out nursing home paperwork. When I met her, I learned she was  no longer able to get out to see her doctor because of her right foot being amputated and  her left leg being amputated and had been in the hospital six times over the previous four months  because of multiple chronic problems including heart failure and diabetes and pressure sores.  The patient shared with me that part of the reason she lost her legs was from frostbite caused by cold winters in a concentration camp. Through quality home-based primary care,  we were able to quickly get her heart failure and diabetes under control. We ordered home health that  she was previously not able to get because there was no doctor to sign orders. We got her a hospital  bed and enabled her pressure sores to heal. She got so much better that we were able to arrange and pay for transportation to an outpatient rehabilitation center where she got new  prostheses so she could actually walk again. Over the next eight years, she only went back  to the hospital twice. Besides powerful stories, we also have compelling data such as from the VA's  home-based primary care program, which is the largest home-based primary care program in the  country. The program's director, Dr. Tom Eades, about 2005, was told to cut the program because  they were spending $11,000 more per veteran sending doctors and nurse practitioners and  physician assistants, mental health workers, and others into the home than usual care such as home  health. Dr. Eades asked to have all the cost data reviewed and they went back to 2002 and what they  found, I think, even surprised Dr. Eades. They found an 87% reduction in nursing home use, 87%. They found a 63% reduction in hospital use, an overall savings of $9,000 per veteran,  and when you multiply that by the 11,000 veterans in the program, it came out to $103 million savings by giving them $11,000 more care in the home, by giving them what they wanted.  As a result of this data, the VA program has grown to over 30,000 veterans and would serve even more were it not for the shortage of providers. This data also led to significant  support for home-based primary care on Capitol Hill and at CMS. The last part of home-based  primary care's value equation I would like to discuss is cost-effective quality end-of-life  care. The last year of life is the most medically expensive, consuming 25% of all Medicare dollars. 70% of Americans say they would like to be at home at the end of life,  but in 2009, only 33% died at home. Hospice use markedly increased over the past decade from 22%  to 42% and is now up to 50%, but also over the last decade, ICU stays in the last month of life  increased to 29% and hospitalizations in the last three months of life went up to 69%. End-of-life care at the house call program I founded, Northwestern Medicine's Home Care  Physicians, is much different. A quarter of our patients die yearly and over the past five years, 76% have died at home. 77% were on hospice and the median house call length of stay  that they were on our program was 1.3 years, and so we covered them during that costly last year of life and dramatically reduced hospitalizations. One side benefit to this is  because we have so many patients pass away at home and less go to the hospital, we actually  were able to help reduce our hospital's mortality rate, which is another selling point to health  systems. The last force we will discuss, which is helping to expand home-based primary care,  is payment reform, and we're going to start with fee-for-service. We have seen an increase in  fee-for-service payments to support house calls. As you can see in the slide, over the past two  decades, payments have doubled for both house calls as well as assisted living facilities, where now I am getting paid over $180 for a typical house call. Medicare has also created  new payments that support house call providers, such as advanced care planning, chronic care  management, transitional care management, and for prolonged services before or after a visit for things like reviewing medical records. A great example of value-based payment reform  is the highly successful Independence at Home Medicare house call demonstration that began in 2012. The ongoing demonstration involves 14 experienced home-based primary  care programs that care annually for over 10,000 medically complex patients with functional  impairments. IAH is a shared savings program where the first 5% of savings goes to Medicare.  Additional savings are split with 80% going to practices if they meet the quality indicators  and the remaining 20% going to Medicare. IAH has been Medicare's most successful demonstration.  It improves quality and patient satisfaction while reducing hospitalization and emergency department use. This has resulted in cost savings of over $100 million in the first  five years, which came out to over $2,000 savings per beneficiary. Cost savings paid for the program and qualifying practices received a share of the savings. Since its launch,  the three-year demonstration has been extended twice because of its success and interest in becoming a new Medicare program. The most impactful payment reform is the new value-based  models. CMS has announced new value-based programs such as the Primary Care First program that would pay a per member per month fee for complex patients as well as a visit fee  and would provide shared savings. There's also the possibility that home-based primary care  programs could come together to participate in the direct contracting program where currently  you need to have 5,000 Medicare beneficiaries. These programs are rewarded from the cost savings they generate from the wonderful care they give in the home. The last thing I want  to say is we are seeing venture capital come into this space to start home-based primary care  and again take risk on these patients and share in the cost savings. Successful programs have  also contracted with Medicare Advantage programs for per member per month payments on their  costliest patients as well as participate with them in shared savings that has helped increase  revenue to their programs. With these forces creating a huge demand for home-based primary  care, now we need the workforce. Over 2 million patients could benefit from home-based primary  care and this number is expected to double over the next 20 years. Only 15 percent are currently  being served. Imagine if only 15 percent of oncology patients were being served. Currently  there are about a thousand house call providers that make 500 or more visits and their distribution  can be seen on this map. What you can also see is that there are 13 states that do not have even  one high volume house call provider. We need about 10,000 providers in order to meet the need of the 2 million patients that are homebound in this country.  The geriatric 5Ms is a framework for caring for complex patients. As you'll see these geriatric 5Ms  align perfectly with the home-based primary care model. This is what we do every day. The first M  is what matters most and it is the one that matters most. We need to understand health goals  and preferences of our patients. We need to help them consider what they want to do with their  We need to help them consider prognosis and medical decision making, take into account risks,  burdens, benefits, their functional status, and quality of life. We need to make sure a person's  goals and care preferences are reflected in their treatment plans and most importantly that they are  honored. Finally, we have to help coordinate advanced care planning. The second M is mind and mentation. We need to help them maintain mental activity, help manage their dementia.  We need to help treat and most importantly prevent delirium and work to evaluate and to treat  depression. The next one, mobility. We need to help them maintain the ability to walk and improve  their balance, improve their function. We need to help prevent falls and other types of common injuries and we need to help create home environments that facilitate mobility and  nothing better than home-based primary care can do that because we are in the home to make that  happen. Medications. We need to help reduce polypharmacy through deprescribing and we need  to help optimize medication for an older person's needs. The fifth M is multi-complexity. We need to  help older adults manage a variety of health conditions. We need to assess their living conditions when they are impacted by age, health conditions, and social concerns. We need to  optimize therapies and care plans. We need to choose therapies that optimize benefit, minimize harm,  and enhance quality of life. And again, the most important M is what matters most to our patients.  So what are some of the key takeaways? We have reviewed the converging forces that are creating  a tremendous demand for home-based primary care. We have also seen the great value that comes with  home-based primary care and how it is being rewarded by the new payment models. In order  to meet the need and realize the value though, we must expand the workforce because if we don't,  the vast majority of those patients who need home-based primary care won't get it.  Thank you for that video. I think as you guys probably know, we have been doing a lot of  work on this. I think it is important to continue to fill out the learning plan and we will talk  more about that. But also, you know, how is this and everything that we are outlining truly a  solution for, you know, how is this a solution for, you know, how is this a solution for, you know,  is this and everything that we are outlining truly a solution for the IHA quadruple aim, right? And everything Tom is talking about, how do we improve quality, lower costs,  improve the patient experience, meet them where they are at, and improve the clinician experience.  We will keep talking about this piece and I do a talk on burnout later, but the opportunity to do  home-based medicine improves vocational interest and attaches to mission where never before.  And a lot of what we get together, what I have learned over a couple of years of being faculty  here is it is not necessarily about all of the clinical pieces as much as it is demonstrating  the business value to others of why this should be funded, how we should do this, why it should  be supported, how it should be well-resourced. And so, those things we kind of continue to talk  about. One thing that Tom really hit on in this video was these four M's. So, the IHI and Johnny  Hartford Foundation formed the four M's that you see today, and mind, mobility, medications, and  what matters most. And then the age-friendly health systems added a fifth of multi-complexity.  And that really creates your geriatric five M's. I think about this as a framework. So, you may not be as familiar with this. Some people have really adopted this framework already.  All of the tools that you put in place, you may think of Staples as your organization does those things. But if you step back just one more step, I think in the next five years,  we're going to see this type of framework and then all of the application of what we do become  tools to test against the framework and these five things if we're getting them right or wrong.  If you also put this in a, and this is what our organization has done, if you put this in a graph  and you say, you know, let's do a true gap analysis of where our tools, you know, meet where someone  is at in these five. And where do we not have tools? And we have a big opportunity to focus  on a new area. We have a big opportunity to focus on de-prescribing or whatever that might be.  Make a gap analysis using a framework like this. Certainly HCCI supports it, but as years go on,  I think this is going to be really important. I'll take another slide. So again, this health and aging added this multi-complexity piece. Multi-complexity really describes the whole  person. So typically an older adult living with multiple chronic conditions, advanced illness,  complicated psychosocial needs. And so when you start to think about this, think about kind of  this PDCA or PDSA, how do I plan, do, check and adjust? And we do this from a clinical standpoint  through and through, and we do it from a business standpoint. And so we implement these quick  measures of, I tried something, I did it work. Do I need to adjust it? Do I need to rethink about  my approach for this? So multi-complexity gets again added as a fifth one from health and aging, as you think about the framework. So, you know, before we go into introductions,  which I'm looking forward to just a couple of things as we set the stage for the two days here,  you know, there are a number of these industry forces kind of coming together to say primary care is poised to grow. It's poised to be well-funded. It's poised to be vocationally  interesting and a solution for stress and burnout in our field. It's the right thing to do. It's  mission-based work. How do we add and continue to prove this tremendous value and lower the cost of  care? And then as these new payment models are coming in, and we'll talk a lot more about that  too, because Tom referenced CMMI direct contracting and primary care first, and CMMI has put a pause  on some of these new entrants for programs. We'll talk about what are other options and, you know, how do you think about generating your value and who do you contract with and  what does that look like? And there are a number of resources available with HCCI as well, but  these new payment models are starting to create a sustainable environment, a thriving environment  for practices focused with these right mission-based work and home-based primary care that  isn't just the churn and burn of fee-for-service. So it should be a fun two days and I welcome you  to this. Now we're also going to take this opportunity to do our icebreaker. So if you would turn on your cameras and so everyone can introduce yourselves and we're going to kind of  talk through, you know, we saw where you're from, but just probably a very short where you're from  and what you want to get out of the two days, what you're excited to be here around, and welcome back  to some of my colleagues I saw last time on the essential elements. Yeah, here I can kind of get  our round robin going. And let's see, Amanda Henning, we're going to pick on you first. That's fine.  Can you just share, so can you introduce yourself for the group and remind us what you'd like to  get out of the next couple of days? Sure, my name is Amanda Henning. I'm a nurse practitioner. I am  a specialty certified in geriatrics. I've been doing home-based primary care for almost five  years. Really exciting in December of 2020, they actually let me leave office work and I'm doing  this full-time now. I have over 110 patients I see. I cover probably 200 square miles of patients  and I'm a solo provider. So it's gotten pretty difficult because my numbers continue to climb.  So I really want to work on like learning how to schedule better. I try to schedule for location,  how to approach those specialties to beg them to go out to see these patients.  I don't know if you guys have any resources. I'm trying to do a transportation grant for my  patients because a lot of them are very poor and I can't get them out to see their specialist.  And then the other thing is how to do this and keep family work balanced when you don't have  a staff in place yet. But that's pretty much what I'm here for, for the next two days.  Well, thank you, Amanda. Wow. Home-based primary care is tough anyway. And so as a solo practitioner,  I just, I really applaud you. And I know our faculty will strive to help you achieve your goals for this. Thank you. So how about Anna Devenney?  Hi, good morning, everybody. I'm excited to be here today and tomorrow. So first of all, I wanted some mental space and the best way to get mental space to kind of think through any  project is really to go to a conference so that you don't have to do other work at the same time.  so that's number one. And then I am at Penn Medicine, I'm in the Department of Family Medicine, our primary practice is 22,000 patients, and I'm primarily office space. But  out of those 22,000 patients, we've identified about 700 that would benefit from home based primary care. I see 62 of them  on a half day a week. So my goal is to figure out the business model for building it out. Who do I need on board? How many  other providers do I need? How many staff do I need? And then how is that going to get funded? So nothing happens without that  return on investment model. So that's kind of what I would really like to get out of the next couple days.  Thank you so much, Anna. All right, how about April Odom?  Good morning. My name is April Odom. I'm a family nurse practitioner. I'm in Illinois. And I was a home health nurse years ago. And I opened my own practice in 2017. But I was  initially cash based and I was doing just some cash based services. And last year, in end of 2019, I had started to do the insurance panels. And of course, one of the first was  Medicare, and then the pandemic started. So last April of 2020, I started doing house calls, because I know there was a need  I knew patients were out there that needed to be seen, and they virtual visits weren't working. And since then, I started with  two patients on April the 30th. And I've grown, I have over 150 patients now, and it's just me. So I think it was a mandate, I  was saying being a solo provider and trying to manage has been so difficult. But I service almost anywhere in Illinois, but I go  as far as Aurora, which is probably about 40 miles from me.  And as far north, all the way almost to Wisconsin sometimes. So I'm taking care of the patient. So I'm here to learn as much as I can, as far as scheduling and hiring resources  for referrals, which is another big thing and just managing the patients appropriately and responsibly.  So I'm here to soak up everything I can get today, because I need it. So I haven't taken any educational courses since I started this. So this is a treat for me.  Well, thank you. And you know, we're in the Chicago area, too. So we're glad to meet you and have you be part of this workshop. That's great. So thank you. All right, let me see.  Bilal Malik. Hi, so I'm Bilal Malik. I'm a family physician, recent graduate from residency. I was interested in kind of home house calls  during my residency training and wanted to continue doing it afterwards. So I started my own independent practice in Southeast  Michigan. Started last September. I have a panel of around 40 patients that I see a few days a week and on weekends and evenings. Also palliative medicine fellowship. I did it  while I was starting to practice. So just trying to learn more about how to balance things, slowly grow the practice in a manageable way, and kind of best practices in terms of  scheduling and hiring staff. I'm looking through those things next.  That's great. Thanks so much. You know, getting a really good rotation in residency programs across the country is definitely  one of HCCI's goals. So I love hearing that, you know, someone who's just come out of residency and identified this as a, you  know, a career path and, and a passion. So thank you so much.  We may circle back around to you as we're helping other residency programs to how we can inspire other other residents. Thank  you. All right, so I've got Cliff now. Cliff from Premier.  All right, wait. Okay, I'm going to circle back to Cliff. How about Dr. David Rader? Are you on?  I'm here. Hi. Hey, how are you today? Good. How are you? Welcome back. So I'm the medical director for Premier Medical House Calls. And we're in Alabama. And I was trying to  figure out how to get a job. And I was looking at a lot of  and I was trying to figure out exactly how many patients were taken care of now, but it's somewhere between I think six and 800 patients. And collaborating with two nurse  practitioners and a physician assistant. That's where we are.  All right. All right. Thank you very much. And I know you've got a team here. And Cliff, I know you you were able to join us  last minute. And we're so glad you're here. Would you like to introduce yourself? And you're on mute.  There we go. Yeah. Hi, I'm Cliff Arsenault. I'm a physician assistant. I have been doing house calls part time for nine years with the geriatrics practice. And I recently started  work with Dr. Rader and his practice with Premier Medical House Calls about three weeks ago. So that will be a full time  gig doing house calls. And I, I enjoy it. I actually tried to start a house calls business as a solo practitioner, back in  2006, when I first graduated from from, from school, and it was a spectacular failure. So we're hoping to do things better  this time. Because it's tough doing it by yourself and then trying to trying to navigate all that. So looking forward to learning tips and tricks and new things and how to do things  better.  Well, welcome. And HCCI has had some behind the scenes work with leaders at the American Academy of Physician Assistants, hoping  to get more PAs to do this to do this work. So we're glad that you're that you're part of this workshop. Thank you. And Greg  Tisdale, I had the pleasure of speaking with Greg not too long ago. Are you on Greg? Yes, I am. Good morning. I'm Greg Tisdale. As she said, I am  from the Jackson, Mississippi area. And am currently in the process of getting my home based primary care practice off the ground. I'm still working through credentialing and  getting set up with my EMR. So I've not started seeing patients yet. But hoping to do that within the next month and a half. So I, I relate to all of you solo providers, because  right now it's just me trying to learn any and everything that I can. So I'm just here to be a sponge and soak it all up.  Well, thanks, Greg. Welcome. Joshua Pope, another premier staff member. Is Joshua on?  He says he just got kicked off. He's trying to log back in. Oh, okay. Sorry about that. Help. We'll circle back. Karen  Jackson, are you on?  Good morning. I'm Karen Jackson. I'm a geriatric nurse practitioner in Pensacola, Florida. I own Beacon Medical. I started out as a solo practice. I've been doing house calls for  other people for 14 years. And then I owned part of another practice at one point, and then I decided that I was going to go out on my own. I am now three years old, I have nine  providers, and almost 600 patients. And I have a total of 22 staff. Altogether, we do have a scheduler. Now, we have a biller, we do all of our billing in house, we have only nurses  in our office, we've actually been very healthy. But in the panhandle, of course, there are a lot of geriatric patients that need home care. And my goal is to keep people out of the  hospital. And we're very successful with that. We have probably about a two to 2.5% rehospitalization. I work with all the home health care agencies, they have all bought  into what we're doing. They absolutely love Beacon Medical. And I am growing by leaps and bounds, I'm getting probably 50 to 60 new referrals a month right now. So there's a lot of  people here. If there's anybody on the call that would ever like to, you know, reach out to me, because my goal for being here  today is I want to see how other people are doing it. I always want to grow, I want to do more, I want to take care of this population. It's a very, they're just, it's a very high  service need. And it's my passion. So we do, we can do anything in the homesteading that can be done in basically in the hospital, we do a lot of IV antibiotics, IV fluids, we have  radiology that we can do in the home, we can do EKGs, ultrasounds, Dopplers, anything, we've got a phlebotomy team that goes out and draws all of our blood, collects our urines. So  we have a great team of people that work with us that we've just kind of bought into, we've built relationships. I'm a firm believer that the more relationships you have, the  stronger you can be. This is not something that you can do alone. If you think that it's your sandbox, and you don't want  anybody to play in it, then you can't, you're not going to be successful in this, you have to incorporate all the parts of the  team, you have to be respectful to the provide to the nurses.  With home health care, you have to be respectful to hospice, we're really into the right level of care at the right time.  But that's what I'm looking for today is I just want to see how everybody else is doing it. I have this premier medical over  in Alabama, kudos to you. I live in Alabama, I've been driving over to Pensacola for 14 years to work. Because I just, but I  have a great passion for the people in Alabama. So good luck, you're going to do great. Have a great day, everyone.  Well, Karen, thanks so much. Hey, we have a great project in Florida. I don't know if you followed it on our website, we have the Florida house call project. And we have 12 home  centered care champions dispersed around the state.  Nobody in Pensacola because I don't think we knew about you. So but we would, I'd love to maybe chat with you at some point about that project. And, and you can see some of the work  that our other champions have been doing. And just a little bit of explanation of we do want to try to facilitate as much as  possible the networking of this group. And, and so you'll be invited throughout the next two days to share whatever information you're comfortable with sharing with with the group  in there. If you know if you want to put your phone number or your email or, you know, and invite others to reach out to you directly. You know, we hope you'll do that and feel  comfortable sharing within this within this group. So let's, let's move on. Is Joshua Pope back? Maybe not. Maybe not Okay, I'm gonna move on Karen Thurman.  Is Karen on? I'm here. Hi, Karen. Hi, good morning. I'm Karen Thurman. I'm in Katy, Texas, which is just west of Houston. I'm very new to this. I came from the skilled nursing  world and joined accredited group and we currently have a hospice company and the team and the administrators have really just seen the need for home care primary visits and we're  looking to start that and so unfortunately I didn't find HCCI until after your essentials. So I went ahead and jumped on here  but I really am looking forward to learning from everybody here who has so much experience and just to kind of get this going so brand new baby steps.  Well, Karen, don't let don't let that intimidate you at all. I think this is a great place to jump in so don't feel like, like  it's not. And, and we have a number we work with a number of hospice and palliative programs that are adding home based primary care as a service line, sort of recognizing that it's  the full service solution for people with serious illness who can't get to an office for longitudinal primary care. And,  and so it's it's a wise move on the on the part of your organization to add this so welcome. Thank you very much.  All right. Um, and so I know we've we from payloads is it Veronica? Do you go by Veronica or Maria? Terala?  Oh, I'm sorry, I hit it. And you did. I go by Veronica, but my full name is Maria Veronica Terala. So I joined payloads, not payloads, Northwestern Medicine. And I joined them  about two and a half years ago for the palliative program. So I'm a palliative care provider. And one of the reasons I'm here to learn from you guys is because, you know, all of our  patients don't just have palliative care needs, you know,  they have primary care needs, and most of those patients can get to their providers. So I end up doing much more than just palliative care and transitioning them into hospice  when when they're ready.  That's great. Thank you. Thanks, Veronica. Nicole Bateman.  Hi there. I'm a PA in Northeast Oklahoma, Miami, Oklahoma. And I'm the lead clinician for a community paramedic program. However, our patient population is really, you know, CPP  program is really geared to onboard patients, give them their resource options, help them really access care, and then offboard them with the intent that they sail off into  the sunset being able to manage their own health care. But our patient population just isn't really capable of doing that we  have an aged population and they need more support than that. So  COVID really disrupted our program significantly. And I was the outpatient COVID collector, which is I guess maybe like being the tax collector in the Old Testament, maybe. But that  completely disrupted our program. And so I'm really looking to restructure our home visit program and house call program into our outpatient primary care setting with our  outpatient clinicians. Our patients need longitudinal ongoing home based care. That's really where our patient population is. So I'm looking to find tools to make the sell to  our administrative leadership. We're transitioning to a rural health care initiative model as of January. So I really want to  integrate that into that model. Instead of a cost avoidance program, I'm providing medical services to patients and I should be reimbursed for those services that I'm providing. And  so that's really my goal today is to network with other people and find the tools to develop that proposal to my leadership.  Well, you are singing our song about the value of home based primary care. And that's a huge part of what the next two days is about. So I'm pretty confident you're going to get  some help in that. And hopefully we can also all learn from each other, from others experiences. So thank you, Nicole. Sounds great. Thanks.  