could be a crisis in the emergency room. There could be a lack of training. I've been out of medical school for many years now, but I just don't remember having a class teaching me how to have a good conversation about topics like this in medical school. We're afraid that if we gave them a diagnosis or talk about their serious illness that we are causing distress and taking away hope for our patients and their loved ones, that could damage our relationship with them. We're often not certain about the prognosis of the condition. Family members often ask, you know, how long does grandpa have? And often we're not sure exactly how long grandpa has given the condition that he is. There are cultural variations that we need to be aware of in terms of having this discussion. Some cultures, they want us only talk to a particular family member. Often they say from the eastern culture would be the number one son rather than the patient, for example. Challenges could be not the provider per se. It could be within the family. As in the role play here, there could be some disagreement between the brother and the sister in terms of, you know, what kind of care should be given going forward. Are the families ready for this conversation? Are they in denial regarding say Minerva's case? They still think that Minerva may come back and be able to walk and be able to have a conversation again and so forth. It could be the family may not be ready in that respect or simply they just, maybe they're just busy people and they just don't have time to sit down and reflect on some of the deeper, more challenging topics. And there could be a lack of clarity regarding, you know, who's the provider doing this? Should it be the cardiologist talking about this with the patient? Should it be the oncologist? Should it be the pulmonologist? Or should it be me as the PCP? So sometimes there could be some vagueness or confusion there. And then finally could be some bias on my part. She's like, no, you know, she looks great. She's not going to die anytime soon. Yeah, I know she's only 80 whatever, but I don't think anything's going to happen. So it could be a bias on our part in terms of not carrying out that discussion. Next, yeah, thank you for the slide. So when is a good time to have this conversation, right? As I alluded to earlier, it could be like when there's, you just learn about or present it to the patient. There's been a major change in condition or significant new finding on a scan or report. It could be that the patient is back from the hospital say for the sixth time in the last eight months for their COPD exacerbation or their hepatic encephalopathy or SVP related to their ascites, right? If there's been a change in condition or function post-stroke, for example, if there's talk about starting or stopping a medical procedure or intervention, a few weeks ago, I don't know, 10 days, two weeks ago, we had a conversation in our practice where the caregiver wanted us to terminate the patient's pacemaker. Okay, so we had a group discussion in the office about, you know, what are some of the issues that needs to be discussed? What are some education process that needs to go not only to my providers, but also to the family members? I mean, in addition to, you know, how is this actually technically done at home and what does that look like? And obviously this discussion should be had when there's a request by the family say, you know, can we talk about this? You know, should dad have another surgery or should dad have the TAVR procedure for his aortic valve? Those are some of the times for us to intervene and have that discussion with our patients and loved ones. So here's some steps in terms of having that discussion with the patient or family members. Okay, one is to review the records and current conditions. That's obvious, right? You don't want to talk about, you know, such and such as such and only to be blindsided by a CAT scan report that shows this big tumor or tumor getting worse that you were not aware of. So make sure you get all the records and information from any consultants, any notes from them so that you are equipped with the latest information on the patient's condition. It's important to set aside time for discussion, turn off your phones, turn off your smartwatch or whatever, and just silence the electronics. Put aside time for this discussion because it can get, it is a serious discussion and we want to put our attention really focused on the issue at hand here. It's important to determine patient's capacity. Does the patient have decision-making capacity such as Minerva? Does she have capacity or should we be talking with somebody else about this advanced care planning discussion? We need to figure out a place to have this discussion and who should be there as we discuss the case. Should we do it at the bedside with the patient? Some patients want that, other patients do not want to hear anything that you have to say. Should we have it in the kitchen? What is the best place to have that conversation and who should be there? Should it be the power of attorney or just the entire family gather around the living room? That can be a little daunting. Sometimes I feel like I'm on stage and it's a performance. So it's a little bit challenging for me when there's a huge, I shouldn't say a crowd, a number of people I should say in the room just wanting to hear everything you're going to say about their loved ones. Gauge the patient's and the caregiver's understanding of their conditions. I often do that by, I've said in other lectures, I try to remind myself often, try not to make a statement, but learn to ask questions. So this is a way to help you understand what is their understanding of the patient's conditions. For example, you can ask like, mom