All right. How about Millicent? Millicent Malcolm? Yeah. Hi there. Thanks for having us again. I really enjoyed the first workshop. And actually, since that time, well,  for those that weren't on, I've been doing home visits for 21 years. I've been a geriatric nurse practitioner for that long  and I started in the office and patients weren't coming in because they were too sick. So I started going out to them and  then started doing that on my regular basis. You know, because I was the only person kind of in our whole, we have 13 primary care offices, I'm the only person doing routine regular  house calls. You know, it kind of burns you out because you don't have, you're trying to fit into the office model and you  don't, it's just different. So I kind of actually continued the work part time and I become an associate professor at the UConn  School of Nursing. So what I did with that is I married my work in the School of Nursing with the problems we saw in our clinical practice with older adults going to the emergency  room, you know, me as one provider, not being able to service all those with high need. So we did a, we got a grant from HRSA, a $1.4 million grant to do an interprofessional  collaborative geriatric home visiting program for workforce development. We had 264 students from family medicine residents  to nurse practitioner students to licensure nursing, social work, PPE, pharmacy, dental, and public health. And we had a  really integrated robust program that we really, it was more for workforce development, but we did have to measure outcomes for HRSA in our vulnerable population. We had like a 36%  reduction in ED use. We had, we've gone and done secondary analysis on our metrics and the cost saving and looking at factors of those patients that are most likely to have high  costs, kind of targeting those. So, you know, we're all excited about this because we, we put together the findings and use  the IHI age friendly metrics and IHI quadruple aim, which we used and kind of gave an initial pitch to somebody from strategy  in our, in our system. And it was kind of like, well, yeah, you're going to increase services to some of our other resources like home care and palliative care and you know,  home draws, et cetera, but those services already don't make a lot of money. So, you know, it, it just disappointing in terms  of how you have to sell this, knowing the value, knowing, and I think it, it's really, you know, for some of us, it's going to take, I'm in central Connecticut, you know, that the  joint replacements are king, you know, and, you know, so we're competing for, for funding and COVID times for programs, you  know, and, and it's kind of the strategy as well, go back for another grant and, you know, this shouldn't be a grant funded  work. This is, this is work that has proven value. It's just trying for me trying to make that case. So this, these workshops have been incredibly helpful for that, you know,  being a clinician for a long time, I, I, I appreciate hearing the case studies and kind of saying, Hey, this is, you know, I'm on track, but hearing the business case and  making the business case is really like, so important. So thank you for providing, you know, the whole, the different varied options in the workshops.  Well, you're, you're welcome. I know we're going to talk about,  about value, about preparing for value based payment, about negotiating those contracts, you're going to get some great content, I think through this workshop, but, but continue to  stay in touch with us through the next two days, if we're not touching on the points that you think are going to help you. But  yeah, it's, it's, it's tough. How about Patrick? Patrick Owensby? Hey, good morning. Glad to be back. Had a great time. Back in  April, I'm here with two of my colleagues, one that attended last time with me, Dr. Walker, she's our medical director for  our House Calls program on staff at Carolina Caring, that's, I'm sorry, I left that out, Vice President of Home Based Primary  Care at Carolina Caring and Telios Collaborative Network. So we are in the throes, like, like many on here, launching a new  House Calls program. So Dr. Walker is our medical director, and then Dr. Walton, actually, Renee is, she's a DNP, she's our  first nurse practitioner for our program. And so she started with us just a few weeks ago. And so she's attending with us today.  And we're really excited because we have a meeting, follow up meeting with an independent living facility in our service area this coming Monday, and we'll potentially be serving  those patients in the next couple weeks. So we're excited.  We're finishing up our EMR build, and credentialing, you know, kind of like what Greg mentioned. And so hopefully, we  will be seeing our first patient in the next few weeks. So we are excited about that. And, and basically, you know, here today  to learn from some of the experts and, you know, get some more information on how we can provide, you know, quality efficient care to this patient population. So yeah, glad to be  back.  Yeah, thank you. And that is great news about getting connected with an independent living facility. I mean, for a new program, that is often a very effective way to get  started, you know, where you can group your visits in a facility like that. So why don't we go to Laura Walker, Dr. Walker, to introduce yourself. We'll tag on.  Good morning, everyone. I'm Laura. I'm a family practitioner, I have done a variety of things in my career, and including rural family medicine, worked as a  hospitalist, spent five years doing non patient care leadership activities with being the chief medical officer for two different accountable care organizations, and did a lot of  work in clinical informatics and quality during that time. But my heart brought me back to patient care a couple of years ago, I  spent a year as a sniffest. And then, most recently, a little over a year ago, I joined Carolina caring to work with their hospice program. And that has just been the perfect job  for me. I love it. Best job I ever had. And Carolina caring is a very progressive organization here in North Carolina. We serve  about 12 counties. And we prior to our house calls program coming up, had footprint in the pace area, as well as hospice  and palliative care, a couple of inpatient hospice units and a big population of palliative care, and home based hospice patients as well. And so bringing up the house calls  program for me, has been an exciting new challenge kind of dipping into some of the things that I worked with in the past,  as well as a completely new area that I have never worked in before. And so when Patrick and I attended the essentials program back in the springtime, it was very helpful for me,  because I prior to attending that I kind of couldn't mentally connect the dots about what we were doing and why we were doing  it. I just I was I was just not quite getting there. And so so attending the first seminar was just terrific, terrific in terms of learning from the other clinicians and practically  understanding what a house call visit looks like and the capabilities and limitations and, and that's been helpful. And  then the second part, of course, the administrative and business case for all of this also started to gel in my brain. So  we're totally excited that we're almost ready to start seeing patients and Renee has come on board. And so it's great to be back and really looking forward to the next couple days.  All right, awesome. And Renee, do you want to just say hi? And well? Yes. So my name is Renee Walton. And I'm here in Charlotte,  North Carolina. And like Patrick stated, I've just started working with Carolina caring with the home based primary care  company. I've been in house calls really, since 2009. I was just thinking sitting here. I remember going to a company called Excel Health here in Charlotte. And Excel Health was  bought up by United Healthcare. We were working with them peering into their house calls company. And I remember working house  calls. And I was like, this would never get off the ground. And it was like about five of us working in this area. And the  company grew so much that we went from seeing like about 100, you know, visits per month to like 250,000 visits per month to  you know, over two to 3 million per year. And working in house calls going from clinical to then a leadership role and helping to write the policies and procedures for the house  calls program, up until now, where I'm back in clinical where I feel like I was born and bred to do house calls. From that  perspective, I'm just overjoyed at you know, getting to help start this program. I'm looking forward to our first day. And I  feel like this is where I've always meant to be in nursing. And I'm just happy to be here. So thank you.  That's wonderful. Thanks, Renee. You know, and we've got a few more folks that we're gonna have introduced themselves. You know,  I'm going to give a shout out to Sarah Wright, who was had to be up very early this morning, I think on the on the west coast.  Sarah, are you? Are you there to introduce yourself?  Yes, I am. Thanks, Melissa. I'm awake. I'm okay. I am a physician assistant with Stanford Home Based Senior Care. So I'm I'm lucky to be like affiliated with Stanford, like  an academic medical center. I'm so impressed hearing from all of you who are doing this independently. I'm a new provider. So I'm almost a year into this job. But I do have  like a wonderful medical director who's worked really hard to advocate for this program. And it's continuing to have to advocate for more resources. And you know, that's  one of the challenges of being part of this is that we have to get approval for pretty much everything that we're allowed to do. So I'm hoping to be a better advocate in that way on  my team, we have like an NP, our medical director, who also runs Stanford Senior Care. So she has a lot going on. It's basically APPS, you do all the house calls, and then to social  workers who are like, you know, real life superheroes and do amazing things for our patients who need a lot of help. But  basically, I'm here to become a better home based care provider and here, you know, and be inspired by everything you all are doing. And yeah, I'm glad to be here.  Well, thank you for joining us and for getting up early. I hope we make it worth it for you. And all right, Caitlin, super. Are you on?  Caitlin, I'm here. Hi. Thanks, Caitlin. Super. I'm a nurse practitioner, and I work with life spark health and our home based geriatric care program, and the clinical manager as  well and working on getting the program up and running. We do value based contracting with health plans, health systems,  and Medicare. I should mention also, we're in the Twin Cities area, and the greater metro. Well, there's really nowhere we  won't go, it seems. But here to grow, learn a little bit more about how to structure workflow processes and inspire more  clinicians to do this kind of work. We have a lot of patients and through these contracts, so learning how to get out there and access them and improve outcomes.  All right, thanks. You're in Amanda's neck of the woods. They're in the Twin Cities. So  all right. Dr. Thomas Moiti, I know you, you were one of our very early workshop learners a couple of years ago. Are you on?  Yeah, I'm on. Thanks for having me back. So yeah, I'm Dr. Thomas Moiti. I'm one of the physicians with the Amita House Call  Physicians, which is part of the Amita Health System, which is a large medical or hospital based system in the Chicagoland area.  So our practice has actually been around for 15 years, and it was started by Dr. John Liu, and I jumped on about six years ago.  And so it's been very exciting. I would say when I took the essentials course, very early on, this is a few years ago, we  were in a very well supported program. You know, a lot of us were, you know, working, you know, day and night, and, you know, a lot has changed in the last few years. I think the  hospital system has really recognized the work that we've done. We're now very well supported with palliative care and hospice and been excited to see the growth of our group  we've added on. Now our group has four physicians, we're looking at adding on a fifth. And we have three nurse practitioners and probably going to add another one within the  next year. So yeah, we're looking at, sorry, I'm going to let this train pass. I'm in the heart of Chicago right now.  Okay. So we're looking at probably close to 10 providers. We probably see, I would say our panel is probably between five  and 800 patients. We continue to grow, I'd say exponentially. So really, the growth has been exciting. And, you know, despite  COVID, I mean, we've really, I think that's just, you know, kind of helped us grow even more, because these patients didn't want to come to the office anymore. So I would say  mostly what I'm looking to get out of this session, you know, I'm hoping to expand my clinical knowledge and learn from those  that have been in the field longer than I have. And, you know, we're always looking to improve our practice and connect with other colleagues in the field as well. So I'm excited to  be back. Oh, awesome. Thank you very much. And Dr. Talisa Atkinson, I know you just put your intro in the, in the chat, but do you  want to say hi? She may, she may have had to step away. All right. How about Julianne Geit?  Yes, hello. Sorry, I was just getting settled here. So  geriatric solutions is in Phoenix, Arizona. We are a large practice covering most of Maricopa County, which is quite large. 1600 patients, around 1600 patients currently. So we  have quite an undertaking, we have three MDs, including Dr. Atkinson, and two PAs, and then we have the rest are nurse practitioners. What I am hoping to get out of this today, I'm  the office manager, I am looking forward to some strategic planning, some process improvement, and just  collaborating with all all of you and learning.  All right, very good. Thank you. And we're just finishing up here. Josh Pope, are you back on?  I see your name in the list, but you may have stepped away. So  and, and having connectivity issues. I'm sorry about that.  All right. Hopefully, hopefully we can get you connected here soon. Is there anybody else that I've missed?  All right. Well, listen, I, I love hearing from all of you and getting introduced or reintroduced to you and hearing what you're hoping to get out of the next couple of days. So  let's get back into it. Let's start our next session. Can you go ahead and queue that up and Janine with the slides.  All right, so I'll go ahead and invite our faculty to get this started. Dr. Paul Chang and Amanda Tufano.  Well, thank you and thank you everyone. You know, before I get in to the presentation, can I just say something?  You have, you all, you know, I'm the faculty, but you all have just recharged my battery this morning.  I love your passion to hear about your desire  to do better, to serve these patients, to take care of them.  So it is so good for me to hear that.  I don't know about you, sometimes I get bogged down with the, you know, the nitty gritties of work and about finances, about the practice and so on.  So it is just refreshing this morning. So thank you for sharing. Thank you for your work. Thank you for your passion and being out there taking care of this group of patients  who are really in need. And without us, without you all, I don't know what kind of care they'll be getting in our fragmented healthcare system.  You know, early on, I jokingly said, you know, my bio should be just, you know, I'm a house call doc and I love my patients and I love my job.  And that should be it. And then I also love my providers.  There's an internal document that I wrote and it's entitled, for ACCI, it's entitled Better Mondays. The goal for that document was, you know, I want to make your Mondays better.  You know, we all talk about, you know, TGI Fridays, you know how great Friday is. And then the Monday comes, we're kind of dreading it. But I want to make your Mondays better  to equip you with the necessary information that you need to better take care of our patients. So I hope that the information that we're going to present  over the next day and a half or so will make your Mondays better. So you will have more confidence, more skills that you can take to your patients  indeed on Monday and be excited about your work. Next slide, please.  So the objective for this session,  let me just, here we go, is to apply, recommend a practice in transitional medicine,  in transitional care of our homebound patients with the domains of accountability, communication, assessing the needs and goals, medication management and safety.  We'll talk more about the Naylor model later on. A lot of this is based from the Naylor model in terms of transitional care. Describe the responsibility of a care coordinator  and cite appropriate behind the scenes function to ensure effective care transition.  To discuss the role of educating and empowering patients and family in caring of our loved ones and during transitions on how to improve care coordination.  And finally, to think about resources and strategies for identifying and connecting with community services beyond home-based primary care practices  to provide more comprehensive care for our patients.  And I don't know about you before the next slide there, our patients, my practice, I'm sure yours as well, they go in and out of the hospital a lot,  or in and out of the ED frequently. And transitional period or what we call handoff times can be a time of confusion and stress,  confusion about medications. How many times have you heard, as you go into a home to do a TCM visit  and you go over the medication, you say, well, how come you haven't started this medicine?  And the reply would be, well, gee, I went to the drug store and it cost $400 or whatever. And so I decided not to pick that up. So even though the hospital doctor prescribed  a certain medication for the patient, they're actually not taking it  because of costs or maybe there's some other barrier like language barrier or understanding what the medication might be for.  So we can help clarify some of that.  And also let's not forget the caregiver, right? They are there and they're confused about what was done in the hospital or if they have some medical equipment,  like what's the tube feeding, how do I get the tube feeding, what's the rate and so on. And it can be a very stressful time for them.  And home-based primary care, as we've said in the past, it's about taking care of the caregiver and also taking care of the patient and also taking care of the caregiver.  And Tom mentioned in his video about healthcare being very fragmented. And I was thinking about this  as we talk about care coordination and transition of care. Several years ago when I was visiting a patient's home and I walked in and I noticed that there were multiple large sets  of beautifully made Legos of ships, of buildings, of structure, of Star Wars things and so on and so forth. And when I was thinking about that,  I said, in the context of fragmentation,  we're like Lego builders. We're gonna take some of these pieces and put them back together the best as we can and make something beautiful from this.  And hopefully this course will give you some tools that you can become, hey, master Lego builders as you put the pieces back together for our patients  and make something that's beautiful, perhaps from a little bit of chaos.  So we're gonna meet Minerva. We're gonna talk about Minerva. So if you can take a moment here  and take a look at the Minerva case, I'll give you a couple of minutes to review that.  We're gonna be talking about Minerva throughout our time today and tomorrow. So I'll give you a couple of minutes to review the case. And then I'm gonna come back  and just highlight some of the points that's relevant,  or I should say, especially important as we think about care coordination as she comes back home from the hospital. So why don't you guys all take a couple of minutes to review?  Thank you for watching!  Thank you for watching and I will see you in the next video.  Okay, can I have the next slide, please?  So, you can continue to refer in your workbook the Minerva case, but just quickly, Minerva is an  older patient. She's homebound due to dementia, and she's got mobility issues like so many of our patients. She was recently hospitalized for congestive heart failure, exacerbation,  and leg swelling and infection. She was discharged home two days ago, and now you're  seeing her for the first time for a post-discharge visit. Before I get to the next slide, what are  some immediate, and we can have an open mic session here, what are some of your immediate concerns regarding some of the challenges in terms of meeting the transitional need  of this patient and hoping to prevent her from going back to the hospital?  You can use the chat box, and my staff will be monitoring that along with myself.  Yep, she's homebound. Right? It's hard for her to get out of the home. Often, the hospital doctors say, you know, follow up with your PCP in a week, and the daughter's like,  I can't get her out of the house. Right? She's got dementia. We're going to talk about management of dementia-related behavioral disturbances later on this afternoon, but  that creates a whole host of other challenges related to the care of a patient with dementia.  Changing cognition. Right? Caregiver burden. We're going to talk about that as well later  today. And multi-complexity, multiple chronic conditions. Kidney function. Perfect. Awesome.  It's a high, excuse me, wound is at high risk for progression  and complication. Great. Appreciate the comments. Kidney function, we'll talk about that in a little  bit as Michael is going to share with us in his session about medication management. It is really  important for us to keep that in mind as we prescribe doses of medication for our patients according to the kidney function. All the comorbidities. Yeah, sometimes it could be  challenging. Even for me, after so many years of doing this, when you go into the home and you  look at all the problem lists, and sometimes I just have to take a deep breath, and I don't know  about you, just say, you know what, let's just take one at a time and try not to be overwhelmed  by all of the competing ideas and information that's coming into my brain. Great comment. Yeah.  Absolutely. It may take several visits, and we'll talk about that. Amanda will allude again,  talk about the Naylor model. It may take several visits. Yes, try not to drink in everything at  the first time and address everything because that could just give you a feeling of distress.  Yeah, great comments.  Yeah, focusing that one thing that will send them back to the hospital. Great. Yeah. Terrific. All right. All right, let's go to the next slide.  So, these are the challenges, and you guys already hit on probably essentially all of them. Multiple chronic illnesses, heart failure, COPD, dementia, neuropsychiatric disorder,  heart failure, COPD, dementia, neuropsychiatric disorder, and we talked about our patients who  use the hospital and emergency room a lot. Why does that happen? They don't have good follow-up,  multiple medications, health literacy issues, and reduced social network and other social,  reduced social support and other social determinant of health. Next slide, please.  So, from reading and looking at the medical literature, these are some of the reasons why our patients go back to the hospital. The previous slide talked about, and you guys talked  about a lack of follow-up, polypharmacy. There's not a universal definition of what is polypharmacy.  I think the general accepted idea is more than five medications, multi-complexity,  specific condition that sends them back to the hospital. Often it's heart failure, right,  could be dehydration, renal failure, cancer, low health literacy. That's a challenge for our patients, whether it's from an educational challenge or a cognitive issue or perhaps a  language barrier that's affecting their ability to understand and carry out what they need to do.  I used the example, you know, my wife was in a hospital a few years back, and when she was discharged, we were given this beautifully printed out after-visit or discharge summary  that was 14 pages. And I was just thinking, you know, that, you know, that's a challenge for our  patients who may not understand all the technical term, and you give them this stack of paperwork,  although it looks really neat and nice and all, but I wonder how much useful information  were they able to get from that. And reduce social network and other social determinants  of health, whether it's, whether you have, you know, with COVID, do you have internet service  that you can do, maybe a tele-visit, of course, and the other things such as, you know, food  insecurity issues that may impact their overall health. So those are some of the reasons for readmission. Next slide, please. So what are some of the barriers in transitional care?  And I kind of just, I looked at the literature and I kind of put them in three buckets. You can  put them in the buckets as you see better for your recollection and so on. The first bucket  is what I call the medical level. Clinician workload, hospitalists are very busy. They may not be able to get to all of the medical information or attend to all of the discharge  needs related to the patient. There may be last minute changes from maybe the specialist that  comes in, even though the after-visit summary is completed and that the specialist comes,  the specialist comes in and say, you know, I want to do one more thing or I want to see the patient  in two weeks instead of four. That could disrupt the discharge or the transitional care plan.  There could be error in medication reconciliation. Just yesterday, I saw a patient for follow-up after the hospital. And as it turns out that she is on two calcium channel blockers.  On top of that, she's taking digoxin. And one of the calcium channel blocker is a non-dihydropyridine  CCB, and that's diltiazem. And her heart rate was very low. And actually, I saw the blood test this  morning. She's actually in heart failure because of bradycardia. Okay. So again, it's just important  for us to keep that in mind as we take a look at the medications that our patients are taking post-hospital. And lack of timely discharge summary. I'm fortunate enough, I work with  Fort Northwestern and we're on Epic and all the notes from the hospital doctor and so on and so  forth are available to me to review. Some of you don't have that capability. And when the patient  comes home, you are working off very little information, right? There's no discharge summary,  what was done, what needs to be done, what medications were changed. So that's a medical level challenge. On a system level, there's a complexity of the discharge process.  There's a lot of paperwork involved in the discharge process. There's insurance barrier,  you know, is this covered? Is that covered? Who is in your network? Which home health agency can  you use? Which DME can you use? And as I talked about before, you know, medication, is that covered  by your plan? Is that too costly? And so forth. And what follow-up are necessary? Who are you  going to visit? When are you going to visit this doctor? How can you get there? What blood tests  or follow-up imaging are needed? So these are some of the challenge on a system level. And then there is the knowledge level. Sometimes the patients or the caregiver, you know, what  happened in a hospital? What do I need to do for grandpa once grandpa gets home? Perhaps the  hospitalist or the nurse did say something to them, but it wasn't entirely clear. So there are  just some knowledge deficit that we can help our patients overcome as we make these transitional visits. Next slide, please. And I will turn it over now to Amanda.  Thanks, Paul. You know, I think you did a great job outlining the problem and certainly many of  the solutions. We're going to kind of talk about, you know, what are important aspects of quality  transition? How do we think about it? How do we all work together and create ideas? So as you have  ideas, jump in here as well. I say everything's fine in healthcare until it's not fine. And often  it's some change of condition, right? If everything's going the same and there's nothing has changed,  then typically there's not a massive issue. And the more complex you are, the larger the issue is. And so now we've taken people and all the things that happen inside of a person,  we've put them in situations and how do we kind of push forward and what does that look like? So  luckily we have all the answers for you here today. Just kidding, but we will one day in  healthcare. That's what we're all working towards. I'll take a slide. So here are just some strategies.  I have two slides on strategies for improving transition. So jump in if you don't see something  on here, because really what are we missing? And these are all just ideas. We'll talk about  the Naylor model, which is more of a framework and model of how to care for these patients, but these are ideas, right? How often are you reaching out after a hospitalization?  Who's the person calling? Is it a care coordinator? Is it a provider? What are you looking to collect?  What does that data look like? How do you get the medical records in a timely fashion and review  those? Can you make a visit, but with a provider within seven days of post-discharge? Sometimes  depending on their location, you may say within three days. How do you reconcile all of the  medication? And so I'm not clinical, but I've heard it a thousand times. As you create a plan,  they go into the hospital, they go somewhere else and someone messes up the plan. And now you have another six medications that have been added on. And how do you think about  those and where do they fit in the plan? And maybe then how do you,  you know, maybe need to contact someone else to say, you know, for the ER doc or the hospitalist,  you know, what were you thinking? Is there something I can do? Is there even anybody who will answer that phone call? How do you address DME, especially when change of condition  occurs, right? They were perfectly fine. They've fallen. And now what additionally do we need?  Something has taken place and who is the right person from a partner connect standpoint? And one thing that we'll talk about here is you just, you can't do it all yourself. You're,  you're not also going to be the DME company. So who are your partners and who's in it with you  and who meets your expectations of timeliness, your mission work, you know, your values. What  are those things do? Your, you know, your actual structural needs, who are those groups that do  that? So can you get the DME you need in place to, to move someone from X to Y here? How do you  place an order for home care hospice? If there's any follow-up testing, how do you ask for barriers  for compliance? You know, and one of the biggest benefits is you're in there, you're in where they  live. And so you can see some of those pieces, but there might be other pieces that put them  in the hospital or put them in the transitional care. And you didn't know about those. And so  now we need to address the fact that, you know, you're not taking the medication because you're  either not buying, you know, you're not getting it, or, you know, we talk about it and somehow  it keeps landing on the floor and the dog eats it. Well, you know, okay, now we know that has  landed you in the hospital. We need to do something differently. Karen put in here, how do you find  out the patient was in the hospital and is being discharged? That's a barrier in my practice.  Yeah. One of the biggest issues, and I talk a lot with our EHR vendor is where is the patient  and how does no one know where the patient is at any given time? Someone knows where the patient  is, but they're not telling the right person or the right person, you know, group where's the  patient. For us, I can say, we really work pretty hard to set an expectation with the family right  away to say, if your loved one does anything, goes anywhere, let us know, because we won't  always be notified by the hospital. We won't always be notified. If you're in assisted living,  we won't always be notified you're in the hospital. Let us know so we can be partners with  you in that, because unless there's a really robust HIE in your area, and I can't say there's  one in Minnesota, it's very difficult to know entry and exit in the hospital. Next slide.  How do you assess caregiver concerns, especially if there's been a change of condition and so now  mom's coming back with some hospital-acquired delirium and this is going to look slightly  different and we need to talk about what that looks like. You know, how do you think about the  goals of care for the patient and the caregiver? You know, do we need to review the advanced  directives? How do you, you know, identify and address knowledge deficits? And you maybe have  already been working on these things or they're brand new. And so sometimes these, especially with  the population you're working with, these transitions, they change the course, they may modify the course, and some few times they don't change the course, this is just part of it.  But what we're trying to do is assess the situation again, and that's why we put on the last slide, you know, try to get out and see the patient and do that assessment of in what  in what state are they actually returning to me, and what do I need to do now, and how has my plan  changed given their plan has changed. Written instructions, and certainly the teach-back  method is a leading educational tool for how you teach information and get across here's what I'd  like you to do. And many people are familiar and use that method, but here's what I'd like you to  do. Can you teach it back to me and tell me what I just said, and how you're going to do that? And  I, you know, with patients and caregivers, depending on the instructions, how do you understand that care plan? How do you understand your next visit? When are you going to see them  next? How do you understand if their trajectory has changed or if you need to talk about a new  emergency plan? How do you think about, again, I'd like, and this is how I always state it when I  talk about the business component of why we do what we do, and how why we do so much advanced  care planning early on, is I know if it was my mom or dad, I'd want the same care at 2 a.m. that I got  at 2 p.m. when everybody's on and businesses are all open. So how do we put that plan in place in  front of whatever the next thing may be? And then who are the team members around you, and how are you coordinating with them? There's another note here. Okay, slide.  So some successful transitions, you know, we've kind of talked about this from a clinical  standpoint. Paul did a great job of saying, you know, address the clinical pieces first, you know,  get out of the crisis, get past the hospitalization concerns, move into now this is the new normal,  how do we manage the medications? How do we understand what you've been on or not on? How do  we think about advanced care planning? And again, any changes that may have occurred, it's worth  revisiting if there's been a significant event. And how do you support the patient and family  caregiver, especially in a transition where the patient is returning in a state where the  caregiver responsibility is increasing? We need to recognize all of the tentacles of the patient at  the center of someone's life and say, okay, now, you know, you were home two hours in the morning,  you're going to need to be home eight hours a day to take care of this person. Let's talk about  other options and what that looks like. Slide. So who's on the team? And I'd love to have other  people jump in on kind of who's on the team for you guys, but certainly the providers, nurses may  be on your team, therapists, you may work closely with therapists in a short stay and not have them  in your practice, but a short stay practice. You may have social workers, you may work closely with  social workers, you may have kind of favorite social workers, spiritual counselors, pharmacists,  community resources. And we're going to talk about a couple other community resources because again,  it takes a village as people transition. And then all of the administrative support people. And so I  join many of my colleagues on the call today who are not clinical. We care for people who care for  people. So other people that were missing on this list that you have in your practice.  April says having good relationships with the home health nurse and LPNs has been a big benefit for  me. Absolutely. Absolutely. You know, we find also having a strong relationship with hospice,  you know, who are the hospices where we know their name, we know what they're going to deliver. We  know the product. We can say in all confidence, here's a vendor and extension of us. Here's the  hospital, you know, the home care extension of us. Hospital case managers. Thanks, Sarah.  Absolutely. You know, those hospital case managers have 101 different priorities at any given time.  And so to find the right hospital case manager, who's going to walk you and your patient through  what a transition looks like. A social worker. Absolutely. For discharge planning, especially,  you know, how do we make sure that everybody's on the same page with the discharge planning,  but again, they're not circumventing whatever plan you've put in place. These moments can be  very overwhelming for families. And so how are you by their side in these moments? Absolutely.  Speaking about being by your side, if I could take another slide, I'd like to talk about the  Naylor transitional care model. So the Naylor transitional care model was started by Mary Naylor,  a nurse at, is it Penn nursing team? And, and we're kind of going to go through this, but this is a model or a flowchart for how you think of caring for patients. And at what point  do you do intervention and who is doing that intervention and what does it look like? And so  it's based, it has this really rigorous scientific base. It's an NIH funded. And actually I was  looking it up earlier in 2020, maybe right around the time COVID hit, it got another $6 million for  clinical evaluation for a venture group that was supporting local or large scale evidence-based  research to do this because it has value in, I see someone who meets this qualification,  who needs some additional supports. And now what are those supports that we're going to put in  place? And so you can also refer to the Naylor model in your handbook, but it's a nurse led model  and nurses within the hospital start coordinating plans and putting together goals of care while  they're still in the hospital and then continue home with them. So take a slide because I know  you're saying, well, what is it if I don't use it? Evidence-based and clinical efficacy of this  model and preventing readmissions. So it's been scientifically or the data has proven that it  improves acute older adults. So again, it's a hospital-based model, but it improves their care,  their experiences, their health, and their quality of life outcomes. It demonstrates a reduced  rehospitalization and total healthcare costs. I have a lot of thoughts about rehospitalizations.  I've been in rooms where hospitals have said, well, rehospitalizations don't look good for us, but they actually make more money or the hospitalization makes more money than the  penalty of the rehospitalization. And I've been floored by these moments. But what we do see, especially with older adults and where you can kind of go  back and push against just the typical hospitalization or hospital mentality is,  to Paul's point and Tom's point about the total cost of care towards the end of life is so high.  And as we think about the experience and the outcomes on older adults as they consume  unnecessary hospitalizations or hospitalizations maybe that also don't meet their goals of care,  the quality lowers and the costs go up. And so these interventions here of reducing hospitalizations is actually saving any system quite a bit of money, but certainly the overall  system of what we're trying to do. And it's a better cost of care. Paul, were you going to jump in, say something? You're unmuted. Sorry, I'm on mute. So the Naylor model basically  highlights six or seven areas to improve transition of care. The first one is, I don't  think this is in any particular order. The first one is obviously managing the symptoms that the  patient is having. The second is education and promoting self-management. The third is collaboration. I think I see the chat box there talks about collaborating with other providers  that's involved. The fourth is continuity of care. And that's what we do here, home-based  primary care, making sure that we are following the patient. The patient is not falling through  the cracks. The next is coordination of care. We need to be kind of the driver in terms of making  sure that the services that the patients need, whether it's a DME, social worker, PTOT and  whatnot, is appropriately and timely implemented. And the last thing I think is really important  is maintaining relationships. And I think relationship with the patient and family and the caregivers, obviously, and also maintaining a relationship with the other providers that's  involved in the care. My final comment about this is that just the other day, I had a conversation  with our health system and with a home health agency about readmission, about reducing that particular number. And we did talk about the Naylor model and so forth. And something for  you and your team to think about is for, say, a patient with congestive heart failure that comes  home, how often should you be seeing this particular individual weekly, monthly, and whatnot  to prevent this person from going back to the hospital? And also, and I think  Brianna and Michael might be talking about this later on, is about the possibility of implementing  RPM, either through a home health agency or perhaps with a vendor that can help better monitor your patients. I am using heart failure in this case to keep them out of the hospital.  So those are some of my comments. Yeah, that's great. If you go one more slide here, this is just a slide to indicate also the specific per patient cost. And so,  you know, the Naylor model, again, has been studied of how do we reduce kind of with this  intervention versus a controlled patients. And the total health care savings is around $3,000  per patient. And the information that comes out of HCCI in the next two days, plus the other  information, is always trying to connect those things, lower costs and improve quality. And  these are the types of numbers then you can extrapolate for your business plan and take it and say, this is what we're looking at. You organization are in an ACO. You organization  are signing Medicare Advantage contracts. You organization are at risk for this commercial  population. Great. I've taken our patients and I've extrapolated some of the savings based on  these other models, if we could do this work the way we want to work. And so that, you know,  I really like putting up specific numbers around what this is going to look like.  If you go one more slide, we'll get exactly into what Paul's saying is, what's the right intervention and where do you do it? So, I mean, again, this is more of a hospital nursing  intervention and you can follow the flow chart. I won't walk through it all, but you can follow  the flow chart in your book. But essentially in the hospital from within kind of that 24 hour mark,  you're immediately screened and say, are you, do you meet the TCM screening and risk assessment?  And if yes, you get assigned a nurse and that nurse then meets with you daily during your  hospitalization and then starts that transition plan with you. And again, they're not circumventing  the social worker, but they're with you as part of the entire experience inside the hospital to  try to get you home or wherever your location may be. And then they stay with you on the program  with daily visits, sometimes weekly or excuse me, weekly visits, but seven days a week,  they're available for you throughout the process. And it could be a couple of months you might be  on this, but this is a way to connect the patient not being lost. So I'm trying to keep up with your  chats, but I maybe missed a couple, but I would say the core theme of the chats during this is  there's a communication breakdown. Either I'm not getting the information that I need, or I'm not  knowing where the patient is or what's happening with the patient in any given time. And that's the  entire, that is the entire problem with healthcare. Well, technically for the record, I guess, I think  the problem with healthcare is how it's financed and maybe it's just my business hat, but a  subsequent problem of that is the communication component is, I just don't know. And so then we,  we create all these words around care management or population health, or, and we say, okay, this  is what care management means to me. And we don't really focus on here's what's broken and here's a  way to fix it. So here is a way to put a model in place to fix a transition in and out of the hospital. A couple more thoughts of care coordination coming up. So I'll take one more  slide. And then here's some, this is a CMS transitional care management requirements. So this  is just a comparison again, and how you think about, we're giving you models or ways to start  thinking about these pieces. And we've kind of gone through this, but, you know, again, Medicare  pushes this out of saying, can you see that patient within two days of discharge, you know, or can you  contact them? Can you then see them within that seven to 14 days when you actually see them, what  is the work you're doing? How does it tie to medication, to pulse, to what the family needs,  the DME and some of those pieces. And so these are just models that you think of to, that you can use  if, as you think about transitions. And so I'll go to another slide around care management. Care  management is, I get one more slide. Care management is the strangest term to me. It means  something and nothing all at the same time. It's what we're all expected to do. And then what  certain people are expected to do a lot of. So I don't, you know, there is kind of no universal,  well worked out figure, you know, thing of care coordination. So I don't know if anybody else  feels like that, but I really try to specify when I say care coordination, I try to specify  who's doing it and what are the expectations. And so define that, what that means to your practice,  what is everybody's role and everybody's role. And we talked more about this and we certainly  talked about it in the essential program is everybody's role is to work at top of license,  right? How do we, how do we work at the top of license? So what you are paying as the employer  towards your employee, they are giving back to you the very maximum that they can do within their  skill set. And it couldn't be, it could not be done with someone with a lesser degree or skill  set. Right. And so I think that's like really key piece. There are some sample job descriptions in  your workbook, but really think about how are you using care coordinators at where are your holes  in which you have problems? So I think Michael put in there, Hey, we have a pretty good HIE.  We know where patients are. You may not need someone to kind of track down patients for that.  Some of you may say our biggest hole is the patient falls off the face of the planet when  they go into the hospital. And then we know their home basically because we get a 2 AM call because  something's wrong, you know, a medication error or a medication issue or something. And now,  now we know they're, now we know they're back. And so where do you put those things? How do you  create the policy around the functions, the expectations, and how do you formalize that? And then what's the, the licensure that you're going to use to fill that.  As you, can I take another slide? As you think about that, think about then, you know, what are  the care coordination responsibilities? If the change of condition has occurred, you know, from a primary care standpoint, this is how often I see the patient. I see them, you know,  roughly every 60 days based on these clinical conditions of why I'm seeing them, you know,  but now they've had some, some acute level and there's some change. And so I, as a provider  going to respond, think about that as care coordination. What's the start? What's the stop?  How often are you touching base? For example, we have a number of SNP value-based contracts where  we either have full or significant risk. And we employ clinical nurse managers who go out and  they work specifically with patients if they're on certain products. So for us, it's product  dependent. And the model that we're working on now is creating a more of a risk stratification  for allocating resources appropriately. So you say, okay, here's the touch you get from every  level, every type of employee, right? Provider and care coordinator. If you are, you know, one  on the acuity scale for us, right? And you're, or you're a five or you're red, yellow, green.  Now you're a five and you need a lot more check-in. What does that look like? And then  how does that end? And how do you take people off of that? How do you coordinate with the health  plans and the wavered services? How do you go through your state? How do you understand? And a  lot of that comes again, what are the other groups that you're working with? What are the DME? Who's  the home care group that you're working with? Who's the hospice care that you're working with?  And how do you create to make sure that all of that is completely on file in your EHR in a timely  way to make sure if your colleagues get a call up at two in the morning, they can go, everybody knows exactly what's going on and what plan was put in place. And again, assign those  responsibilities. And why I like the Naylor model is not just its goals and not just as  its successes, but it says at different times, here are the touch points and here's what we're  going to do. So we do a lot of our work and maybe many of you that do this too, but we do a lot of  our work in flow charts. Here's the, here's the person and what the touch point looks like.  Take a slide. So one thing that we talk about too is, you know, how do you build in some of these  templates within your EHR to make this easy? And then where are you going to put them? Has  anybody had the conversation of, if they call a care coordinator, do I put it in a triage note  or do I put it in a telephone note or do I put it in the main document? You know, where does it  actually get even filed? You know, figure out what information you're collecting and where you,  and who needs to see it and how quickly they need to see it. Some of the information a care  coordinator is going to collect, you may need to put in a banner, right? And so how do you create  this structure so it can be more hands-off and your staff can easily see some of these things?  Because what we're trying to solve for is this balance between some of these things just automatically happen. An EHR, when I close the note, can fax it to the assisted living and I  know it's there versus some things we can't do and we need people to intervene because the system  is too complicated and the EHR or other technology is not ready to interface in that way. Or my  two technology pieces are not touching appropriately. So some things that you might say is,  you know, do you have all of your medications? So Paul's point on, you don't even know they're not,  they're maybe not filling them when you write it because it's $400. Does the patient feel safe in  the home? You know, we have a number of stories coming out of our, especially our dual population  over the years that I've heard where, you know, you walk into a house and there are mattresses on the ground, you know, do you feel safe in your home? Is the,  is a child living in the home whose sole purpose or sole income and living arrangement is tied to  the patient that's in that home? And how do you assess that? And again, you get all this advanced  access to being in their space. How cool is that? Does the patient feel capable of caring for  themselves? Is the caregiver capable? Do you actually assess the caregiver is capable and  make sure that the care coordinator understands all these things and, you know, understands,  hey, if I get a no, I put some of these pieces in place. You may be collecting some of this  information and then how you communicate it again in the EHR or verbally to make sure that it's  appropriately documented. So I like to say, if you ever get hit by a bus, someone else can pick up  your work, which is horrible. My team hates it when I say that, but I still say it that way.  Slide. And we talked a little bit about that, but there are really cool sites. And so here are just a couple of sites out there. So connecttoeffect.org, eldercare.acl.gov  and antbertha.com. These are lots of different places that you can get free information and different services in place. You know, I need a home, homemaking. I need,  you know, I need, what was the other, I was on a email the other day and we were trying to figure  out a different type of adult diaper, right. And how, you know, how do you, how do you figure that  out and what are the different services that can be put in place? And so do you guys have  other groups? Every state kind of has maybe their own system as well, but these are some that are  more readily available. Are there, you know, partners that you work with locally that, you know, help find resources for you?  The other thing to do is as you're collecting resources is how are you going to store them and  disseminate them? So many of you said, which is super exciting that you're growing and you're growing quickly. And unfortunately some of you are growing quickly because of COVID.  And I have to say that in a way because COVID is a global pandemic and it's great that,  it's great that you're growing. And so as you grow, what is the handoff of here are the resources?  And I don't think it has to be much for us. We keep an Excel document of here are the resources  that people have. And then we have a list server distribution list where people can just ask  questions to end people to the resource list. And so we can say here, you know, here's the  email to the 10 people on this, or, you know, for us, 60 people on this of saying, Hey, does anybody know this solution? Hey, I need this DMA. Hey, does anybody have anybody  that could move an air conditioner? Yeah, there's, there's some options here. And so how do we put those resources in an easy to find location? So we're not doing duplicative work  because that's where a lot of all businesses waste time is someone's doing something that  someone has already learned how to do better. Let's see. Let's see, Michael. Oh, Anna. Great. We use Aunt Bertha. Michael says we have a statewide self-referral. That's fantastic.  Local group of stakeholders. Yeah. And a non-competitive space. That sounds fantastic  of what are you using? If it's in a competitive space, you might be hesitant to put some of that  stuff together, but, you know, recognize that we're all using the same resources and the faster  we all figure it out together, the better. So how do you, how do you partner up, especially in this space with resource and resource allocation with maybe competitive groups?  And then a two-one-one line, which is a resource line funded by United Way. That's super cool,  Karen. Thanks. So I think, you know, as you, as you start to, and especially start to put this  stuff together, especially Greg, who's just starting your practice and you're building it  again, we all wish you the absolute best of luck and are grateful that you're, you're hanging in  there here. Start putting together who are the people around you and what does that look like?  And who are you going to call? And these are great places. And then when you don't like somewhere,  make sure you share it as part of your growing practice and share it both with that entity to  see if there's a solution and within your practice. So they don't use it again. The bigger you get, the harder it is to control where people go. Slide.  I mean, I just think that if we all do this together, and that's why I love these days,  because we learn so much from each other, is we can create quality transitions and the patients  are a very vulnerable population and really need it. And again, to my point around financing of  this, not everybody is financed in a way where they put a lot of utility or energy into making  this a true quality transition. And so sometimes you have to work around the disincentives that  have been accidentally put in place by the financing of healthcare to get here. And those may not change. And the frustrations may not change because again, there's this immediate  rub between a disincentive and incentive that's being put in place that just may not jive with  what we're trying to do. And so as you're trying to put that together, you do have to put places,  you have to put some things in place from a protocol, from a procedure, from a policy  standpoint, from a staffing standpoint of who are the right people to recognize that some places are  just black holes and we have a ways to go. And sometimes depending on this, probably the biggest  area right now that I would say is hospitals. They've not transitioned enough of their  financials to be aligned with you and what you're trying to do. And then how do you give that power  back to the patients and caregivers, certainly with knowledge and then with a clinical base to be able to move forward after a transition. Questions for me?  Questions for Paul or any other faculty, or am I just standing between you guys in a break?  April, yeah, go ahead. Feel free to unmute if you'd like.  Yeah, that would be quicker. I was just wondering, is there, I don't know if HCCI has anything about  getting the policies and procedures, so we have it printed, or if there's a way, or does anyone  know where we can get policies and procedures manual for different things like the coordination  of care, transitional care? Or do we just use the Medicare guidelines? That's what I usually do.  Brianna, do you want to take what you guys keep on file?  Yeah, so we get that question kind of often. One resource that I've pointed people to that  we're really looking for something formal is the VA published their home-based primary care  policies and procedures, which is extensive. So that's a good framework. I'll find the link and  I can put it in the chat. I just have a general list of like, hey, here's some good ones to  consider. But Amanda and I have had an interesting talk about this quite a lot too. Like you don't  want to be too regulated and you want to think about like what's a process and a protocol and  what like federally and regulatory do you actually have to have as a policy and procedure? Because I  think sometimes we overthink policies and you know, oh my gosh, we have to have it in place  and things like that. So, I mean, I would kind of start small with some general guidelines,  obviously have the policies that, you know, by law you're required to have and those kinds of  things in a framework. But otherwise, you know, just think kind of process and protocols. But  I have kind of a general list since this comes up a lot that I'll throw in the chat for you.  And can I just add one thing to that? Like that's why I love the 5M framework because  what happens in any growing practice, which we're all doing, we're not saying we're doing,  we're going to be this way, you know, we want to be bigger, we want to, you know, do X, Y, Z.  And so what happens is you accomplish, you do something and then you kind of forget about it.  You don't, you kind of are like, oh, I'm glad that's done and out of the way. And so I've created a care coordination policy, I've created a transition policy and a procedure,  and this is how it's all going to work and it's out of the way. But, you know, those are still,  again, tools trying to get you to solve for these underlying framework issues of these 5Ms.  And if you put it, if you think about the tool by itself, you kind of solidify it and you never  revisit it. If you think about it as a solution for your framework, as your tool, you revisit  your framework enough to say, oh, the tool I put in place two years ago that was working is now too  rigid or it's not specific enough and we need to change it, we need to adjust it. And so how do we  make that change to the tool and not to the framework? And that's really, I have probably  in the last 18 months, I've really moved my head from what we're doing really well is X. No,  we're living within this framework and everything is on the table to adjust at all times. Thank you so much, everyone. We are about to go into a 10-minute break to rest and refresh.  We will start again at 10.45 a.m. Central Time. See you back in 10.  Thanks.  Okay, everyone, we're going to get started again in just a moment. So if you can hear me, please join us. We're going to have enhancing productivity and reach through telemedicine with Michael and Brianna. Give it one more minute.  Brianna and Michael, I am ready when you are, just queue me up for slides.  Okay, good morning, everybody. Our next session is enhancing productivity and reach through telemedicine. Next slide for objectives.  In this session, Brianna and I hope to share our experiences utilizing telehealth throughout the pandemic. I have to admit, I spent a little time thinking  about the last 15 months or more  and the traumas that we have likely all endured. And it's a little bit fuzzy to kind of recall all of the various changes.  But we really hope that this will be a group to conversation and really thinking about where did we start in the initial pandemic and where is everybody now and what have we learned  and what challenges did we face in this virtual environment visiting patients? And probably the most useful aspect for many of us  is the coding aspects in regard to the virtual environment that Brianna will review. Next slide.  So over the various versions of this, of talking about the pandemic and kind of transition to the virtual environment, we kind of tried to think about the framework  that we were using. And this is sort of specific to my program at Hopkins J-Home. And as I mentioned, reflecting back, initially when everyone was first shutting down,  before we really had any kind of framework at all, our initial approach was just sort of safety phone calls.  And we did have sort of a thoughtful approach to that,  but at that time it was just sort of, do you have meds? Do you have food? Are you safe at home? And that didn't really last too long.  And then we were probably over the matter of several months, we were able to transition to this sort of plan.  Initially, all of our visits went to virtual,  whether that was phone or audio with video.  And it was really important to engage the patient and the caregiver in preparation for those visits.  