just had a CAT scan. What is your understanding of the results of the scan? Rather than just saying, you know, the scan shows metastatic cancer, you want to gauge what is your understanding of the disease process. Ask for permission to discuss condition and prognosis. For example, like, well, you don't know, is it okay? Would it be okay for me to share with you what I found on a CAT scan report? I'll ask for permission. Provide the best estimate of condition and prognosis and recommendation. We'll talk about some of the tools that we can use for prognostication. We're also going to talk about, you know, not giving specific dates, like, you know, grandpa's going to die in five days, rather than we should be giving ranges instead. Be comfortable with silence, with pauses, with emotions, and give them time to reflect, to ask questions, and to acknowledge the emotions that they may have. I can see that you're upset. I'm so sorry. I'm so sorry for your tears. Those are just, I think, good things to, for us to practice, recognizing that it is hard for them to hear the news. And those tears are just, it's just pain in their hearts. And it's good for us to be reminded, you know, we're taking care of people. I know Brianna and, you know, we're going to talk about, you know, billing and coding and, you know, making a practice work and financially, so on. And that's all important. But I think it's good for us to be reminded here and often that we're taking care of people. Our patients should be our focus, and not just purely the financial side. Take time to summarize, plan for the next step. You should document the discussion that you've had and share the outcome of your discussion with the cardiologist, with the facility head nurse, and so on. So that there's not, there's not this like, well, what, you know, what was the outcome? Is the patient going to go on hospice or not? So that everybody's aware. So there's as little confusion as possible. Next slide, please. So what are some of the guidelines we can use in terms of discussing prognosis? Again, using decisions tools to help us to guide our discussion in terms of, you know, how long does grandpa have? Prognosis is important for our patients in terms of planning and perspective. Often there are comments like, if I knew how much time I have, I may change the way I live, or I may want to reconcile with my son, or I need to get this done before my time is up. And also be careful when you share difficult news or difficult prognosis. Give a warning shot, as they say. Don't just blurt out and say you have cancer and it's everywhere. But be much more obviously tactful than that. You know, what I'm about to say is difficult. I wish things were different, but I have some tough news to share with you. And try to deliver medical conditions in a clear layman's term, non-medical jargon, and in a way that they can understand and process. Discuss treatment options in the same way, and the range of potential outcome, again, in layman's terms so they can understand. Next slide, please. So here are just some tools in terms of helping us with prognostication. These are some of the tools I often use. E-prognosis, Calculate by QXMD. It has multiple calculators in terms of conditions such as, say, the Seattle heart failure prognostication or bold index in patients with advanced COPD. It does give you a range of, you know, five-year mortality or three-year mortality and so forth. Fast Facts, it's an app, really helpful in terms of palliative and hospice issues, and also they have a lot of guidelines related to specific diagnoses. There are limitations to these tools. It's the applicability of these tools to our kind of patients. By this, I mean these tools are often disease-specific. It talks about, say, lung cancer. It talks about COPD or heart failure and gives you a prognosis. It doesn't account for our kind of patients, so just keep that in mind. By that, I mean, you know, our patients have advanced lung disease, COPD, but they also have CKD, CHF, neuropathy, they have had a stroke, and so on, so the calculator does not pull all of that information in, in terms of giving you a prognosis, so just be careful of that. Having said that, I think all of us would appreciate some numbers that we can share with our patients and loved ones rather than just kind of shrug their shoulders and say, well, I don't know. It could be tomorrow. It could be a year. I'm not sure that's really helpful in terms of having that prognostication talk, so get use to these tools, or you can find other tools that's helpful. Anybody else? I'll just stop here. Anybody else using a different tool for prognostication? In addition to that, you have a question. What would you say if someone wanted to record your discussion? Yep, so there are state rules, so I would check with your particular state about a recording of a conversation between a provider and a family member, and then there are also institutional rules. By that, I mean Northwestern does not allow that, does not allow recording in terms of a private conversation between a patient and their provider. There may also be state rules about whether a bi-directional consent, that's not the right term, but you get the idea. You have to get consent from both parties before recording is allowed, or is it just a consent by the provider or somebody. So, do look into your state rule and also with your particular organization regarding recording of your conversation. Anybody else? That's a great question about recording. Any comments? Yep. Actually, it's not a tangential question, answer. I think it's really important because prognostication often leads to the talk of hospice, right? So, I think and this is beyond the, okay, we're going to be careful of the time. Okay, this is beyond