And we really needed to be prepared for what degree they were able to manage technology. Otherwise you'd spend a lot of time  trying to get the technology to work rather than meaningful time, even if it's just over the phone.  In our interdisciplinary team meeting, we had those every week, which continued, but we also very quickly incorporated the use of daily huddles every morning.  And initially we had them every morning and every evening and sort of the initial pandemic period.  And that was really to help enhance communication, whether it was about patient concerns or operational issues with our team, with everybody being remote.  Out of our IDT meetings, we generated patient lists  and those lists generally considered concerns or outstanding issues for our patients so that we were sure not to miss things.  And then we also allowed for flexibility of scheduling still so that we could accommodate acute or urgent visits, whether they were virtual or in-person.  We did feel that through the use of the virtual environment, we were able to minimize risk, but still provide our patients with access to good sound medical care.  When we were able, we partnered with Home Health or other community partners to facilitate a visit. This was one of the most successful ways to address telemedicine,  because usually if you had a community partner or an agency partner in the home, they were probably pretty used to using technology.  Oftentimes our Home Health nurse might help facilitate a visit.  As I mentioned initially in the pandemic, all of our visits were virtual. And then as PPE equipment really became readily available,  and probably the better way to say it is that we weren't concerned of a shortage any longer, because I can't say that at Hopkins we ever were really out of PPE.  So really the concern was appropriate rationing.  We eventually did two virtual visits followed by the third visit being in person.  And that really did work quite well. There was always a handful of patients where they needed to be seen in person. And in those cases, we would see them in person.  All the patients naturally were screened and are still screened for symptoms. And if they have symptoms, we would avoid an in-person visit whenever possible.  And if necessary, we would continue to wear complete PPE.  We have since gone mostly back to full-time in-person visits  and the one thing that virtual has been very, two things virtual has been very beneficial for our program are the first one, admitting new patients to the program.  Many of us have found that during the first visit in virtual where a lot of the time is spent interviewing,  the patient that is readily done virtually  and then we would plan a close follow-up for an in-home visit. And I think that we will probably continue to do that as long as we're able.  The second one is for our medical residents and our fellows.  It's really been, virtual has really been used  to enhance our fellows time because the resident can be in the home on video and the fellow can be managing the visit virtually over the phone.  And that really frees up the fellows time to not only manage the residents, but also have additional time for the other work because they're not out traveling.  So those are kind of, those are I think most of the things that resonated for our program.  Next slide.  So now we thought we'd spend some time thinking about group discussion and specifically how telehealth has been utilized in your practice, what you've learned, what's been valuable  and how do you plan to utilize telehealth going forward?  I think if we can try,  I think if those of you who'd like to contribute could raise your hand  and then we can try calling on you. And if you can raise your hand on the bottom banner bar under the reactions tab, if you click on it, there's a hand, a raise hand button.  It looks like Laura Walker, do you raised your hand first or saw your name first?  You can just unmute your, oh, you're muted, sorry, Laura. Yeah, unmute Laura. I'll just quickly share that in our hospice program, we had so many issues during COVID  with team members having to be working from home, other team members who were able to be out in the field. And so we had some innovative ways where we would do a buddy system  for the telehealth visits. So we would actually have the nurse who was able to be out in the field doing hands-on care, doing that care as she was tele-healthing back  to the nurse that was at home on COVID restrictions or at home with a sick child. And then that buddy system worked real well in an innovative way where one person could be  in the field actually working and then the other person could be back at the office or back at home, charting, ordering meds, care coordination, that type of thing.  And the patient was part of the piece as well.  Yeah, I agree. The tag team really was what worked best and our home health and our hospice nurses were definitely involved.  Some cases with telehealth,  we've been able to get specialty visits in the home and that one is usually been like one of our J-home providers are in the home and we want a dermatology consult  for a homebound individual that obviously can't leave. We've been able to utilize the platform to get those sorts of consults,  which that actually still continues as well. In a couple instances, there was some pre-op visits where we're able to coordinate a pre-op visit  so the post-op patient didn't have to go back to the hospital for their post-op visit.  So that is, I totally agree.  Dr. Malik, it looks like you raised your hand if you wanna unmute.  Yes, thank you. So essentially what we've been utilizing kind of just to re-emphasize is the home care nurse when they're there at the bedside  to provide some better clinical examination more than anything to get a better assessment so that a proper plan of care can be implemented from the provider's side.  And then also more recently as kind of things have eased off and we're doing more visits with myself as a provider and a PA I've been working with here and there  is getting consultants and doing a coordinated visit with consultants if we need cardiology, neurology where the provider will be present in the home  and then it'd be a telehealth visit with the consultant so that we can get the recommendations and further implement the plan for the home-based patient.  That's great.  Renee.  I was gonna say, we've used it for like advanced care planning with the family involved. We've also used it, you know, of course on the COVID time  and recently prior job, we used it for, you know after hours and on call with the patient we've used it for several times.  That's one that I haven't heard on call. We are available 24 hours a day as well. Most of the hospital residents cover on call.  That's, I don't know why we never thought of using the platform for those on call needs. That's a great idea.  I love what Dr. Malik added to the chat too about having virtual family members being able to be present, especially in assisted living. I know I've heard it from a ton of providers  like especially, you know, when things were shut down and they weren't allowed to have visitors and the medical provider happened to be able to be there  to be able to connect the patient or the caregiver or with that family member during the visit or even to be a, you know, independent historian for you  because it's a dementia patient can be extremely valuable.  Definitely. I think some of the positive of all this new technology has been that it's normalized to some degree that people are used to using the video platform  or having a conference call for, so families can be present with advanced care planning.  Something that I did, I never, I rarely did, you know, a year or two ago.  I just want to make sure we don't have anyone else  raising their hand. The one thing that I don't have all the details, but thinking about this, you know,  we can't, Amanda, to Amanda's point, we can't think about healthcare without thinking about the dollar. So, you know, we were all worried about the financial impact to our program.  And while I can't tell you specific numbers, I can tell you is that at the end of our financial year, we were still in the green and, you know,  made a little money despite all of this. I am at a two-day conference, come a virtual, come a,  for the home-based primary care.  Sorry, I think that was, she just meant to mute. Okay.  No, that's great. The other thing, you know, and feel free, you know, we can continue this discussion. If anyone else wants to share,  you can either use the reaction or raise your hand. But as I was kind of thinking about this myself and also from a workflow efficiency standpoint, Amanda, I was thinking of you,  I believe you said the 210 miles as a solo provider, you know, you're not gonna be able to get to your patients all the time. You know, how can you use telehealth  when you don't have to be in person or how can you supplement telehealth, you know, in virtual visits? You know, in between, I know several programs  that use it as kind of a triage or acute add-on. So rather to send the provider on a different route and go, you know, when a patient comes up, you know,  can they do an initial telehealth assessment to really understand, do you have to be in person or can you address, you know, and give some treatment  and guidance over the phone or over video? So that, you know, it made me think of you. And then also what resonated with me is the specialist  and I think especially with mental health. I'm working with a program in New Jersey and we're kind of thinking about a model where,  you know, there's a formal kind of Medicare service that's called behavioral health integration services. So it's essentially like a care management, like chronic care management,  only specific for, you know, mental health needs. And you may or may not have a psychiatric partner involved. And so essentially, you know, the psychiatric partner  isn't actually seeing the patient, the primary provider is, but they're collaborating virtually. And there's a behavioral health care manager involved.  And, you know, from the dollar perspective, you know, Medicare pays for things like interprofessional consult or, you know, can you contract with them  for behavioral health care management. So there's some financial aspects that you can consider once you kind of figure out what the best model for your practice is.  Our sort of model was very boots on the ground. We did all the work. There wasn't a whole lot of support, but that is the other thing. If you're not doing this currently,  that I would add, you know, there's opportunities for you to be efficient and have the MA get the patient on the phone or on the video call,  work through all the technology issues, enter the vitals,  have your system IT present if there's any problems.  And then the provider doesn't have to work through any of those issues. Some of the big Hopkins community physician practices,  they had that support. We didn't have any of that support, which, you know, it led to some hiccups that we all worked through. But if you're kind of thinking through  how you're gonna operationalize this, I just throw that out as sort of options to recruit help.  Dr. Walker was asking if anyone's used telehealth as components for Medicare annual wellness visits, which again, you know, talking about a visit  that's really not a physical assessment besides vitals, you know, and really is interviewing and preventative. That's also one of the services  that's allowed to be audio only on Medicare's telehealth list. We're gonna get into some of the billing and I'll review that with you all too. But I have been starting to hear,  or at least they're having a nurse, one program in Illinois I know uses a nurse to kind of do the annual wellness visits initially, virtually, like start collecting the information  and then, you know, tags the provider in at the end to finish the visit. So I have heard of that one approach. Yeah, there's very select services that can be audio only,  and I'm gonna go over that, but annual wellness visits happens to be one of them. Usually Medicare telehealth, it has to be that video visit, two-way audio,  and the majority of services still do have to be a video, but advanced care planning, for example, like Renee mentioned, that can be a phone call  and you can bill for it the same way, same with annual wellness visits.  Okay, I think the next slide, I'll turn it over to Brianna.  Thank you. Anyone else, any closing thoughts or anything about telehealth in the future? The one other resource maybe Betsy or one of my other colleagues can throw in the chat.  I had a interesting opportunity to be on a panel webinar with Amanda Tufano and another one of our faculty, Tammy Browning, where we were just kind of talking about  how do we see telehealth for the future? How can we take what we've learned and the benefits of it and really not knowing what the policy and the payment might look like,  how did that change or how are our practices developed? So that recorded webinar is available for free on HCCI's HCC Intelligence Resource Center.  And if someone can throw that in the chat for me, that'd be great.  Anyone else wanna add anything before I move on?  Okay, next slide, please.  So I think most of us have gotten used to this concept and hopefully if you tried to keep up with it like I did, there was, I think we had three different  interim Medicare final rules, like a different payment and policy every single time. But to Michael's point about how his program has probably maintained financial  is Medicare really started reimbursing the same rates as in-person for your E&M visits during this, that's temporary if it's telehealth. And they did that because they realized  practices needed to be able to survive and be sustainable in order to provide care. So they really acted so incredibly quickly. If we think back to before the pandemic,  not knowing how familiar you all with Medicare telehealth guidelines, but the patient, the home is not an approved, originating site, which is a Medicare term  meaning where the patient has to be located for Medicare to cover a telehealth service. It was really designed only for rural areas  where the patient would actually still have to travel to a healthcare facility. And it was the provider that was virtual and there's had to be in a rural  or healthcare professional shortage area. And that was the only way that Medicare would cover telehealth services. We still don't know at this point,  what's gonna happen after the public health emergency. All of these flexibilities that we have right now are kind of subject to the waivers that we have in place.  Public health emergencies are declared every 90 day periods. Right now it's through the end of July, but the HHS secretary extends those.  We predict through the least the end of 2021, we think we'll have all of this telehealth flexibility, but we'll have to see what happens after that.  There's a ton of supportive legislation right now that's pending to change, but without congressional and legislative action to actually remove the telehealth originating  and distant site requirements, it'll go back to being limited besides certain services, which I'll talk about.  And there was a recent report by the government accountability office actually that kind of expressed concern to Medicare, like, hey, we really don't have enough data yet  on the quality and the effectiveness of telehealth to completely expand reimbursement, to completely continue all of these waivers. They wanted it to be more fully analyzed  because the data was showing, no surprise to all of you, I'm sure that more people under the age of 65 were using telehealth than not. So there are definitely some options,  which we'll talk about, but just know that all of the flexibilities that we currently have in place, and there's some resources on this screen here,  and also included in your workbook that goes in more detail, but these are all dependent on us being in a public health emergency. As soon as that's declared over,  we'll have to see what Medicare decides as their final policy.  Next slide.  So if we think about the different types of, telemedicine has become such a broad term, right, and telehealth and remote patient monitoring, all these different things.  If we think of first about video visits, that's truly what Medicare defines as telehealth, where you have two-way audio and video. Right now there's HIPAA flexibility,  so maybe you're just doing that over Apple FaceTime or Skype or Doximity or one of the various other applications, but it really needs to be a video visit  to a real-time connection with the patient, audio and video.  Phone calls can be used. We know, especially with older adults that may not be able to have technology. Do they even have Wi-Fi in the home? Those kinds of barriers  and things that we have to think about, there are options for audio only.  And actually, even before the public health emergency, Medicare started to introduce what they called kind of communication technology-based services, or CTBS,  which we'll talk specifically about those codes and what those are, but that was kind of their way to say, hey, here's some options for virtual care  that falls outside of our Medicare telehealth regulations. And then I'll also talk about remote patient monitoring. And that's when you have to have a technology vendor,  the patient has a medical device at home, whether it's blood pressure monitor, remote glucose monitor, scale for weights for CHF patients, those types of things.  And that data that's collected, that physiologic data is automatically and digitally transmitted to the provider. And so you have some real-time clinical data that you can use.  You heard Dr. Chang, I believe, mentioned it during transitional care management, how having that real-time clinical data on your patients can make an impact on outcomes.  Next slide.  So hopefully you are all familiar about this. The reason we wanted to make sure you're touching it, and these slides are also really meant to be more resources for you  in case you don't have the information,  but as much as Medicare has been supportive of telehealth, they are still doing auditing a lot of it. OIG has Medicare telehealth services on their active work plan,  but that's really to try and measure the quality. But you do need to understand because we have so many different codes and options, make sure you're billing  for your virtual services correctly, and that you're doing internal monitoring. Because I can tell you, I've done a lot of audits in the past year.  And what I'm finding is unintentionally, people are confusing what codes when to use when. And so I'm auditing something that is not a video visit, but is built like it was,  or I'm auditing something that is an online digital E&M that they could have built something else for. So just really make sure you understand.  Right now, your same home and domiciliary E&M codes, you can bill those if it's a video visit. It can't be audio only, it has to be a video visit.  And you would need to use modifier 95 for traditional Medicare purposes. And that would allow you reimbursement at the same rate. Again, this is all temporary,  but if you're doing a video visit, you can bill your same home and domiciliary E&M codes with that modifier 25.  I mentioned to you earlier about the audio only services. Medicare is temporarily playing for these telephone E&M codes, which are all just time-based. That's another option.  Advanced care planning will pay the same if you do that just as a phone call. And then we also, not telehealth services, but don't forget about your care management services.  If you have a CCM program, chronic care management,  which I'll talk more about tomorrow, you can always capture your phone call time that way as well. But there is an Excel list,  and I'll put the link in the chat when I'm done speaking, but Medicare has an Excel list on their website and it has a column that shows, okay, this is a permanent service,  this is a temporary service, this has to be video and this has to be audio only. So that's your source of truth when you're trying to figure out  what can be billed under Medicare telehealth regulations and what needs to be video versus audio only.  Next slide.  Just make sure your video visits are documented the same way as a progress note would be. You know, you still have to do, you can do a limited physical exam over a video.  I mean, you still have to rely on those components. That doesn't go away.  You know, one option, of course, is to bill on time. If you can make the case for, that the visit was greater than half of it was spent on counseling or coordination of care,  which, you know, especially right now you probably can, and then you don't have to rely on the history exam and medical decision-making that we know we need  and, you know, traditional E&M visits. But I do recommend a smart phrase, and this is just an example. And depending on your state, you know,  the CMS FAQ actually said they don't require consent  from a federal standpoint, but your state policy might for true, just E&M visits that are done telehealth. But you wanna validate that it was a video visit.  And the reason I'm saying where the patient  was located at home and I was located at the office, again, this is just to protect you. You can build this in your EHR as a smart phrase  or a macro or a template that you can kind of, you know, quickly use. But this is really showing that if you did get audited, what kind of virtual service it was  and validating what you're billing for.  Next slide. So these are those telephone E&M codes that I mentioned, and you can see the reimbursement. Medicare increased these to match the office visits.  So what you need to know about these codes  is again, they're time-based. So it doesn't have to be a full progress note, but you do need to, you know, show me what was the problem  and what evaluation or treatment guidance did you give? And you have to have your total time. I need to know exact minutes, not five to 10 minutes, not greater than seven minutes,  exactly how long that phone call was. These codes will go away after the end of the public health emergency. Medicare has already finalized that,  that they only plan to temporarily pay for these. And they also wanna see that it was like a patient request, like not just you, you know,  your outgoing scheduled systematic care management protocols, like the patient called with a need, and you decided maybe that didn't need to be in person  and you were able to address that over the phone. Because the caveat with using these codes is if you decide during that phone call, you need to go see that patient face-to-face  and you make a face-to-face visit within the next 24 hours or next available appointment, just a phone call to follow up on a visit that you had in the past seven days,  you can't bill for it. So those are some of the restrictions with these codes. They're a good option in the meantime, and all of this information is summarized in a resource.  I'm not expecting you to remember everything. I'm kind of verbally going over with you today, but just so you know what codes are available.  Next slide.  There are also for our non-providers, you think of other interdisciplinary team members like your licensed clinical social workers. If you are fortunate enough to have them,  you can have them bill for their time. So just so you know, same requirements I just went over. These are just, if it's not a physician, it's not a nurse practitioner,  it's not a physician assistant, these are some other types of professionals that can bill.  Next slide.  So again, just make sure that total time and that what Medicare is wanting to see here is that it was a medical discussion that was evaluative, excuse me, in nature,  that you addressed an acute need or issue or provided some sort of guidance if you're using those codes.  Next slide.  The other thing I wanted to throw out, and I alluded to this earlier with the difference between chronic care management, like logistically, if you have a CCM program,  it's probably easier for rather than you having to document separate encounters each time is to just count it as CCM minutes and continue counting it that way.  And there is a little bit more favorable reimbursement with CCM because we can bill up to 60 minutes a calendar month. So again, we'll go into more detail from this tomorrow,  but you wanna think about, there's a lot of options right now, what makes the most sense from an implementation standpoint that's logistically gonna be easy enough  for your team to use?  So remember, I mentioned earlier the CTPS codes or the communication technology-based services. So these were actually introduced before the pandemic.  These are not Medicare telehealth services. So these are right now your audio only options when the PHE ends, if we don't have policy change.  You know, the G2012, that's that five to 10 minute medical discussion. The problem is it pays very low, as you can see the $14. So right now you wanna be billing  for the telephone codes instead of these, but so that you know they exist. These are the two that we have right now. And then there's also one,  if a patient sends you a photo or a video and you review that over your patient portal, you don't even have to directly, you know, once you receive that photo,  you do have to do some sort of follow-up within 24 business hours. So call back to the patient interpreting that, but there's actually a code again, only $12,  but that can be used for that service.  Next slide.  So these are online digital E&M. So what this is saying is again, if your patients are using a patient portal and maybe I have an example, but over a seven day period,  you're going back and forth with the patient starter on blood pressure readings and you're kind of, you know, she's giving readings, you're giving advice,  you're having her call back and you're reporting, you can add that time up over that seven day period and bill for that digital, electronic, not even a phone call communication  and collaboration with that patient.  Again, all of these CTBS services, they require annual consent. So you do have to get consent for these ones, but it could just be once a year for all of them.  So logistically, maybe make that part of your new patient paperwork or your new patient enrollment process if you're planning to use these kinds of things.  And then that caveat is if it results in the need for a face-to-face visit or some sort of more specific service, or it's just related to a face-to-face visit,  then it's not billable. Those are always kind of your caveat. And yes, Dr. Chang asked, will CTBS continue after the public health emergency? Yeah, all of these things are not new.  Actually, a lot of people don't know about them, but I believe they were introduced in 2019. These are not considered Medicare telehealth. These will all remain payable.  Next slide. Just an example of what that documentation might look like. Because again, that's usually one  of the most common questions I get is, well, what should my documentation look like? So, these slides are more just resources for you all. Next slide.  So, again, thinking about CTPS, you know, what's going to be your process for that annual consent? You know, do you, if you have staff, can you make that part of the scripting? But  also understand patient limitations and target populations. I think Michael shared one of,  in J-Home, they really had to assess which patients were, you know, had readiness, telehealth readiness. Do they have Wi-Fi at home? Do they have a computer or a smart device where  they can even do a video visit? Or does it need to be phone call? Can you do some education with them? But really understand, and this is more not just CTPS, thinking about virtual  services as a whole, what patients is it really going to benefit for you to use this for? Maybe it's just you want to use it for, you know, frequent check-ins with patients that  just got out of the hospital or, you know, something like that. Identify a target population for virtual care and make sure you're kind of assessing that. And on intake, that's  a great place to do it, whether that be a flag in your EHR that you kind of notice the readiness for telehealth and virtual services, and if you have that consent or not. And then  going forward, you kind of use that appropriately. Next slide. Before I move on to RPM, are there any questions about anything I just talked about?  I thought maybe, I'm not sure if the whole group, Brianna, is familiar with CCM and sort of how you bill for that and how you document over the month.  We're actually, I'm covering that in more detail tomorrow, so I'm going to save that for tomorrow's advanced coding talk. I promise we're going to talk about a lot of codes,  a lot of different ways, but chronic care management is essentially you count your time  per month of you and your clinical staff that's non-face-to-face care coordination and medical  management, and then you can bill for that under Medicare fee-for-service. So we'll talk about that tomorrow.  Hey, Brianna, I have a question. Can a televideo visit be a hybrid version? We actually talked  about this before, like if there's a facility nurse or a home health nurse that's at the  home and you do a televisit and the home health nurse listens to the heart and lungs and relays  the information to you, like, you know, no crackles, you know, heart tone press, whatever. Can that qualify as a televideo visit? Is that okay?  Yeah, so it's, you know, all of these things you have to take with the gray, but I mean, during a video visit, a telehealth visit, those vitals on the physical exam is always  like patient, you're guiding the patient, it's patient reported by the patient and caregiver. So if we really go back to what Medicare guidelines say is, you know, as long as you're  documenting how that information is obtained from, that doesn't disqualify you from billing for the telehealth visit. I know a lot of providers that are using the, you know, the  technology or the home health nurses, excuse me, to kind of be their facilitators or even nurses on their team, they're sending their nurses out to the home and the provider staying  at the office. So that right now, you know, from the flexibility, there's not, you know, like a black and white FAQ, but the patients are reporting those physical exam findings  or you're guiding them to move the video. So you, you know, think about your constitutional findings that that's just commenting on the patient's appearance. You can do that over  a video. Think about, you know, asking them if they've, you know, had any changes in their diet or weight. And so there's things that you can collect, but if you have somebody  else there that that's helping you with that, that doesn't disqualify you, just make sure you document that. And then there was another question about the G2010, which is the review  of the pictures of videos, if it had to be a phone call or a portal message would suffice. I believe it can be a portal message, but let me just double check later today and I'll  confirm with you in the chat. Good question though. All right. So remote patient monitoring  is a big topic. This is a heavy slide. Again, we have a resource on this too, but I've seen a lot of programs. It's a great resource, but you just have to think about compliance.  You really have to understand, okay, you know, think about my business plan, if you will, or what's going to be my action plan, you know, what the document, these kinds of things  and understand what it really is. What it's not is the patient and caregiver just calling you and self-reporting vitals. That's not remote patient monitoring. You have to have  a technology vendor. The patient has to have that medical device that they're wearing,  you know, those wearable devices that's automatically, you know, transmitting this to your practice  and you're reviewing it on a monthly basis and you're communicating with the patient and caregiver on those findings. And you can use, if you're lucky enough to have clinical  staff, you can use them for that. The benefit with RPM is again, this is not considered Medicare telehealth. So this is going to remain billable and payable after the public health  emergency. The other thing that's important to understand about RPM is they have what is called care episodes. So this isn't supposed to be endless for every single patient on  your panel and, you know, never ending. You want to define what am I using RPM for? You know, what are the treatment goals? And when that patient obtains those treatment goals,  in theory, the remote patient monitoring would end. So, and it also requires a care plan. There are certain codes, which you'll see throughout this as well, that require what's  called interactive communication. That has to at least be a phone call. That meaning that you're, you know, part of the minutes per month that you're counting as your RPM  time, you are directly communicating with the patient. I think this is something too, because it's fairly new. I think two years now, CMS has been paying for this. We're going  to see a lot more guidance about in the future. So it's definitely kind of a hot topic, but  you also need that separate formal care plan document. You have to identify what the specific  treatment goals are and how you're using it. Next slide. So I'm going to take you through  kind of sequentially, because there's, I think, six or seven altogether different RPM codes. But like I know one practice, I think in the first five months has ended up being about  $5,000 in revenue for them. So it really does add up. But you have to kind of understand what code to use when. So the first code, 99453, is what you're doing for the initial  patient and caregiver and set up. And this could be your clinical staff even doing this under your supervision, especially through telehealth. But, you know, you're giving them  the device. You're telling them how to use it. You know, you're kind of going over things. This would be one of the first codes that you bill. The 99454 is, you can bill it every 30  days, but it's billed at the end of the month, because one of the caveats with RPM is you have  to have at least 16 days of data. So this is, essentially, it's intended to reimburse the  practice for the expense that you're having to pay for, because you can't bill Medicare for what  you have to pay that technology vendor. You're supplying the patient with these medical devices.  So it's intended to give you some reimbursement for that. It's once a month. You bill it at the  end of the month, as long as you've had a, you know, continuous 16 days. It doesn't have to be consecutive days, but throughout a 30-day period. So throughout a calendar month, you  would have had to at least collect data for 16 days to bill for RPM. There is an exception right  now for two days, but that's only if it was COVID-related. And that 16-day requirement, Medicare already came out and said they're keeping that. That's not going away. If you  don't collect data for at least 16 days, you can't bill for any RPM.  Next slide. So I mentioned that care plan, and you can think about how timely that is,  especially if you're doing it as a provider. To me, this is an option to pay you as the provider  for doing the care plan. So this is non-direct patient time. You don't have to be on the phone  with them or anything like that, but it does have to be a full 30 minutes. What CMS and their  rationale, and all of this can be found in their final rules, not that any of you want to read  those long, terrible documents that I have to read, but they're saying, you know, you get all  this data from the patient. What we would expect you to do is review that first month's data,  and then that guides your care plan, and that's going to inform you on how you're going to use  it. And if you spend 30 minutes doing for that, we'll pay you for your time. And that's where this code would be coming into play. Next slide. And these are those kind of monthly  care management codes. These are the codes that specifically require part of the time to be that  interactive communication. So it can't just be over the digital platform that you're using.  Somebody has to pick up the phone and call the patient or do a video visit to talk about their  services. Again, similar to chronic care management, it's 20 minutes per calendar month.  It can be in addition to your provider, your clinical staff, their time can count for this as well. So if you think about rolling out an RPM program, maybe you're going to have that  care manager or that care navigator really be the one that, you know, as you're reviewing the  readings and interpreting advice to them, they're talking with the patient or they're calling them  if their blood pressure is out of range. They're doing all of those things. So you can use your  team for this, and then this could be billed monthly. At the end of the month, again, if you've  met the time threshold, first 20 minutes is the 99457. If you spend 40 minutes, you can bill 99457  and 99458. That's for each additional 20 minutes. But again, keeping in mind this is under the  treatment plan. So again, what are, I kind of always like to tie back to implementation  considerations. You know, how are you going to actually make this work? Even as an independent  provider, I know several independent practitioners that have RPM programs, they've been able to find  some affordable technology vendors that are using this for their patients. But you do have to  consider that. Also with this, you know, older and medically complex population, you know, are they  going to be able to use it? How easy are those devices to use? What kind of use cases are really  going to find it? Because I've also heard some negative stories where I tried this, my patients  hated it, you know, they were taken off the devices, I wasn't getting the data, and it was  just an epic failure. So really understanding, you know, what it's best to do. And if you have a team,  how can you use them? Amanda said, can I bill for RPM when I review the telehealth from home  health? No. So this is really just, the patient has a medical device, and you're reviewing those  direct readings. And they have to be, CMS defines automatically as digitally transmitted to your  practice. So again, it's either remote blood pressure, glucose, weights, pulse ox, those kinds of things that are being digitally transmitted to your practice through a technology  vendor, because they have a medical device in your home, and that's what you're reviewing. But Amanda, we will talk tomorrow about some other ways you can bill for your time  interacting with those home health nurses. So if you go to the next slide, these are the resources that I mentioned. They're in your workbook. Maybe someone on our team can put  the page numbers in there for you. But everything we went over about what am I billing for right now  with telehealth? When can I bill a video visit? When can I use telephone E&M? And then all of  those requirements I just spit at you about RPM are summarized in these documents for you. And  if you have any questions, you can always reach out to HCCI. We have a help at HCC Institute  email that I monitor. You can reach out with questions anytime, and we're here to help you.  Brianna, one thing about remote patient monitoring that I've heard since we lasted this presentation was that a patient had to have a hospital encounter within 30 days to be able to  initiate RPM. I don't know if that's a Medicare requirement. Yeah, I'd be curious where you heard  that. So it definitely doesn't have to be a hospital. It does have to be initiated during  a face-to-face visit, which right now could even be a telehealth visit. So you would have had to,  it can't be after the public health emergency, it's only for established patients. You have to  during that face-to-face visit, support the need for RPM and initiate it. But I've seen nothing,  if you find anything out that you hear otherwise, Michael, but I just spent extensive time reviewing  all the guidelines that came out about this. I've seen nothing tied to a hospital encounter. It's  tied to a face-to-face visit, but not a hospital encounter. It's very possible. It's how the agency  just rations resources. Yeah. Yeah. Thank you. Thank you so much, Brianna and Michael. If you  want to put questions in the chat about this session, you are more than welcome to. We're going to go ahead and transition to medication management. In that session, Michael will be  leading us. There will be a slide presentation and then we're going to go into two breakout groups.  Have a facilitated breakout session, and then we'll come back and debrief together. Again, if you have questions for Brianna, please do utilize the chat and know that she's going to  be with us for extensive coding advisement tomorrow. Michael, just let me know when you're  ready. Okay. Thank you. I'm set. We're going to be going over medication management. This is  your first interactive session where we'll have some group work. This is also our first  opportunity to apply and think about Tom's discussion of the five Ms. Remember what matters most. The second one, maintaining mind and mentation. Third, mobility. Fourth,  medication. Fifth, multi-complexity. This is where Paul will also think about Paul's discussion about the physiological changes in medication management in our complex older adults,  as well as the TCM and the transitional care management and care coordination and thinking about med changes that may have occurred during those care transitions.  So, in doing that, we're going to talk about some evidence-based practices and tools that are available to help you consider medication management, identify pitfalls and potential  dangers related to polypharmacy, and really think about a structured approach to de-prescribing,  and then review strategies to maximize adherence with medications for your patients and caregivers.  Next slide. So, thinking about polypharmacy, just some data points here. Although the elderly patients comprise of only 13% of the U.S. population, they use over 33% of the annual  prescribed medications. Approximately 50% of hospitalized or ambulatory care patients or nursing home residents receive one or more unnecessary drugs. And then lastly, the adverse  events that occur that are related to drugs represent at least 15% of older adults, which contribute to ill health, disability, and hospitalization. Next slide.  This table shows several articles that you can represent. There are six studies that think about polypharmacy in older adults. And the first study by Quattro was in an ambulatory  setting. And here they found that one-third of male and female adults greater than 75 years of age were on greater than or equal to five prescription meds, and almost 50% were using  over-the-counter and dietary supplements. In the Rossi article, almost 60% were on one or more  unnecessary prescription medicine. And then Hajar and Niboli looked at hospitalized patients.  Hajar looked at the USA, United States hospitalized patients, a study with 384 patients, and found that 37% were on nine or more prescription medicines, with almost 80%  on five or more medication. The Niboli study was in Italy, and those hospitalized patients found on admission that 52% were on five or more prescription medicines. And at discharge,  67% were on five or more medications, which is a 15% increase in the percent of folks that were on  five or more meds. Imagine what happens if you have a patient that's repeatedly admitted  throughout a year. And then Dwyer and Bronskill looked at patients in the nursing home setting.  Dwyer's patients were in the States, 13,507 patients, and 40% were on nine or more prescription medicines. And Bronskill was 64,000 patients in Canada, and 15% were on nine or more  medications. What I found curious here is what's Canada doing? There was only 15% on nine or more  medicines, as opposed to in the US, 40%. For those of you that have worked in the nursing home  or subacute rehab setting, you know that prescribing and the prescribing cascade is really  looked at regularly in those environments, and it looks like maybe Canada is doing something  different than we're doing. But what these studies really say is what Paul alluded to earlier, is there's no clear-cut definition of what polypharmacy is and or how many medications  are considered safe. And these articles really talked about, you know, is it five? Is it nine?  We're not really sure. And even in no matter what care setting you're talking about. Next slide.  So this picture talks about polypharmacy-associated factors and commonly used terms, which we'll just spend a minute or two going over. I think in your intro session, you talked  about the physiological changes associated with age. Remember, these are those things that,  such as the change in the composition with muscle, fat, and water within the body. And then  the changes in organ function and how medications can be metabolized and used appropriately.  Next slide. Under-prescribing, sorry. Back one.  I'm sorry about that.  No problem. I just want to illustrate a couple differences that are always clear. Under-prescribing is not treating an illness that has  a readily accepted, avoidable, catastrophic events. And that would be something like  not getting blood pressure to goal that results in a stroke or not getting heart failure to goal  that results in exacerbation in a hospital or worse. Over-prescribing is generally pretty obvious.  Over-prescribing a drug at a dose that's not recommended considering the patient population and their associated morbidities. Mis-prescribing is simply drugs prescribed in error.  Prescribing cascade, we talked about a little bit already. It's the addition of medicines  to counteract symptoms associated with another medicine. So like, you know, adding potassium when they may not need the supplement if you can modify their blood pressure regimen.  And then recent hospital, you always want to think about that and the medications that have been changed and are they still appropriate? They were hypotensive in the hospital. Now  they're back at home eating their regular diet and their blood pressure is back at goal.  Or above goal. And do they need their anti-hypertensives back? And then those visits to specialists, are they going to cardiology? Are they going to endocrine? Are they sort of  looking at their one disease and only thinking about that? And oftentimes I find sometimes they have to undo what they've done with the specialist visits. Next slide.  So I'm thinking about sort of a standard approach to de-escalating meds. The first one is really  to identify what's the issue. And to do that, there's two tools that you can use that you may  or may not be familiar with. I think most people are familiar with the AGS-BEERS criteria. The most  recent version was published in 2019. In 2019, I believe they made it a little more difficult  to get the information if you're not an AGS member. But the BEERS criteria really focuses on  over-prescribing and mis-prescribing. And it categorizes medications by body system or treatment.  And then it says medications that you should avoid or versus avoid when possible. And that's  sort of, it's a little more liberalized than the previous publication.  And then the start-stop criteria is a European published tool by the Age and Aging Society.  And the stop portion of the tool is a screening tool of older persons who are potentially inappropriately prescribed drugs that they shouldn't be. And then the start tool is a  screening tool to alert the prescriber to the appropriate treatment. The start-stop tool is  also organized by system. It's not as readily used as the BEERS criteria in my experience.  Next slide. So thinking about a deprescribing algorithm. First, you want to reconcile all medications and an indication for them paying particular attention to possible prescribing  cascade. And always remember over-the-counter supplements, a lot of times patients don't  report them. And then you look in their med bin and the Benadryl's there. Or I had a patient that  was using Afrin just the other day. And so, you know, keep your eyes peeled for the over-the-counters  and supplements. And then thinking about reconciliation, here's a mnemonic webs which asks you to think about what's the medication. And the one that I find most important is how  are they taking it? Because sometimes we say, are you taking it? Rather than how often are you  taking it? Or when do you take it? So how I find is most important. And then efficacy or does the  medication work? You've been on gabapentin, this great big dose for how many years? And we're not  even sure if it's helping at this point. What are barriers to taking the medication? I'm thinking  about multiple daily dosing. Paul mentioned copay barriers, those types of things. Any potential  side effects that they're having related to the medication? And then how often do they miss or  skip a dose? I always incorporate caregivers in this discussion because generally they may be able  to be the source of truth or they'll tell you, you know, they kind of are, they may be more ready,  able to admit when medications aren't being taken appropriately.  Then you want to review the overall risks of the medications using the beers and or the start-stop  criteria, as well as your clinical knowledge of the physiological changes in your patient, as well as their adherence. Next slide. And then thirdly, you want to assess each drug  for the ability to be stopped or discontinued. Generally you want to pay attention to the  highest risk medications. The beers criteria gives you good definitions for this. Thinking about like  benzos, pain, opioid pain medicines, and what you can stop those highest risk meds stopping first.  Drugs that are no longer found beneficial, you may think about tapering or stopping those.  I find that it's very common when patients come out of hospital or rehab, they may be on more than  one antidepressant, more than one pain medication or medication that's intended for use of pain.  And then the last bullet point there, I kind of already talked about the financial burden, and can you try to either stop duplicate medications or if you're able to prescribe  one pill that has two drugs, many antihypertensives, lipid drugs may limit co-pays.  And then four, as I said, prioritize the drugs for discontinuation,  and those should be the ones with greatest harm, and those that are easiest to do,  to stop that you don't have to discontinue slowly. And then five, finally implement and closely monitor. I always tell my patients to call if they have new or worsened symptoms with  deprescribing, and that we can always go back up on a medication if they can't tolerate  those symptoms. It helps to give them a sense of control. Sometimes you know that they've been on these medications for years and years and years, and it can be very difficult  to get them to agree to stop a medicine. Next slide.  Okay, so Paul talked a little bit about Minerva. Hopefully you spent some time reviewing our case  study. This is where we're going to actually get to know Minerva for the first time during our two  day session. You're going to be divided in two groups, and you'll have a facilitator with you  that'll help you manage your work, but essentially you're going to look at all of Minerva's medications, and then think about the evidence-based tools that we just reviewed quickly,  and what medicines you would attempt to deprescribe. You have a table in your workbook that will help you think about how you may systematically approach deprescribing.  I've got everybody ready to transition into breakout groups. So there will be Michael's group. I'll be in there helping you, Michael, pulling things up for you, and then Melissa  will be in with Dr. Chang. So give us just a moment, and we will place everyone into those two groups. Thank you. Okay, so hopefully you all had, is everybody here?  Yeah, I guess so. Looks like Dr. Chang's group is still working their way back in.  Yeah, I closed down the groups, but I think it gives a countdown, so they'll start coming in. Oh, there's everybody. They're showing up.  Can I advance to the next slide?  Or maybe if you can pull up the medication list, if it's easy.  Sure, I can. Give me just one moment. I would say start your debrief, and I will go and grab that.  So how about if I just go down the list of medications real quick, and if you'd like  to say a few words about what you would do with that, what your group decided to do with the  medication, that would be, I think, easiest. Just try to raise your hand, and whoever gets to the  unmute first, I think, is fine in the interest of time. So the Dinepazil, how about the Dinepazil  and the Memantine, we'll talk about them together. Anyone want to talk about those two?  The Dinepazil and the Memantine is something that I kind of brought to the table, or was one of my thoughts, is because the Dinepazil,  this patient has had a dementia or Alzheimer's for six years or more. So after what, two years, they're saying that these medications are just not as effective anymore. So to me,  in an 80-something-year-old female or patient, it would become more of a pill burden, and you can have side effects from both of these medications. The more medications on board,  the more problems that you're going to have. And what I always try to do when I'm going in to see my patients, is I'm always trying to think about what is the most important thing,  what is the thing that makes them the sickest, what's the thing that's going to send them back  to the hospital now. So she has been utilizing the emergency room in the hospital a lot because  she has had congestive heart failure and she has had cellulitis. So I'm assuming she was treated  in the hospital for the cellulitis. A lot of times when they go into the hospital, they'll come home  and they don't have all the medications that they started with. So there'll be some changes in that.  So first thing I would do is I would look at the medications and Dinepazil and Memantine are two  that they're not adding to the treatment plan for her congestive heart failure or her cellulitis,  and they possibly could be causing some problems in her behaviors and as a pill burden. So that's  kind of my take on those two. Yep, I think that's what I, anybody want to add anything else? You might think about choosing one and tapering it down, monitoring for changes.  Michael, that's what I was going to say, maybe just starting with the Memental and tapering that down and see how she does the next couple of visits. And then maybe,  you know, we may need to taper down the Dinepazil and maybe come off of that. My thing sometimes  too is that we don't think about the quality of life for these patients. We're so focused on how  they're feeling physically, but mentally, you know, when they first come home, they may be  feeling groggy. They may just be feeling confused overall because they've been in hospital and  rehab for a while. And it just takes a minute to get readjusted being at home. So that may not be  a decision that I can make on the first visit, you know, I have to see him, see them when it's a  transition to home visit. So that may take a couple of visits. So sometimes that's not one of those quick decisions that I'm going to make, you know, so just wanted to add to that.  Thank you. And then how about the isosorbide?  So here in our group, we talked about the value of sort of the history of prescribing and is she on isosorbide for a reason that we're not sure about right now?  Has she had chest pain in the past? It doesn't sound like she's had chest pain in the past,  but we may cautiously think about stopping the medication. She's not having any obvious chest pain. This may be a remnant of when she was more functional  and up and around and was she having chest pain with exertion or who knows, was it a behavior that wasn't even chest pain? It's hard to decide,  but it's something you might think about trial dose reduction. And if I could just say something else on this, either way, I'm gonna let the cardiologists know  cause they may not know that this patient was in the hospital. I'm gonna let them know that this patient has just been recently discharged and whatever the plan is,  whether I'm gonna keep this patient on this medication, not reduce it or whatever, I am gonna let that cardiologist know as a collaborative provider working with me.  Great. And then how about the diuretic? Let's talk about the diuretic, the potassium, the magnesium.  Does anyone wanna talk about those three?  We talked about those, kind of the dosing of the diuretic twice a day. It seems like we might be able to do a simpler regimen and weiner to what we think the safest doses  that's managing our symptoms, that taking into consideration the potassium, we would need to clearly cut back on that as well,  especially given chronic kidney disease, kind of ensure that her renal function's stable and then looking at her electrolyte panel with the magnesium, does she need it or not?  Was it just thrown on there cause it sounds like a good thing for hypertension or was she truly with the hypomagnesium?  And then the discussion was brought up about the PPI and hypomagnesium implicated with diuretics.  And they're like, just really making sure does she need it or not? And if she does need it, that we're gonna utilize it. And if she doesn't, we'll stop it.  Yes, excellent. And Nicole adds that she needs that second afternoon dose to try to get it earlier in the day, which is good.  And thinking about the adherence mnemonic webs,  I just throw out there to evaluate efficacy here. And is the diuretic even working?  And yes, absolutely about our electrolytes with the potassium, the magnesium.  And what about the metoprolol?  Again, that's a medication. I'm looking at her symptoms. First of all, her blood pressure, I guess you said her blood pressure was controlled. Her pulse, making sure that's fine.  That's another one. We're also gonna consult with the cardiologist just to let them know what's going on. We may reduce the dosage. And just depending on what my collaboration is  with the cardiologist, we'll go from there.  I don't know. Those are one of those that we just have to see what the condition is of the patient in mind and just the input from that specialty provider and go from there,  looking at the patient in a collaboration.  We agree.  In our group, we talked about possibly changing it to the extended release to minimize the burden of multiple daily dosing.  And what about the hydrocodone acetaminophen? And her pain medications?  I had mentioned to our group that the behaviors that she may be having may be secondary to pain. And is she actually getting the hydrocodone or even the Tylenol scheduled?  So something to consider and talk to the family about. Yep. Making sure that if she is getting it, that she doesn't exceed the total daily dose of Tylenol.  Also addressing constipations.  And then how about her levothyroxine?  Here, our group, we talked about making sure that we have a thyroid, at least a TSH panel before we would make any changes there.  And the omeprazole.  So our group talked about possibly, yep, she doesn't have any documented symptoms recently. So it may be a medication that you can try to stop.  It may be a medication that was part of a prescribing cascade, you know, to counteract the symptoms of a medication or antibiotic that she was on short-term.  So you may be able to just stop that or taper down or even use PRN.  And then how about the occuvite multivitamin?  Here we said, these may not even be indicated anymore, especially considering pill burden.  And they're likely, would be able to be discontinued.  I agree, Nicole, about the rebound reflux. And I generally always try to taper the PPI.  Because if those symptoms rebound wildly, you're never going to get them off of it.  So just for another quick minute, I'd say, if you had to prioritize one or two medicines, which would you start with?  If we were deprescribing, I would start with the deneprazole. If we were treating her edema in her legs,  I would probably switch from Lasix over to Bumetanide and start with one milligram in the morning.  Good.  Nicole says, votes for stopping the vitamins. It's probably the easiest. Yeah, I agree with the vitamins. The deneprazole taper.  So I'm going to move us to our key takeaways. This conversation has been phenomenal. So it can continue in chat. We just want to give everybody time to go grab their food.  So if you want to continue chatting about this, that would be wonderful. Continue to confer with one another. Michael's expertise will remain available to you regarding this topic.  So if you do need to go grab some food, please go ahead and do it. And then you can rejoin. I just want to give everybody that opportunity.  We're going to get back together at one o'clock Central Time for Workflow Efficiencies with Brianna. But Michael, if you want to hang out a little bit  and see, I will just keep everything open. If you do leave the area though that you're currently working in, please don't exit the Zoom. Just mute and turn off your camera.  That way we don't have to worry about making sure you can get back in and all of that. Because we want to make sure that at one o'clock Central Standard, you are ready to go.  So I'm going to mute myself. And if you guys want to continue, if anybody wants to hang out with Michael for a bit, please do.  I'm here. I mean, there's really no right or wrong answer.  Hopefully this just gives you sort of a structured approach to think about deprescribing.  We really covered all the key takeaways here and there are resources in your handout if you're interested in looking at those in more detail.  Thank you, Michael.  Hello, everyone. We are about to invite Amanda and Brianna to lead us in the workflow efficiencies session. So, if you are nearby, please return and turn on your cameras.  