this particular talk here, but I think as house call providers, when we do prognostication talk, we need to be versed in hospice criteria as well, right? Because we talk about prognosis, let's just use Minerva, for example, we talk about Minerva, so on and so forth, or heart failure and whatnot. And often the comment would be like, well, the hospital doctor or the emergency room doctor said, you know, there's nothing more I can do for you. Go home and sign up for hospice. And the comment, the question often asked of us is, is dad hospice appropriate, right? As you're talking about prognostication, as you're talking about maybe, you know, deprescribing and the overall prognosis isn't good. I think for us, we should be aware of hospice eligibility for the common conditions, right? For chronic kidney disease, your creatinine clearance has got to be less than 15, unless you have diabetes is less than 10, if you have diabetes is less than 15. If you have heart failure, if you have dementia, and so on. So I encourage you, that's a great comment, I encourage you to go over some of the common hospice criteria, because this conversation will likely lead to the next. I'd say, Paul, one of my big jobs with hospice is writing up the hospice eligibility for the Medicare people. And initially, I took that tool as kind of the gospel, you know, I would look at that tool and try to do my bullet points and double check things. But in the same way that you talked about how our patients may then have chronic kidney disease, plus congestive heart failure, plus COPD, plus they've had a stroke, you don't have to kind of box yourself in to using the tool down to each exact bullet point. Because when you're doing eligibility, you can tell the story for, okay, so maybe they don't quite fit in the CKD box or quite fit into the stroke box. But you know, all of these things additive together, do actually make them eligible. So I'm a little cautious about saying that, like, like, yes, the tool is correct. Yes, it's written to the Medicare guidelines. But you also do have some leeway in terms of certifying patients, quite a bit of leeway, actually. Laura, I appreciate that comment. Thank you so much. Thank you. Any other comments? All right. Next slide, please. And now we're going to do the role play here. The goal of the role play is not to get Dr. Chang nominated for Academy Awards, which she will not, based on the role play you're about to receive, or whatever, to witness here. But to give you an example of what a conversation may look like. And also give you some, say, you know, Dr. Chang, I think you did pretty well here. But you didn't do so well here. And if I could improve upon your presentation, I think I would do things such a such a way. So it's meant to be informational, not entertaining, informational, and hopefully, it will give us a chance to kind of dialogue and say that was well done. Or, you know, you could use some improvement here. All right. Okay. So I will start. So I'm going to give a brief introduction into Minerva's case. And then Melissa is going to be the daughter. And Michael is going to be the son in this role play here. So I'm just going to quickly go through the role play. Just to remind ourselves, Minerva's 86. She's being seen for the first time post-discharge at home. She was there for heart failure, leg swelling, leg cellulitis. She was discharged two days ago. She has a history of multiple other admissions this past year for kind of the same thing. Cellulitis, leg swelling due to CHF. She had another admission for altermental status, UTI. Her dementia was diagnosed six years ago, but her behavior has worsened over the last six to nine months. The son there is the healthcare power of attorney. And the history, we were able to speak with him by phone. Patient's daughter actually lives with a patient. And she's the main caregiver, but she's not the power of attorney. Both son and daughters have noticed increased forgetfulness. And we're finding in words that Minerva speaking is often incoherent. She's becoming agitated when personal care is performed. And there's increased frequency of verbal aggression, loud voices, foul language, and some physical aggression as well, such as swinging of the fist or pushing the daughter away when she's trying to deliver care. Daughter reports she is physically weak, cannot walk. She's spending more time in bed, cannot sit up straight when she's in bed. And she's having a difficult time swallowing as well. As with most homebound patients, Minerva has a lot of problems. Cellulitis, heart failure, CAD, dementia. She has a stage four pressure ulcer, history of recurrent UTIs. She's got depression, hypothyroidism. She's got GERD. She's got generalized pain. So the setting is in Minerva's home. Her son and daughter are there. Dr. Chang introduces himself and explains the reason for the meeting. Dr. Chang, I'm here today to conduct a post-discharge visit. Before I examine your mom, I would like to ask what your concerns are regarding her condition. Sorry. We're looking for some advice about what stage of dementia she is in and what we can expect. Yes, we can discuss her dementia. But before I begin, who should we include in this conversation? Do you want mom to be included in this conversation? I know that this is difficult. I'm going through the same thing myself with my parents. No, I think she'd be upset. And we've talked with her and we've had good understanding of what her wishes are. What is your understanding of your mom's current condition? Well, we've both noticed that her dementia is getting worse, but I'm not sure how far along she is in the disease process. Yes, we often discuss dementia in stages, which refers to how far the patient's dementia has progressed. Defining a person's disease