Brianna and Amanda will be ready to go in another minute or two, and you can let us know when you're ready for slides, Melissa will be the person  that you're queuing through the session. Thanks, Melissa. Thank you, I'll try to be on cue. I'm pretty sure you're a pro, so. You guys, I was going to say you all are, always are.  Thank you. Thank you. You guys are phenomenal, phenomenal faculty to work with. So I think whenever we're ready, oh, good. I'm seeing some sharing in the chat.  We want to give everybody an opportunity just for that for the next couple of minutes. Please do share your contact info to connect with fellow learners, if you would like to.  Your website, your LinkedIn profile, anything you feel you want to share. You're very welcome to do so in chat so you can connect with your colleagues after this workshop.  Yeah, I was just going to give everyone a minute, I didn't know if you guys wanted to talk about that, but I think that's so great.  I know a couple of you that I had the opportunity to connect with were asking about virtual networking opportunities.  So we are facilitating that the best we can, but I think you've overwhelmingly heard from your peers and your colleagues that you're all kind of in this together and it takes  a team. And so for those of you that are wanting to connect with other people that are doing this  work and compare strategies, I think this is one great way to do it is just share your information in the chat or private message each other. Definitely encourage you.  We always learn as much as we teach every time we do this, because you all have such great insight and experiences to share.  So just wanted to give everyone the opportunity to connect with one another. But with that, Melissa, whenever you're ready to transition to the slides, we can switch over.  All right. So I, Amanda and I are going to tag team this, I'm going to start us off and then Amanda will join in.  But Amanda, you're welcome to, you know, pull your camera on and chime in as always, anytime. So when we started this, a lot of you were talking about wanting to, you know, how can  we be efficient? How can we optimize workflows? What can we do to be able to provide the best quality of care, access of care, but in a  timely and efficient manner, which is really challenging in home-based medicine that, you know, a lot of in a clinic-based practices, there's just a lot of things and factors that  you don't have to worry about that you do here. So if we start us off and go to the next slide.  So learning objectives are, we're going to talk about some functions within a team, you know, what your front and your back office might look like within a house call program.  What kind of professionals are you going to use to do those tasks? You know, you may be starting off on your own and growing from there, but, you know,  what kind of considerations and things need to be accomplished. And then also, you know, think people, processes, and technology, you know, three things to optimize your workflow.  So how do those three things blend together? So this triangle is really just to emphasize, which again, we've overwhelmingly heard today,  home-based primary care or house calls medicine, even if it's home-based palliative care, you know, is really a team approach.  You know, you can't do this together, so you want to recognize the value of who you can surround yourself with to be successful and impact patient care in the most meaningful way.  And for those independent providers, you know, I'm thinking of April, Amanda, Greg, you know, think of informal team members.  I mean, your team doesn't necessarily even have to be someone that's employed. You know, I don't know if we brought up today, like your local area on aging or senior services,  generally they have social workers, or if your patients have home health or hospice, you know, do you put a flag in your EHR so you know when you can, you know, utilize the  home health and hospice team in your patient care? So really, like, develop your network, and I would encourage you to think of, you know,  informal team members as well if you are starting small. You know, obviously you're going to start off, none of this can be accomplished without the clinicians.  We need people to provide the care, and again, many of the clinicians may be doing your own practice management at the start, and then networking with those social services, but  I wanted to take a moment to give everyone the opportunity either to share in the chat, or if you are comfortable unmuting yourself, that's fine too.  For those of you who have teams, what, how is it different from when you started to where you are now?  Are there any roles that have really just been so impactful to your practice, and do you want to share a little bit about what those roles are and why you decided to go  that direction with that team member?  And while everybody is maybe thinking about this, I'll give you an example. I was working with an independent physician assistant in Maryland that owns her own practice,  and it was just her. You know, she had a little under 100 patients, doing everything herself.  I was working with her to review her chronic care management program, and, you know, just really seeing, you know, the workload and the bandwidth and everything that she had  to go through, and out of the work, she ended up hiring some care managers, and really chronic  care management, which we'll talk about tomorrow, was the way she funded those care managers, but it has just made such a difference in her workflow.  So even if you can get someone part-time, I mean, you have so much to do to just take providing direct patient care and taking care of these patients, that having, you know,  knowing when to hire and what that person can do as far as making a difference in how many patients you're able to see, what you're able to do, maybe just having a little bit  of a work-life balance. So definitely encourage you to think about when to hire, and when you do hire, it's equally  important to realize what kind of skill set do you really need, who's the best person you're going to have on your team, and hire the right people from the start, and then  retain that talent, and, you know, keep those people on your team, because it's really hard,  and this work, you know, even in the front or the back office really takes someone that's understanding of the population you serve and what you do, and that's going to look  different for smaller programs than it is for a larger program. You know, a smaller program, you're going to start small.  People are going to wear many hats, like that care navigator. You know, you might lean on community services rather than having your own social worker,  whereas a larger program, you can get more specialized. Maybe you have just a set scheduler or some other things.  So LCSWs, I saw, Michael, those social workers on his team, yes, absolutely, and, yeah, Sarah, you're echoing the difference that the social workers make and things like that.  Anyone else want to share? Or you can feel free to continue sharing in the chat. Okay, next slide.  So one of the core processes I want to start with is when you think about your patient intake.  So when you first start your program, or for those of you who are new, yes, we know that we take care of generally older people or people that have difficult, that are medically  complex and it's difficult for them to get out of the home, but what's your eligibility criteria and then how does that relate? What kind of screening?  When you first get that phone call or you first get that referral or you first find out about a new patient, what happens?  You know, what kind of questions, whether that's built into your EHR or it's just a questionnaire that your team, you know, even a paper word document that they're going over  verbally over the phone, maybe it's in your new patient packets. Think about what kind of information, yes, demographic information, but also things like  why do they need home-based care? Have they had any recent hospital admissions? Do they have a healthcare power of attorney?  Are there any pressing needs that they need their provider to be aware of at the visit? You should definitely have an intake screening questionnaire.  What are the questions you're going to ask all new patients and what is the information you're going to collect and how are you going to house that?  In your EHR, great, but, you know, there's other ways to do it too. Just make sure it's documented and that it's unified.  And then when you're thinking about those new patient forms too, are you just going to have them on your website? Can people fill it out digitally?  Obviously not maybe the patients, but their caregivers that might really be a time saver  or are they going to send it in fax, mail, you know, you're getting the information electronically, whatever the case may be.  Think about flexibility and options to collect that information for your patients and ease for caregivers.  That telehealth screening too that we talked about earlier, their readiness for virtual care, maybe you integrate that into your intake assessment.  The other piece too, and I wanted to wait to end is not having correct demographic and insurance and not verifying your patient's insurance information before you see them  for the first visit is a huge impact. I mean, you know, just for example, especially if it's a patient themselves that are kind  of having to go through their enroll themselves, a lot of them don't know when they're on Medicare Advantage plans.  My family members would still tell you they're all on Medicare, even though they have a United Healthcare Medicare Advantage plan.  I know that. They don't. So really making sure that you're verifying and collecting correct information up front  and before visits, best practice, it should be verified every time, you know, or at least,  you know, again, if you're a solo practitioner, you know, periodically enough that you understand  if their insurance changed that you don't get those pesky denials and you're not getting that revenue that's coming in on the back end.  We have a home-based primary care practice intake guide to kind of help you develop your script and what that might look like and that resource is in your workbook.  But also encourage you on intake two to ask smart questions about who are you calling for appointments?  Who are you calling for, you know, communication preferences and things like that and document  that in an easy central place that everybody on your team can find it because sometimes it's different.  Maybe one daughter handles appointments and the son is a nurse and lives out of state, but he wants to be called with medical results.  You need to know those things up front and store it in your EHR somewhere. Next slide. Brianna. Yeah, go ahead. It is Amanda. Yeah.  One other thing is if there's an insurance you don't take, make sure that everybody knows that and that you allow for timely in the fall because everybody's picking their Medicare  Advantage plans and you want to know quickly what everybody has and if you don't take one, if they still have time to switch. So. Yeah.  I mean, in a pervert world, right, you want to see every patient every time, but you do have limits.  You know, know what payer you're credentialed with or, you know, if you start receiving denials and that payer won't credential with you, you do have to understand that.  So again, those intake on intake, how are you verifying this patient lives in my area that can accept their insurance?  I have all the information I need and I'm collecting as much as I can before that provider goes out for that first visit. That's a great point, Amanda. Second. Great point.  Again, we're all about people working to the top of their licensure. You know, clinicians, not everybody, again, has support staff, but how can you be maximizing your time?  So you're doing direct patient care and using your clinical judgment and doing things that only you can do.  If you do have clinical support staff and you do hire even a medical assistant over a nurse or an LPN or an LVN, depending on your state, you know, what kind of triage  protocols can you put in place? And they don't have to be extensive, but think about things as simple as, you know, standard  number of refills on medications, continuation of home health and hospice orders, DME, you  know, simple wound care orders, or home health nurse calls about a patient having UTI symptoms,  you know, automatically get that UA and culture, you know, ordered or what's your process? Do you start with just the UA?  So things like that, and that'll depend, you know, medical assistants and RNs have different scope of practice and what they can do for you, but you can really maximize that, and  you should have this documented, and then you should review it with your team, you know, make sure your providers are comfortable with what your clinical staff can authorize without  that message having to go to you. I call them touches, you know, how many things have to go to the provider without there being  any action taken, you know, that's kind of the definition of waste. So, you know, where can you decrease those redundancies or the work, you know, and really  empower people to work to the top of their scope? Next slide. Prior to the visit, number one, you have to confirm appointments.  They have to know, you know, don't do it too far in advance. I usually say two days to a week prior before you're going, there should be a reminder call.  Yes, we like to assume that these patients are homebound and that they, you know, don't go places, but sometimes they might have dialysis, daughter has to be there to open  the door, and when you're thinking about an assisted living facility, I'm a big fan of verifying room numbers, too.  These patients move around sometimes, the last thing you want is your provider having to spend time when they're at the facility trying to track down where the patient is,  and that also gets into talking to the DONs or somebody at the facility and letting them  know who you're going to see on that particular day so they can have those patients, you know,  the first patient's in their room and not at lunch, you know, can they send you a recent MAR and wait, all of that information in advance, and it also kind of flags them if there's  any additional patients you need to add to your schedule without that having to be a last-minute thing.  So appointment confirmation and kind of getting that information up front, extremely important.  And then, you know, of course, from the provider perspective, you know, it helps you prioritize if you're reviewing things in advance, like the chart in advance, that's really going  to help you, you know, do you need additional supplies, or some providers may call on the way and ask patients to have their pill bottles out and ready.  You can tell them that during that appointment confirmation, but really taking the time to kind of do all of those things.  So geographic scheduling came up a lot today already, too, so we're going to talk a little bit about it today, and we have some, you know, scheduling resources, technology resources  we'll reference, too, but when you're first starting out, you have to decide how far is too far, right? Where's my boundary?  Can you get that visit window within as close proximity as possible? And if you have multiple providers on your team, you know, what's their zones?  You know, start, it could be basic, you know, start with territories, or if it's just you, what zip codes or, you know, areas really make sense for you to travel to on the same day?  You know, we have a sample scheduling guide. It could be as simple as Mondays and Wednesdays, I'm going to be in these areas, Tuesdays and  Thursdays, I'm going to be in this area, and that way you have a plan for clustering appointments automatically when you're scheduling that.  Again, if you have, you know, teams that can help you do that, think about process, document processes.  I know we talk a lot about documenting processes, but when I do workflow assessments, I'm always kind of apprised.  Sometimes it's just people didn't understand roles and responsibilities, or, you know, things, there was a breakdown that way.  And then assisted living or group homes or senior communities, you really need to know where your patients are, keep running lists, so, again, you can cluster those and communicate  appropriately, but, and tweak it and modify, ask for feedback, you know, if you had a really stressful day where you were crossing each other over, you were like, wow, I can really  never see, you know, Mrs. Smith and Mrs., you know, James on the same day, because that was just too hard. How are you going to fix that for next time?  Next slide. So you also want to think, once you have a general plan for what patients and what areas  are going to be seen on what day, you also need to think about driving routes, because you have to think about where you're going to start and end your day, and then what's  the most geographic route to see each patient that's on your schedule. This is why assisted living and group homes can be such a great business plan, because  you only have to go to one place to see multiple patients, but for your home visiting patients, how are you going to accommodate that?  And also, you know, when you think about the timeframe, you do need to give them a general idea because you want them to be ready and available for the visit, but don't, you know,  put yourself on a, where I'm going to be there at exactly 9 a.m., or those kinds of things.  So giving patients that window of time rather than that exact time, and we also, you know, when you're at the home, I'll come see you in a month or three months or two months rather  than giving them that exact appointment date, so you have flexibility to change it. And then considering, you know, the timeframes, if you have two distances that are super far  apart from each other, and trying to take breaks, you know, there's a lot of needs that your patients that are not on your schedule are going to have.  If you're waiting until the end of your workday to address any of those messages or do any  of those callbacks for those other things, that's really going to add to, you know, bandwidth.  If you have clinical staff, number one, that's really hard for them to get at the end of the day. And if you're by yourself, that's just eating into your evening hours. Next slide.  So again, just kind of summarizing scheduling, you want to have a plan, know where you're going to be on what days, provide those flexibility and approximate timeframes.  You have to have a plan for acute and urgent visits too, whether that's keeping some open  spots on your schedule, maybe you have a provider of the day that has a lighter schedule that accommodates that, knowing what your productivity standard is.  And then, yeah, actually, April, I'm glad that you brought that up, having a driver. So some house call providers will have medical assistant scribe, somebody else that's driving  the provider. That is such a great thing for the provider, because rather than you driving, you can be doing things in between.  You know, you don't have to think about maximizing, you know, billable time or working at the top of the scope.  So if your providers are doing clinical care in between, because somebody else is driving, that can be a really great thing as well.  Not every practice has that opportunity, but it can make a huge difference. Next slide. So these are some of those technology resources.  And I will say, especially for those who don't have a huge team, this can save you so much time with scheduling.  So you're not mapping and plotting that out, you're using a technology solution to do so. These are just some of the ones I'm aware of. Watch Geo is the newest one I'm aware of.  You can really just create a, import a spreadsheet of your patients and their locations, and it puts them in a color-coded map. It's pretty easy and cost effective.  Road Warrior, you can download the app for free, and it'll tell you driving routes for up to eight patients in the free version, and it'll also tell you your mileage and things  like that. Or maybe you're just using Bing Maps, you know, CareLink is a more advanced platform that has a lot of these things.  But look into these things, especially if you don't have as big of a team. It's really worth the bang for your buck to have some sort of technology that's doing that for you.  And with that, I'll turn it over to Amanda. That's great. Thanks. I just love this talk, and keep your eye on the chat because so many resources are being  thrown out there too, if people like it or they don't like something. Okay, slide. So first, again, as we talk about efficiencies here, let's talk about your EHR.  So we do regular check-ins to evaluate how people are using your EHR, your providers, your clinical staff.  What we typically find is, you know, you roll it out, you bring someone in, you say, here's how to do it, you create a worksheet, great.  Typically in EHRs, there's about 10 different ways to get something done, and so then someone gets in a habit. It might not be a habit that you like.  It might not be a habit that's going to work with future workflows as you're coming along. It might be a way that has actually created more inefficiency in the system, and so once  it comes to you and says, I have 25 clicks to get anywhere, and you say, we trained you for five clicks.  I don't know how this could happen, and people try to solve their own problems. So just, again, you want to find your own check-in basis for making sure everybody is  the most efficient in your EHR.  And then, again, these kind of shortcuts, again, could be long cuts, but they're short for them, and then they could be inefficient, and or they could be storing information in  a place you don't want information. So, you know, how do you think about coding tips, template examples, software updates? How are you pushing those out?  How are you pulling information? What does that EHR maximization look from the user perspective and from you as a system enterprise?  Also, you may want to, but you probably think about your EHR vendor today as just a vendor, but start to transform that thinking to how are they partners?  How are you getting the most out of your EHR? How do you know in advance what's coming? You know, make sure you're on their listservs, their chat groups.  If you're bigger, push to sit on a committee of theirs. You know, continue to talk to your account representative about the things that you're  doing and how you would love to be in a beta testing of something. You know, I mean, there are, everybody's in kind of different EHR situations, of course,  and some are tied to using really big ones, but for the medium size or smaller EHRs out there, there's typically a lot of flexibility to have some actual influence in what you're  creating. So, again, I think it's both this like individual user and this system maximization and system programming that you could think about. Slide.  Another one is EHR templates, and so how do you build in all the documentation pieces that you need without weighing the moment down, right?  How do we have and capture the correct information, right, the right information at the right time, the right place?  And so, you know, the templates, these are pretty basic templates, but if you haven't thought too much about them, you know, definitely reach out to Brian, and I'm sure we have a  lot of supports, and some of them come off like annual wellness visit, come off of Medicare and stuff like that.  But how do you build in your system some of the basic things, maybe a key phrase for documentation, your basic new patient annual wellness visit follow-up, what are the things  you're trying to get out of them?  Advanced care planning, are there things that you maybe ask as part of your advanced care planning that's important to your practice that's an extension of POLST or MOLST, right?  Chronic care management consent, what's that workflow exactly look like, and what does the template look like?  I could go through all of them, I won't, but those are the types of things in which you want to look at it.  And Brian is the best at speaking to this, but sometimes when you create all these templates, then you create a process called cloning, where you saw the patient a week ago, you're  seeing them again, you're seeing them obviously for a reason, but you clone the last visit, and then you just change just a couple of the things that have changed in the new visit,  and you want to be very careful with that from an audit perspective. So I'll let you kind of talk about the pitfalls of kind of this copy paste or cloning previous  messages, but some thoughts for us, Brianna.  Yeah, I mean, you want your templates to, like, I don't want you as a clinician to have to remember what are the billing and coding requirements, right?  So I like them more general, like here is the framework, but then you customize it to what actually went on with that patient or what occurred during that visit.  You know, cloning, the formal definition is when two entries look exactly alike or very similar to previous. So where that would come into play is like a medical necessity audit.  All of a sudden I'm looking at your assessment and plans and I'm seeing the same thing for multiple visits. You know, that could, you know, and then sometimes you forget,  like as a provider I've also seen where they're like, oh my gosh, I was, I meant to remove that, or I didn't even know that was there.  And all of a sudden your note starts conflicting each other with a wound that didn't exist, that you told me was healed, but then I'm seeing it in the other part of your note.  So that's really where you want to be careful with that.  Thanks. I see some of the chat is talking about inventory and supply ordering. So we're just, I mean, thanks for the setup on that guys. From a supply ordering standpoint,  some of you are again, a couple of you are tied to really large organizations and there you may be benefiting from their supply chain already.  From a small or medium-sized practice and growing practice, you really need that flexibility so you can minimize or eliminate expired items.  And what does that look like for you guys? You know, what are the things you need most often? How much of that inventory do you actually need?  Does it have an expiration date and who's tracking that? I can tell you from our practice, we really keep it all in an Excel document  and we go through and do a pretty regular inventory check of things we need and things we don't need.  I mean, COVID really pushed us from a supply ordering standpoint, you know, and I think maybe the pendulum, I don't know if everybody's in this boat,  but the pendulum may have swung pretty far the other way. We can't get supplies, we get supplies. Now we're stockpiling supplies as if there's going to be another global pandemic  in another year, so knock on wood here.  And practices can also join group purchasing organizations. So a GPO might be a really good option  and you can reach out to larger vendors, Henry Schein, I think maybe McKesson, a couple of these are larger organizations that can do smaller areas for you,  but you get the benefit of being in a larger purchasing group, maybe for the city or your area of expertise. So that's really cool. If you are with other small practices, you know,  there's some, you know, Chicago, Florida, where there are a lot of practices together, maybe kind of form an alliance and kind of do your own GPO  where you're like, hey, I individually only need X number of chucks, but I really, but we all need this. And it's a bigger order if we join together.  So hopefully, you know, come up with kind of those ways, but yeah, that's something to think about. Slide.  And then from an inventory standpoint here, and one of the discussions is, and maybe everyone can jump in of like, how much do you keep and then how do you travel?  So sometimes people overstock their cars. Sometimes they stock it just for the week. You really want to see how are the providers who are taking stuff out of the supply closet  or whatever that looks like, how are they doing that? So a couple of ideas. One, if you're not going to dictate and say, you know, every Friday, come in and get your supplies  for the next week, that's okay. And each provider, you just need to know what the providers are going to be getting. Are they getting it for the month?  Are they getting it for the week? Are you, if you have a big expansive area, maybe you don't have an office in every location, but maybe you choose to keep some supplies  at someone's centrally located house in areas that are not very convenient. For example, we go maybe 50 miles up from here. And so we keep some supplies just offsite  so people can get those as needed. So really kind of create that system of this check-in of the providers at their convenience when you need to pick up those supplies  and then have this person that's really monitoring the supply piece. From a, what are things that should not stay in cars due to temp sensitivity? I would say anything with liquids,  anything that has any sort of like photosynthesis issues, if you have any of the lab draws or anything,  or anything, especially in very hot places. I know we have Julianne from Phoenix. You really have to be careful with some of the plastic supplies  because your car is going to heat up very significantly.  And maybe someone could actually jump in. I'm not sure, but isn't it like 20 or 30 degrees over whatever the outside temperature is or your car is heating up?  Other things not to keep in cars  that I missed, Brianna or anyone else?  Paul, I don't know if any of the clinicians wanna jump on. Like we would, the extra boxes that like, you know, like things that you, you know,  like gloves or sandy wipes and, you know, things that are pretty commonly used. I don't know if any of the clinical people wanna jump in  and share what you store in the car versus what you don't. And then we can comment on Anna's comment about the cost of an MA. You know, is there any logic with the number  of how many more visits per day? Yep. I think I'll do the MA question first. I do believe two extra visits a day does cover the cost of the salary  and benefits of a medical assistant. And I do travel with a medical assistant and Brianna is absolutely right. I have a quota luxury, which I do,  of sitting in the back and just going over my messages, doing refills, placing orders, and so on and so forth. It is such a more efficient use of my time,  not to mention all the stuff that my MA does during the visit which I won't go into at this moment. The other, oh, the other question is what we,  we try not to keep a lot of supplies in the car. As Amanda said, there are a lot of things, the car gets really hot in the summertime. And in Chicago, it's just downright cold.  So there are a lot of things that doesn't do well with temperature extremes.  So the stuff that we use day to day, we carry back up into the office with us at the end of the visit, just to make sure they are fresh and ready to go. Thanks, Paul.  Yeah, we have a session on productivity and kind of staffing tomorrow. But yeah, I mean, if you aim for the, you know, between five and eight visits per day, you know,  depending if you're doing four alone, if you can make two extra visits, that would generally cover the cost of the MA, I agree.  And I was Googling how quickly your car can heat up. It looks like, you know, in about, you know, 10 to 20 minutes, you can get about 20 degrees hotter than the outside.  So certainly something to think about of what you're keeping in there. And if, you know, I mean, I guess if your plastic's a little soft, that's still the efficacy of it, right? So.  The other thing I wouldn't keep in the car is chocolate, Amanda. So I saw a message there,  does my MA pick me up? Yeah, no, she doesn't pick me up. It's just like, oh, it's like a drive-off service, such service. No, I go to the office every morning.  We have an office at Home Care Physicians. So that's where our staff exists. That's where we keep our supplies and so on and so forth. So we, I meet with my MA in the morning.  We go over to schedule and we talk about, you know, what is needed today? Do we need, you know, how many PPE, you know, for COVID, like how many PPEs do we need to pack?  How many shots do we need? And so on and so forth. So we go out together from the office at Home Care.  I mean, maybe if you had more chocolate in your car, you know. And I was gonna say too, like Renee to your comment, I mean, I have heard of MAs meetings  that like meeting at the first patient's house, you know, if you don't have a virtual office or it's a virtual MA and things like that. So there are other ways that you could do it.  Okay, slide.  We've talked about a couple of things around community partnerships, but anything in your practice that can be outsourced and everybody is just in different journeys on this.  And that's why I love this group is because we're all learning together here, but you know, how much time are you spending chasing down resources?  We talked about this comprehensive resource cheat sheet and it can be certainly more formal in an EHR. It can be on a shared drive, but you know,  how do you even, again, Word document or Excel have a cheat sheet for all of those who are coordinating resources? How do you understand what resources are available to you?  There's a lot of divisions of aging for your city or local partnerships we've already talked about, especially in the form of grants. So I can't remember who said it,  but someone's pretty heavy grant funded. And I think that is super cool. Even if you're not, and you know, we talk a little bit more tomorrow about some of the financing pieces,  but if you're not considering grants, there are grants available. And so they're worth looking into and there could be grants available for specific things.  And so you might have a grant around a person resource, a thing resource, a product resource of what you're delivering in your work. So there are opportunities.  And then are your providers drawing your own blood? Are you hiring phlebotomists? And what does that look like? And what does your local lab look like?  You know, one of the first questions that always comes up and it's less with x-ray than it is with lab is who's going to be collecting the blood? Are you billing for the blood?  You know, and then how are you going to get the blood back and who's, and how quickly can you get that information? And what does that look like?  And so if you're drawing your own labs, where are you delivering it? Is it worth your time to go out there? Are you partnering or are you adding it  on to another visit for being there?  Are you going to say something Brianna? Oh, nope, sorry. Oh, that's okay. Slide.  So key takeaways. We cover a lot of the efficiency things and the essentials piece, but really this is the solid foundation for your practice. And if I could impart you on anything  is every time you're going to change something, we're going to introduce either a new person or we're going to introduce a new service line or clinical workflow.  Just take a quick look. It is worth the day just to revisit what is the existing workflow and does it still work for the situation if we're going to make a change?  And now we're going to do X. Now we've added wound, some of our wound care stuff. Does some of the other touching adjacent work still make sense for this practice?  And so it just, it isn't, I love to think about what keeps us employed is that we always have new things to think about. And then how do you leverage technology for efficiencies?  Technology is a real balancing act, right? Like how do I have enough technology to be successful and in the areas where I really can find these efficiencies  but not so much technology that all my people are logging into five different systems a day just to do their job. Are there any things that can kind of work together?  So as you review, should we move to a different EHR? Should we move to a different type of ancillary vendor? What are the other products?  So in any time we ever do a tech solution kind of RFP, we always put in there, what are the other solutions they offer? And is it possible in the future  to ever move any of other stuff under there? Just in case. Technology, when it works, it's great. And we take it totally for, you know, we take it for, or why am I missing that?  But anyway, technology is great. And then when it doesn't work, it's just the worst. We had a brand new provider starting this week  and the technology didn't work for her for half a day and she was beyond frustrated, right? So luckily we're very kind and nice people up in Minnesota. And so are all of you.  And then how do you partner with local community organizations? How do you define, Brianna talked about these roles and responsibilities. And then how do you empower your staff  to work on top of licensure? That also takes a lot of diligence. So we as a practice have been known to write letters to the federal government and to our local government  and our state government to talk about licensure and what that looks like. And so how do you become an advocate and at a legislative level to push opportunities  that just for the life of me, don't make sense. Like these diabetic shoes that APPs can't prescribe just beyond insane, but that is a thing in our world.  So, you know, how do we keep pushing everyone forward and advance our practice here?  So thank you.  Wonderful. Thank you both so much for that session. So many good practical insights were shared. The chat was amazing. So we will make the chat transcript.  Give us about a week or two. We're gonna comb through the chat transcript and pull out these gems that you all are sharing. And we'll find a way to share them  in the learning hub with you because there is a lot of great advice.  You all are so experienced and it's really you're developing a knowledge base just in our chat for this workshop. So we thank you very much. I'm gonna take over for slides.  Paul, Dr. Chang, whenever you're ready, we've got management of advanced dementia and behavioral disturbances in the home. We've actually got Paul for the next few sessions.  So I wanna encourage everyone to chime in, use the chat, make it interactive. That way we'll keep his energy up because I do know that Dr. Chang is highly energized  by what you all share. So please do anything that strikes you or resonates with you, please do speak up. So give me just a moment and I will get our slides up.  Well, thank you. So we're waiting a couple of things. If you're gonna make the transcript of the chat, you can take out my comment about the chocolate. Just kidding.  But all kidding aside about the chocolate and the supply that Amanda was talking about, and in light of COVID and everything, do keep in mind, you might wanna think about  what's the temperature if you do give vaccinations and if we need to give a COVID booster vaccine in the fall, which we're not sure of,  do you have a cooler and what is your cooler like? How should it be packed to make sure your vaccine stay within the appropriate temperatures so that it doesn't lose his potency?  Again, just thinking about technology, thinking about inventory, thinking about costs and obviously taking care of your patients and not letting things go to waste.  Well, thank you for the introduction. And as Janine said, you're gonna be with me for the next little bit here. So I do want this to be more of an interactive  couple of sessions. Please feel free to share in chat, unmute yourself and participate. More than happy to stop my presentation. So I can have a break and you guys could have  maybe just a change of venue as well. I told my staff earlier on, if we're gonna do this long stretch in the future, I'm gonna put in like a yoga or Pilates session here  in the middle, just so that everybody can get a break. And we've got 10 minutes in ahead of prognostication. So you guys will have two sessions together,  then we'll have a 10 minute break and then we'll come back for advanced care planning. So we did build that in. All right, I'm ready when you are Dr. Chang, just let me know.  It sounds good. And if you wanna do Pilates, those 10 minutes, that'd be great.  Next slide, please.  First, I wanna thank Dr. Allison for providing us with these slides. He is an amazing clinician, geriatrician, and he is so well-versed and such an expert.  And he crafted these slides for us to go through today. So I wanna give credit where credit is due. Next slide, please.  So the objectives today are to discuss optimal care,  treatment goals, management strategies for homebound patients with moderate to late stage dementia. We want to help you identify potential triggers and behavioral disturbances  and to assess appropriate preventative strategies and to discuss non-pharmacologic and pharmacological approaches to the treatment of this condition at home.  Next slide, please. And I don't know about you all, but the many years I've been doing this, this is one of the most, I think, vexing problems for me,  my office, the caregivers, the patient.  It is so challenging for us,  for me to address sometimes. I think partly is because the caregivers are stressed, the patient is non,  how can I, what's the word I'm looking for? Can't really follow direction, not rational. Sometimes it is hard to redirect them and there's a lot of disrupt at home.  Often there's a crisis, there could be physical or verbal escalation.  And I think as a clinician, one of the main challenges is that  there's not a quick fix to this, right? It's not like you got pneumonia or UTI, I give you antibiotics, you're in heart failure, I give you a water pill and a day or two,  you are just great. And we have guidelines to guide us.  This condition is challenging. We don't have what I call microwave answers. We all want quick solutions, right? We don't have microwave answers.  There's not an easy flow chart for me to go by in terms of if A, then B, if B, then C.  So I welcome any suggestions. As Brianna said, we often learn as much from you as we teach to you guys as faculty.  So behavioral and psychological symptoms of dementia or BPSD affects a lot of people with memory impairment.  They're associated with a lot of morbidity  and rapid functional decline. And like I said, there is no FDA approved medication for this and there is not a standard, there is not a cookbook, there's not a flow chart  for the management of this condition. And I think that adds a lot to maybe some uncertainty  and challenges as we face these patients as we take care of them. Next slide, please.  So what are some of the common BPSDs that we encounter?  Well, we can see our patients change in their mood, in their thinking and in their activity, right? Example of changes in their mood is, they could be anxious or a little bit manic  or depressed, change in their thinking.  They could have delusions, hallucinations and suicidal ideation. I saw a patient two weeks ago, she was telling or she was asking one of her assistant  or her aid at this facility that if she ate her jewelry,  can she kill herself that way? There's abnormal thinking there. And then there's changes in activity. It could be apathy, it could be agitation, it could be wandering.  About a year or so ago, I went to a patient's home and the poor son is just exhausted. He actually has pushed a sofa or it was a desk  in front of the door. He's got a front door and a back door to prevent dad from escaping. So he was just so worn out. There are inappropriate sexual behaviors.  There's sleep activity cycle disruption. There's disordered eating behavior. Let me just see if I can pull up, I can show you.  This is a patient that I saw three days ago and the family again, they're just kind of distressed about taking care of mom because, and they have to deploy this particular device.  And I don't know if you can see it on my phone here. Let's see if this shows up.  I don't know if that shows. That's a particular, there's a lock that they put on the garbage can.  And they have a lock on the refrigerator and so on.  So I asked, why do you put a lock on a garbage can?  And they said, because mom goes in and eats trash.  So these are the challenging situations that we face. And again, there's not like a anti-trash eating medicine that I can give for mom. So the patients often look to us for guidance  and I hope I can give you some tools on how to help our caregivers and help our patients.  Next slide, please.  So what are some of the tools that we have today for treating BPSD? Number one, I'm gonna talk about assessment tools.  I think in our group, we talked about, oh, it was on a medication management discussion,  assessing why the patient might be demented.  Is it because that she's in pain, that she is acting out? Maybe we need to keep the Norco going because her behavior is related to pain. So we need to have a good assessment tool.  I'm gonna talk about non-pharmacologic approaches as well. And then we're gonna talk about, we're gonna spend quite a bit of time on medications, even though, as I stated,  there's not an FDA approved medicine for BPSD, except for perhaps one, which we'll talk about in a little bit.  Regarding farm approaches to BPSD,  I'm just curious, what are some of the, you don't have to give specific names, but what are some of the categories of medications that you use when you're faced  with a challenging situation? You can use a chat box, you can just unmute yourself. Again, I want this to be a kind of an interactive time.  Thank you.  So, we got SSRIs, atypical antidepressant, antipsychotic, benzos, antipsychotics, trazodone, Prozac, same, some pain medications, we're going to talk about all of those.  Anybody else? Any favorites? Medical marijuana, we'll talk about that as well. Routine Tylenol  for pain. Seroquel might be a favorite, sure. Neuro, Renee, help me with that. Melatonin,  gotcha. Remeron, mirtazapine, sure. So, we have medications from really multiple categories, right? Whether it's antidepressant, whether it's antipsychotic, we got medical cannabis,  we got benzodiazepine. Sounds like we are all trying medication from different categories to help us manage this kind of patient at home. Feel free to share ongoing chat box  or just go ahead and speak up if you have any other comments. CBD, thank you. Next slide,  please. So, what are some tips that we can give you in terms of assessing what's going on with  our patients when they're acting out or when you get the phone call from a facility or from a  caregiver or family member and say, you know, grandpa is doing such and such, you know, can  you help us? So, there are a couple of things that we need to go through in our minds rather  than reflexively, yes, we'll talk about the black box one in just a second, rather than just  thinking, oh, just give grandpa, you know, quetiapine and that'll be the end of that message. I think it's good patient care that we take some time to do a couple of things.  One is to gather some information, all right? You know, learn about the onset of the patient's  behavior. Is it in the morning or often it's, you know, the sundowning, is it in the afternoon?  What are some of the precipitating events that causes the patient to behave badly? Is it when  it's time to shower? Is it time to get diapers changed and so forth? You know, what is the context of this change in behavior? Is it because now there's a new caregiver that's here  that the patient doesn't know or maybe that the patient just moved to a facility from home?  So, what is the context? Are there other pre-existing conditions that you need to be aware of,  such as frequent UTIs? Does the patient have a history of diabetes and so forth that could be affecting the patient's mood? And the other important piece of information is if it's  possible for you to get some data on, you know, what are we trying to pass? What worked? What didn't work? You know, maybe grandpa was on quetiapine at one time and such a thing,  either positive or negative happened. So, it's important to get that information as well. The  second is to make sure that you have somebody who has legal authority to authorize medication  or intervention on behalf of your patient. We're going to talk about the black box thing in just one second. So, it's important to have that documented and noted in your chart.  Are there some unmet psychosocial needs that we need to be aware of? Is there some insecurity issue? Is there some family stress or family dynamic issues? Is there loss of a friend,  loss of a spouse, or even is there loss of independence, such as driving a car or not managing your own medications, right? And the last thing in terms of gathering some information  is medication. We talked about it. You know, Michael talked about reducing medication burden.  The Bayer's criteria, especially those with high anticholinergic effects, drug-drug interactions,  and so forth, take a good look at the medication that the patient is taking and use the tools that  Michael has suggested for you to go through in terms of deprescribing  the medication that could potentially be causing the patient's problem.  It's important to consider, again, you know, pain, constipation, urinary retention,  sleep disturbance, infection, other metabolic effects, withdrawal from medications, possibly a neurologic event. And don't forget, you know, is there a communication barrier  or sensory deficits, vision, hearing, that we think that the patient is apathetic or maybe  depressed, but in reality, maybe the patient just can't hear. Maybe his ears need to be clean. Maybe  he needs a hearing aid. So, those are just important things for you to think about as you get that phone call from the patient. Next slide, please. Or from the patient's family.  So, when we engage ourself, when we are talking with a patient with memory impairment,  remember, you know, to identify yourself. I go in when I visit with a patient, I have my badge,  and I tell them, you know, who I am and tell them, you know, I'm Dr. Chang. I'm here to  take care of you. It might be a little harder now with COVID with the whole mask thing. You know,  they may not be able to hear you, see your face. So, hopefully, as the pandemic improves, that perhaps some of the mask requirement might be relaxed so that our patients can see our  facial expression, maybe hear us better. Make sure you have good eye contact.  Speak slowly, not necessarily just loud and yelling at them. That may not be effective.  Use short, simple words and give them yes and no questions, if at all possible.  Give patients one question at a time. And if they don't understand it, repeat the same question  with the same wording, if at all possible. Again, try not to confuse them, like, you know,  he just asked me two questions. Should I answer the first one or the second one? All right.  Nonverbal communication can help. You can point, like, are you having trouble with your heart? How is your breathing? Other ways to help patients understand, like, you know, that's  what I'm asking. I'm not good at telling jokes. So, just be careful of that. Sometimes the joke  may confuse the patient or might sometimes make him even more upset. And please be reminded that  we don't have to argue or convince a patient who's confused. You know, you don't have to tell them, you know, your wife died, you know, 20 years ago. Come on, get with the program.  You don't have to. And it's probably just be more aggravating to the patient if you try that route of just arguing and convincing. Try to take on the patient's perspective,  if at all possible. Think about what he might be going through with the changes in his life,  the loss of this and that, and see maybe you can better appreciate why he is behaving the way  he is. And again, embracing their reality and not trying to argue and convince. Next slide, please.  This is just a way of putting the last couple of slides together and put it into an action plan.  This is developed by Dr. Helen Kales. She's written about this approach called the DICE approach. And DICE stands for Describe, Investigate, Create, and Evaluate. Describe,  you know, tell us about the situation when the problem occurs and the physical or the social  context when this happens. Does it happen, say, during the change in shifts at a facility?  That's just an example. Investigate. Again, we talked about, you know, what is the patient's  overall health? What dementia symptoms are we trying to alleviate? What are the patient's medications? And how do you respond as a caregiver or as a staff member, you know,  when the patient is aggressive or agitated? Create a care plan, such as, you know, I'm going to  make a medication change or I recommend a change in environment for this patient or treat some  underlying condition, whether it's hypoglycemia or constipation or an infection. Create a care plan  and then evaluate your plan. How's the plan working? What is working and what is not working?  So, this is the DICE approach in terms of a non-pharmacologic assessment and management  of patients with BPSD. Next slide, please. What are some other non-pharmacologic aids? Caregiver training, and I'll talk about caregiver burden in the next session here. Again,  educating them, telling them not to argue, to, you know, make sure the patient is safe, and then maybe they just need to walk away and decompress from the situation.  And it's really important to have me time for the caregiver. Environmental adaptation, like I said, whether it's modifying a garbage can or I've seen patients' families tape over  microwave buttons, so only certain buttons are available for the patient so that they will not  confuse the button on the microwave or on the phone. Only the speed dial for, you know, the son  and daughter and whoever is available to the patient to use. Tailor activity program, whether  that's a physical program, physical activity, or a mental activity program for patients to be  engaged with, that can be helpful. Music, for example, having the patient listen to his or her  favorite music during a stressful time, such as bathing or changing, perhaps that can decompress  some of the stress. Aromatherapy can be tried. There's been some study looking at robots in  terms of improving communication with the patient and to help with agitation. Pets can be helpful  in terms of helping with the quality of life for our patients. And finally, there's some research  that needs to be done, but simulated presence, such as a recording of your voice or an audio  and video recording of yourself talking to mom or dad and say, you know, hey, you know, I miss you.  I hope you are having a good day or something like that perhaps can be helpful in de-escalate  the agitation and the behavioral problems that we face. I want to stop there for a minute. I want to hear other people's, anything else that others have tried that's non-medicinal.  In the facility that I worked at we used the small cats that are not actually cats, the stuffed animal cats that make the purring sounds that look very lifelike, the baby dolls.  Yep.  I see some comments. Schedule phone calls with family. Respite care for the caregiver. Consistent availability to communicate some major reassurance to my patient's population. Yep.  That's awesome. Having a dementia team and audio books. And fidget aprons. That's awesome. Karen what's on the apron. Can you can you describe.  There's multiple things. Um, we've had patients that were carpenters in the past and they had little plastic hammers they had just little fidgety tools that they could that they could maneuver and they're all secured to the apron or the belt or the blanket.  We've used the women that used to do like work with their hands and things like that we had little buttons that they could button and unbutton.  We had a whole team of people that were making these fidget blankets for us. It was really wonderful. Got it.  Great. There was an earlier question about family insisting that that this is a UTI and but in reality could be PPSD, you know how to deal with that.  I was actually in a discussion with the hospital. It's, it's such a big problem. It's not just know limited to to this discussion on the panel there are hospitalists primary care docs er docs and infectious disease clinicians.  As you can imagine, ID is telling us that we are watering way too many tests way too many us treating way too many anti by a patient's antibiotics when it's really not necessary.  I think from us PCP from the emergency room is exactly what what we're facing is, you know, you know, we're looking at the family's insistent that this is UTI.  And this could be a cultural thing in a sense that you know grandpa has had this 10 times in the past, you guys have always given her him antibiotics and now you're not going to.  So all that is to say that it is a challenging conversation. When it comes to UTI and not UTI antibiotics no antibiotics and the risks we all know with repeated use of antibiotics have a patient on the message I was taking care of over lunch.  Now he has C diff from use of antibiotics. So all that is to say I don't have a simple answer. We can certainly again share decision making.  Talk it over with the family say well it could be this it could be that we can give it a trial of antibiotics, or conversely, can we can we watch grandpa for a couple of days and see how he does, and avoid the risk of exposing grandpa to another  course, and the possibility of C diff. Any, any insights wisdom from others.  I was, I was just going to say I think for women sometimes as they get older atrophy vaginitis is under treated, which can, which can lead to UTIs continuous UTIs and as well as BPH for men I think that's one thing that we need to look at.  That's what I was going to say and I was also going to say for our patients sometimes adult daycare for our demented patients I think that sometimes that helps with respite care, as well as give an outlet for our patients as well.  Awesome. All right.  All right, let's move on. Let's get into the specifics regarding medication, probably the one that most commonly used category medication are anti psychotics listed here is that the original or the typical anti psychotics a prototypical drug is heloperidol.  And you can see the suggested dose there.  And what is the evidence say it's really no safer and no better than a typical anti psychotics, and then there's some side effects that's listed there which I will talk about in about two slides.  In terms of potential risks. Next slide please.  So these are the typical anti psychotics and probably a lot of us are.  We use this category of medications, and whether it's ever purpose all reserved on quote I've been well lines of pain, those are the common ones that I use out of my practice.  So, the one that has the most evidence in terms of benefit for agitation and psychosis are the first to the air, air proposal, and respire don't.  And you can see again the dosages to the right of this box here. Next slide please.  Somebody already mentioned the FDA warning, which we'll talk about in a little bit.  You can make patients tired causes orthostatic hypotension trouble walking, they are already a fall risk, and we are giving them more risks of falling right, whether it's dizziness or orthostasis.  Extra parameter symptoms including target dyskinesia metabolic effects such as the risk of diabetes, would use of these agents.  And the last is the FDA warning of increased cardiovascular adverse events and increased mortality in patients with dementia. Next.  And this is the FDA black box warning it talks about increasing in death. When compared to placebo.  And these, these deaths are often related to heart, such as heart failure, sudden death or infectious process, most commonly pneumonia.  And you can see the drugs that were included in the studies pretty much the common ones, or the popular ones if you will, that we use for our patients. Next slide.  So, the American Psychiatric Association did issue some guidelines in terms of antipsychotic use in patients with dementia.  Again, they talk about tried non pharmacologic intervention first.  And to use anti antipsychotics when agitation or psychosis is severe dangerous and or causing significant distress to the patient. I would almost add there, or to the family members, or to the caregiver.  There's a, there's a phone call that came in a few months ago, the daughter's just begging Dr Chang for some medication, because the caregiver is about to walk out the door and they are just in a panic because dad's behavior has been, has been so bad.  Heloperidol is not the first choice. Again, we talked about using risperidone for psychosis and agitation.  Or eripiprazole for agitation.  Monitor the patient's response with a neuropsychiatric inventory, which I'll talk about that. Well, you can, for the sake of time, you can Google that in terms of the eight or nine different categories and a severity that's graded there in the MPI.  And you can document that to see if your intervention is effective.  Don't use these medications forever don't just keep on refilling them. After a couple months reassess taper if at all possible, and then document you know I tried a lens of pain and it didn't work.  So that on call provider or future providers taking care of taking care of the patient will not try the same thing again. Next slide.  Again, document document behavior. What have you tried.  What symptoms are you targeting and education and getting the consent from the patient and family, or the other caregiver coordinate your care with other clinicians that's involved in managing the patient.  It's a cardiologist, because a lot of these drugs prolongs what prolongs your qt.  And many of our patients, or should say some of them are on qt prolonging cardiac drugs such as amiodarone, and then that needs to be a discussion in terms of you know what to do, have a time frame to assess the results again don't just keep refilling  for 90 days with three refills right we don't we don't want to do that.  Reassess document benefits, and also the downside of your intervention. Again, just like with many other medications lowest possible dose shortest possible time. All right.  And evidence suggests that typicals are as dangerous as a typicals.  Any pearls from you all regarding when you have when you have that FDA warning conversations with care caregivers or family members.  How do you go about doing that is that well received, or is that a barrier thoughts. Comments.  I see Cliff has something to contribute. So go ahead, please, Cliff. Well, I have the conversation with my patients and the family about the atypicals and the antipsyte.  We used a lot of Seroquel and Olanzapine and Risperidone in my previous job. And most of the time, the family really appreciates you discussing it with them.  Because what they hate is when you don't discuss it with them, and then they Google it later, and then they come back to you with, have you read?  Their eyes are gigantic, and they're all freaked out, and then they don't want to use it. So we have the conversation about it's all about the,  and it's harsh to say, but sometimes it boils down to the quality of the life versus the quantity. And just the idea that this may be the way to make sure that mom, grandma, dad is  comfortable in their own skin and is going to be more, because they can't control their emotions. And so when you phrase it with, you just  have to have a very serious conversation about it and let them know that, yeah, there are risks with using these medications. And it might go badly, but it can be very beneficial.  It might go badly, but if the goal is to not make mom a zombie and to have her have a better quality of life during the interim, then they usually  appreciate the honesty in having that conversation, rather than having to discover it on Google later. Great comment, Cliff. Totally agree, having that preemptive conversation  rather than having to backpedal, so to speak. I think it shows that you are knowledgeable. You're confident. You have thought things through. You don't take this lightly.  You are aware of the risks, and you have considered that before you are offering it to mom and dad to treat their condition. So absolutely, yes, it's important  to have that conversation up front, rather than trying to recover.  I just, if you don't mind, Paul, I'd add that I had the conversation early. And if they decline, I also include in the conversation that family and caregivers have to be  able to get their sleep to be able to care for our patient. And if that breaks down, we're going to be in big trouble. And then I leave the ball in their court  to let me know when they're reaching a breaking point, and maybe we need to try some medications. Yep, excellent. Thank you. Janine, just logistics here a little bit.  I think I'm going to end this session at about 2.30, and then we'll move on to the next one at about 2.30. I'm still planning on ending at 2.50, OK? Wonderful, got it. Thank you.  All right, next slide, please.  What about anxiolytics? Somebody mentioned benzodiazepine, or one part of the Z-drug family, right? Lorazep, you can see the common ones that we use here.  Again, there's very limited benefit in terms of acute agitation, but there are significant adverse effects. And there's problematic in getting these medications  to our patients sometimes. By that, I mean, how many of us have gotten those letters that says your Lorazepam is restricted, quantity is restricted, or you have  to write a justifying letter to the facility's pharmacy saying that you understand the risk and whatnot. So getting coverage is an issue, getting these warning letters.  And I'm not trying to be upset about those warning letters. I appreciate the warning letters. And marginal benefits in the use of these medication  makes it a little bit risky for us. Again, we do use it for acute agitation, but just, again, being careful of ongoing long-term use. Next slide, please.  Again, benzodiazepine, sedation, fall risk. Some patients get disinhibition. They get more agitated. It does impair their cognition. And then long-term use, developed tolerance  and some withdrawal if you stop medications abruptly. Efficacy data is minimal to support at best. And long-term use, there is concern about increasing,  actually worsening, increasing the risk of dementia. Buspirone, side effects, headache, nausea, and sometimes it can cause agitation. Next slide, please.  The one category of medication that I've increasingly, medications I've increasingly using more is the category of SSRIs. And in particular, in particular, is citalopram.  That's the one medication that probably has the best data in terms of evidence supporting it for its use. Again, you can see some of the recommended dosage.  Again, it does prolong QT. Some of the other SSRIs listed, again, there's limited data in terms of management for agitation, aggression, psychosis, and so forth.  So me, just personally from my practice, I've resorted to the use of citalopram. Next slide, please.  What harm can they do QT? We talked about agitation, insomnia, nightmares. Some can get sedated. Don't forget hyponatremia can happen  in patients who take SSRIs, as well as increased bruising and bleeding through platelet effects that these agents have. Some medication can cause loss of appetite.  Others can cause increase. Next slide, please.  I didn't see anybody, or maybe I overlooked it in terms of using anticonvulsants. Early on in my career, valproic acid was used,  I should say routinely, maybe frequently is a better term in terms of management. But there's really no good evidence to support that.  Carbamazepine has some data, potential modest benefit. Again, you can see the dosages there. Other anticonvulsants, or antiepileptic, or AEDs,  I think they're called now, the Motrigene Gabapentin Topiramate Oxycarbazine. Again, there is not a lot of evidence supporting their use. Next slide, please.  Again, side effects, carbamazepines, probably the most serious would be Stevens-Johnson syndrome, hepatotoxicity, agranulocytosis, hyponatremia, valproic acid,  sedation, thrombocytopenia, weight gain. And one thing to keep in mind is for my patients who are on this medication, I periodically  check an ammonia level because it can cause serum ammonia levels to go up. Gabapentin, the number one issue that I face with gabapentin,  probably to sedation, leg swelling, probably the two major ones. But you see some of the other potential side effects that you can see with gabapentin. Next slide, please.  What about quinidine dextromethorphan? The official indication, this is a medication called Nudexta. That's the brand name. The official indication is for the pseudobulbar effect  related to neurologic diseases. There's been some study looking at agitation in patients with dementia. And you can see that it did reduce agitation and aggression  rated by caregiver. Clinician ratings show significant change in agitation, although the overall quality of life was not dramatically different.  It is a costly medication, just to keep that in mind. And this is a potential medication you may want to consider in case the other medications are not effective.  What's the side effect of Nudexta? You can see a lot of GI upset, cough weakness, cytochrome P450 interaction. And elevation in liver function test and QT prolongation as well.  Next slide. Somebody mentioned, what about cannabis? There are three agents here listed on the slide. Dronabinol, there's some evidence to suggest  that it could prove to be beneficial in patients with agitation and aggression. You can see the dosages there. Nabilone, I have not used in medical marijuana.  I have heard patient use it. There are really no clinical trial, a lot of anecdotal evidence. So I don't have a lot of experience in the use of medical marijuana  in patients with BPSD. Next slide, please. Some side effects. Just be on the lookout for drowsiness, dizziness, dysphoria, hallucination, headache, and palpitation.  Next slide, please.  What about for apathy and depression or just apathy alone? What can we use to try?  You can use stimulating agents. You can see some of the agents listed there. The one that has probably the best evidence is methylphenidate.  And if you wanna try a stimulating antidepressant, the medication that may be helpful is bupropion.  What are some of the side effects we need to be on the lookout for? Stimulants, agitation, heart rate, blood pressure, loss of appetite, and increased anxiety.  Bupropion, the one I caution most, is seizure disorder in addition to some of the other side effects as listed above, including the loss of appetite.  This is a list of miscellaneous medications.  I'm not gonna take the time to go through every one of them, but I'm just gonna pause here. You guys can take a quick look through these medications.  Next slide, please.  And there are some of the side effects related to some of the medication the last two slides talked about.  Again, I'll just pause here and let you guys read through this list.  Next slide, please.  What about hypnotics? Somebody mentioned, I think, mirtazapine, and I think someone mentioned trazodone as well. There's some evidence to suggest agitation and insomnia  that it may be helpful in terms of using trazodone.  In patients with dementia, depression, and insomnia, perhaps we should consider mirtazapine in that situation.  Zopatum, again, limited study in patients with dementia.  I am very wary of using zopatum in my patients  for the same reasons that I try not to use benzodiazepine,  sedation, fall risk, and so forth.  Next slide, please. What about selenordoxepine for insomnia? Certainly, I think I don't have any experience. Others, any comments about using doxepine low-dose?  I think it's the only one that has an FDA approval for elderly, is that correct? I will have to get back to you on that. I do not know. Yeah.  So, I mean, I do, I use it, it's, it's really helpful for any anxiety that's contributing to insomnia.  I prefer first-line melatonin, and then I'll use doxepin, unless mirtazapine has added benefits for depression and appetite.  Next slide, please. The harm, what harm can they do? Tracidone, low blood pressure, priapism, sedation, and zopatum.  Sedation, falls, disinhibition, and complex sleep behavior, the sleep driving. And again, the impaired cognition, and then the risk of tolerance and withdrawal with long-term use.  Next slide, please. The next is, you know, I said maybe there's only one medication that has an official FDA approval. That's Pimivansirin. The brand name is Nuplacid.  It has the indication for hallucination and delusions associated with Parkinson's disease psychosis. So that's the official indication.  You can see where some of the evidence showing benefit there.  And under Alzheimer's disease, there's one randomized control showing benefit in treating psychotic symptoms in high baseline subjects.  High baseline subject, meaning those with a lot of symptoms, a lot of agitation, and so forth.  So this is a medication we might want to consider in terms of if the more, quote, traditional medication we've tried and it's not helping, this is a medication we may want to consider.  Next slide, please. Side effects, drowsiness, swelling, worsening BUN. Again, you know, we are always worried about dizziness and falls.  Like so many other of these medications, it prolongs QT. And then the cytochrome P450 issue as well. And finally, you know, I think we just, not we just, we have to be honest.  There are a lot of things, there are a lot of things that we cannot easily fix.  And things such as poor attention, rejection of care, unfriendliness, repeated jokes or questions, or having a shadow that follows me as I'm, you know, talking to the patient and family at home, doing what I call, you know, the walkthrough, doing a house call.  And then the pacing and the wandering. There are a lot of symptoms that we simply do not have good medications for. And with that, the takeaways.  You know, try non-pharmacologic treatment first, second, and third whenever is possible, right?  Consider all the ranges of medications that we discussed today.  And choose a medication based on the patient's symptoms, whether it's insomnia or loss of appetite, maybe mirtazapine. Maybe consider the side effect.  If the legs are already swollen, probably gabapentin is not the best drug. Always being careful about drug-drug interactions.  Whether you use, I'm not sure if your EHR has that capability of alerting you to DDIs, or if you have an app that you have on your smartphone that can help you better manage and keep in mind all the DDIs that the patients may have.  Again, monitor for adverse effect. Lowest possible dose and a shortest possible duration. Just keep that in mind. And again, document, document, document.  Comply with regulatory guidelines for use. Document, you know, any benefits or downside to the use of the medication and your plans to wean perhaps in the weeks or months ahead.  And that is all I have on that, I believe. Next slide. Wonderful. If you have any questions for Dr. Chang or for one another, please use the chat or take a moment.  We're about to transition into supporting the caregivers. So we're going to be revisiting with our case study with Minerva.  So if you have that available, you might want to pull it up. If not, we'll make sure to project some information for you.  And we're going to be doing a role play with Melissa and Michael. So whenever you're ready, Dr. Chang, we can continue. Yep. You know, for the sake of time, we'll keep rolling here.  Okay. I think it's a really good segue. You know, we talk about dementia and how stressful that is for caregivers.  And to go on into this session, because they're really interconnected here. And I've often said when I teach, you know, when I do home-based medical cures, it's always a pair.  It's always a dyad, right? It's always a patient and a caregiver. And we're here to take care of both of them for obvious reasons. Next slide, please.  The objectives are to demonstrate the importance of supporting our caregivers at home, to talk about some screening tools that we can use to assess stress,  identify resources and to support them to reduce their burden, to describe different in-home support to aid both the home-based primary care  or home-based medical care patient and their caregivers, and to list some resources for HBPC practices that perhaps don't have a social worker that they can refer to.  Next slide, please. Yeah, for the sake of time, yeah, Sarah, thank you.  Minerva's case is on page 25 to 31, and I think we looked at that earlier in the medication management section. Next slide, please.  If I may just summarize, Minerva, you know, daughter is the paid caregiver at home, but the son actually has the health care power of attorney, right?  The patient was hospitalized for heart failure infection, and she's declining, and her overall prognosis is not that good.  And the children are having maybe a little different perspective around the goals of care and their overall understanding of the disease. Next slide, please.  You know, why is it important to care for our caregivers? Our caregivers, they suffer a lot from stress and financial hardship,  which can worsen their overall health, including mental health, such as depression. These caregivers, they do a lot of work, and often without any reimbursement.  Many of them have no backup. It's what I call the plan B question when I visit with my patient.  I say, well, I see that you're the primary caregiver for mom, and you live here with mom, and what would happen to mom if you got sick?  That question is often met with silence or the shrug of the shoulder or I don't know, right? They often don't have a backup.  And these caregivers have very limited resources in terms of what can be done to help them take care of their loved ones at home. Next slide, please.  This is a major public health problem in our country, the caregiver burden, that is. And as I discussed earlier, it could be a physical thing. It could be a psychological thing.  It could be a huge financial impact in terms of taking care of their loved ones at home. And about half of the caregivers rate their burden as moderate to high. Next slide, please.  What are some of the risk factors for this caregiver burden or burnout, if you will? And there are four based on the studies that's listed below.  Patients with assistance with a bigger number of ADLs, that increases the burden.  Female or adult child caregiver. Caregiver self-reported health as poor or have a lot of anxiety symptoms.  And finally, the use of respite care services all can increase caregiver burden. Next slide, please.  Other factors, taking care of patients like Minerva or what we just talked about, you know, managing BPSD, that could increase the caregiving burden.  Providing assistance with care coordination and medication management. This goes back to our first talk or second talk about, you know, the importance of transition of care  and the Naylor model of having that relationship, having follow-up, that communication.  And also increases the caregiving burden is the need to monitor medical equipment and preparing special foods.  You know, as Brianna's talking about, you know, remote patient monitoring and all that, we need to keep that in mind. Not to overly burden our caregivers.  You know, give me a vital signs every hour for the next seven days. That could be, you know, unnecessary burden added to somebody, someone who's already stressed.  Next slide, please. There are some of the tools that we use to assess caregiver burden. The one that we've used in our practice is the first one is the Zero Burden Interview.  And you can click on those. And, Janine, do we have these included in their handouts as well? Yes, we do. Okay. So you can refer to those later on today. Next slide, please.  You know, how can we support our caregivers? A lot of our caregivers get their support through informal social network, whether it is through a Facebook group  or through a faith community or neighbor. I have a patient whose the husband is the primary caregiver, and she's got dementia.  So he got admitted to the hospital for some medical condition, and the neighbors stepped in temporarily to help stabilize this patient at home.  And they're asking us to, you know, make extra visits just to support them as well.  We should be mindful, you know, how much support from family and friends is available to the caregiver.  And we can provide referrals to whether it's Alzheimer's Association or AARP or your local agency on aging  or senior services to help support the patients and the caregivers at home as well.  When we provide these educational and intervention and coping strategies, you know, what are we hoping to do? We're hoping to reduce their anxiety.  We're hoping to increase the satisfaction in their work, obviously making a positive impact in the lives of this caregiver. Okay.  We want to help them focus, not focus on the problem, analyze the problem and look at the problem and help them find solutions.  And the other is that I often encourage them, you know, I'm not a superhuman being and neither are you. Be willing to accept help from others. It is not a shameful thing.  It's not a sign of weakness. It's not a sign of irresponsibility and so on. Encourage them to accept help either professionally or through informal social network.  I think that's something we can continue to encourage our patients to do. And home visits are most effective for those who live with their caregivers.  You know, I've said this early on, right? We are there to obviously to take care of the patient, but we know that our patients need the support of the caregivers to function well.  If the caregiver suffers, our patient's not going to do as well. So keep that in mind. And some of you might have heard me talk about this at another talk or whatnot.  I often towards the end of the visit, I close my laptop.  And after I'm done with the patient and so on, I often close my laptop and I just look at the patient, not the patient, and the caregiver and say, you know, tell me how are you doing?  This is hard work. How are you doing? And then just see their response. And often that's when the emotions come out, right? Often it's just the quivering of the lip and the tears.  And they're just pouring out of their hearts, whether it's stress, whether it's anxiety, or it could be anger or frustration sometimes.  But giving them that time to share, you know, what they are struggling with, you know, how we as home-based practitioners can intervene to help their lives.  They are so grateful that we take the time to acknowledge what they're doing, to listen to what their needs are, and trying to do what we can to help them with the struggles that they face.  Next slide, please. All right. We're going to do a case study on Minerva.  And we're going to do next slide, please. We're going to do the role play. I think role play will be the next session. Oh, the role play is not. Okay. Sorry, my bad. No worries.  Got it. Okay. So as we are looking at the Minerva case, so the role play will be the next session on prognostication and advanced care planning discussion.  So what can we do to help Minerva? Here are some recommendations. Referral to the Alzheimer's Association. Doctors ought to be teachers.  I often tell my residents, take the time to educate, to teach, whether it's about disease process, whether it's about the FDA warning on the black box, or, you know, what to expect down the road in terms of, you know, Minerva's condition.  Educate the family on techniques for communication, redirection to help minimize patient discomfort and behavior, as well as caregiver stress.  And finally is to meet and discuss future care and encourage family to have that ongoing discussion and trying to reach a consensus if there's some disagreement. Next slide, please.  I think it's important to give the caregiver burden assessment test to each family member who's directly involved in the care of their loved ones and to talk about, you know, what might be the stressors for them.  And, you know, when I talk about, you know, closing the laptop and talking to them about, you know, what's bothering them, what's difficult about taking care of Minerva.  Again, focusing on self-care, and that goes with the caregiver's Bill of Rights, which you can find out more online, that you have a right to seek help, you have a right to be emotional, you have a right to be loved, you have the right to take pride in your work, and you have a right to maintain your own life, right?  It's not just, you know, sacrifice your life at all costs. Next slide, please.  So if you have social services, if you have care coordinators with your practice or your health system, get them involved if there are financial stresses to help them explore what options there are.  The Medicaid waiver program, the PASS4 program, which pays caregivers, adult caregivers directly involved in the care of the patient at home.  And also, you can refer a patient to the Area Agency on Aging, again, for financial assessment. And somebody mentioned already about adult daycare and respite care.  In terms of in-home support, what support, we talked about informal support, you know, what are formal support like?  There are home health aides through an agency. You can see the cost there, depending on what services is expected or desired.  The benefits of having an agency is that they do all the work, the background checks, they provide coverage if somebody gets sick or goes on vacation, and they provide training for these aides.  Next slide, please.  What about if you work outside of an agency in terms of getting an independent provider to help take care of Minerva at home?  Then the family member is responsible for the training and doing the background checks and the reference checks, and they're responsible for having a contract and taxes.  So, yes, going outside of an agency might be less costly, but it does involve more work on your part or on the family's part.  Respite care, definitely encourage your family, if that's available to them, to take advantage of.  Short-term, time-limited, it can be done at home. Often it's done in a facility. Some are covered by long-term care insurance or Medicaid.  Medicare does cover respite care, but only for patients who are involved with hospice.  Next slide, please.  Just finally, just to remind each other, all of us here, financial, emotional stress of caregiving can lead to, you know, lead to burnout, and it creates a lot of problems at home and potentially even abusive situations.  There are tools to assess caregiving stress, such as the Xeret Burden Interview.  There are supportive services available to help our caregiver reduce their burden and promote their health.  And by ensuring that caregivers will care for you, you are ensuring that the higher quality of life is available for your patient as well.  And with that, I will stop.  Thank you so much. Are there any questions?  Yes, questions? Anyone? And I did jump the gun on the role play. It does come in during our advanced care planning, but this session is an input into that.  So you will be interacting with the caregiver and with the son from the Minerva case study.  So if you have any questions before we take our break and then head into that session, now would be a good time.  Okay, I'm seeing in chat. So Dr. Chang.  We want to make sure you get a break. We will monitor chat and then let's take a look at it before we start with session, eight, and the role play to make sure that we've addressed anything.  Everyone we're about to take a 15 minute break so we will see you back at three o'clock Central time, three o'clock Central. Thank you everybody much. Thank you.  Okay, we have one more minute. If you are within the sound of my voice, please rejoin us. For this next one, I am gonna ask people  to turn on their cameras if you are not, of course, driving or doing something like that, but we would like to see you. It is our last couple of sessions of the day.  We're going to do the next 45 minutes with Dr. Chang doing prognostication and advanced care planning. Again, this is an extension of what you've been doing  with Dr. Chang this afternoon. So you will revisit Minerva, and then we will move into self-care and avoiding burnout with Amanda.  So in just another moment, we will start running slides.  Dr. Chang, when you are ready, just let me know.  All right.  So let's talk about prognostication and ACP and communication in HBPC.  Next slide, please.  So we're gonna review materials for estimating and communicating prognosis to patients and families.  And we're gonna talk about the importance of ACP for patients with serious illness and introduce some steps in communication, communicating with patients and families  about advanced care planning.  Next slide, please.  Now, I really think this is an important topic because as many of you know, many of our patients are sick.  They're chronically ill and they're declining. And this becomes, I should say, well, it is a natural extension of our work. You can see the core elements of home-based care  and that symptom management, that is a functional assessment and checking up on the social support. And we talked about caregiver supporting them as well.  And the last core is about advanced care planning because of the condition of the patients we often find ourselves taking care of.  Next slide.  So what are some of the benefits of having prognostication discussions?  And you can see them here. It avoids a crisis decision. I often tell my patients and family members, I say, you know, I much rather have us talk about it here  in the kitchen or in the living room and whatnot and have the luxury of time, if you will, rather than in the intensive care unit  where there's so much pressure, so much information, and it can be a little bit confusing at times in terms of what to do and so forth. So it avoids a crisis decision.  It gives us an opportunity to better understand the patient's values and choices. You know, what do you want? What are you looking forward to? Is it a longevity of life?  One patient wanted to see her granddaughter get married. That was her goal. The other patient years ago, he wanted to see the Cubs win the World Series. That was his goals.  That was a rather unique goal of care, but the Cubs did win.  I don't know how quickly, but he did pass away after the Cubs won the World Series. So that's just, I should say funny, an interesting story  about finding out the patient's values and choices.  Again, it gives us time to consider risk and benefits of intervention, whether it's more chemo, more surgery, or whatnot.  And again, it gives us the opportunity or gives patient and family members the opportunity to digest, to reflect,  and to cope with the medical information that's been given, especially if there's been a significant change in a patient's condition or a significant new finding has been noted  on an exam or an imaging, it gives them time to think things over. Again, we want to reduce the stress and anxiety and the uncertainty for patient  and their caregivers or surrogates.  So what are the impact, the positive impact that can come from a effective prognostication communication discussion?  We reduce unwanted medical interventions. We increase palliative care and hospice care utilization.  It gives patient and family time to prepare, personal issues, financial issues that need to be put in place, increases the likelihood of patient dying in a place that's preferred.  And often it is the home.  And if the patient wants to pass away at home, what does that look like? What support will you need? Will it be hospice? Will you need to hire a caregiver  to honor the wish of the patient who wants to die at home? And again, to reduce the moral distress in the provider, but also I think in the caregiver as well.  So to take away some of the ambiguities, like, well, does she want it? Does she not? You know, should we put in a tube? Should we not put in a tube?  So if the patient and the family had a chance to go through this exercise and discuss the risk and benefit and come to a conclusion that can reduce a lot of distress.  So if it's this great, if it's awesome, which it is, why don't we do it? Why don't we do it more often?  Lack of time.  We all know that we are pressed for time, whether you're in your office practice or a house call provider. You know, we're trying to see more patient,  add another one, see an urgent patient, just that pressure of time. And sometimes this gets pushed to the side, right? You know, I address your heart failure,  your breathing, your pain, and so on. This other stuff, we'll just, we'll take care of it next time. And the problem is there might not be.