stage helped me determine the best treatment approach and helps me communicate better with you. Dementia is often commonly referred to as a progression in three stages, mild or early, moderate or middle, and severe or late. Can you tell me from your past discussion with mom regarding her hopes and her wishes, what do you think she would be concerned about? What makes her happy? And what level of intervention does she want if she became even more ill? Mom just seems to get weaker with each hospitalization and being in the hospital has not been a good experience for her. She seems to become more confused and get more combative and yells that she wants to go home when she's in the hospital. And the hospital doctors would give her more sedatives to calm her down. My mother has said in the past when she was lucid that she didn't want to go back to the hospital, but I'm not sure that my sister, who's the primary caregiver in the home, agrees. My understanding from conversations with mom is that she wants comfort focused treatment. And if she declines again, I think she would prefer hospice versus another trip to the hospital. You know, my mom used to love to knit and she worried about becoming a burden to us. She can't remember how to knit anymore and she's lost total interest in it. And it's becoming difficult for me to take care of her. It's harder to redirect her and to change her diaper without, without her becoming combative and yelling and swinging arms. And I, I haven't seen my own doctor in ages and I'm not sleeping well. And, and because I hear her get out of bed and then she's wandering around the house and I just feel this tremendous guilt and anger. And I know my brother tries to help, but he doesn't have direct responsibility. And he's critical of me when I call 9-1-1, but you know, all of that said, I agree that going to the hospital maybe is not the best option. Can you help us Dr. Chen? I know this is hard for both of you. Let's talk about where I think your mom is with her dementia and then we'll discuss some options. Is that okay with you? I think your mom is heading into the late stages of dementia due to her increased forgetfulness, aggression, incontinence, dysphagia, pressure ulcer, and physical weakness that we are seeing. The dysphagia often leads to aspiration, which is the accidental swallowing of food particles or fluid into the lungs. Aspiration often is the last stage of dementia. And I have some difficult news to share. It would not surprise me if mom passed away in the next 6 to 12 months. Well, what about her feeding tube? That is a great question. But before I answer that, can you tell me what is the most important to you in the care of your mom given her current condition and her decline? Well, I guess we both want mom to be comfortable and to minimize suffering given her illness and the likelihood her condition will not get better, right? Yes, I'm sorry that I don't have a medication to reverse her mind or her dementia, I should say, and make her mind work normally again and she will likely decline more physically and mentally in the days and weeks ahead. Can you give me an idea of what your understanding regarding a feeding tube for a patient like mom? I guess not much except that when it provides nutrition when someone can't eat. That's right. But there is research suggesting that feeding tube in patients with advanced dementia does not increase survival. It does not prevent aspiration pneumonia. It does not prevent pressure ulcers. It does not reduce the risk of infection or improve functional status or comfort for the patient. Feeding tube sometimes can be uncomfortable and even painful. Your mom may need to adjust her sleep position and you will need extra time to clean and maintain the tube to handle any complications. Yeah, that sounds like it would be a lot more work for me with very questionable returns. I mean, plus with mom's aggression and her combativeness, I mean, how do I know she won't even just pull it out and do herself more harm? I don't think either of us want her to suffer and I don't think that's something that she would want. Let me know if you would like to discuss the risk and benefit of a feeding tube some more. But based on what you have told me about what your mom wants, I agree with your decision. I think we are all in agreement about how to move forward. Would you mind sitting with me to summarize our conversation by filling out a PULSE form? The PULSE decision-making process results in medical orders that are intended for patients like your mom who are at risk for life threatening clinical events because they have a serious condition, which may include advanced frailty and dementia. We're going over the form and I come back and say, how are you doing? We've talked about some very difficult things today and I appreciate your willingness to sit with me and talk. Thank you. Do you have any additional questions? I think we're okay. No additional questions now, but we may have some later. If you do think of additional questions, I'll be back to check on your mom in a few weeks. I'm going to do everything I can to honor your mom's wishes. We will call in hospice when it is appropriate. In the meantime, I will send you some caregiving resources and I can provide a referral to a social worker who can help you through some of the caregiving process. I'm going to check on your mom now and we can talk more after I'm done. Thank you, Dr. Chang. Yes, thank you. That was difficult, but I do feel at least better informed and more supported now than before. That ends the role play there. I will stop. We have a little bit of time. If you could just reflect on what happened with the role play, I would love the comments from you all. You can use the chat box or just unmute. Paul, I just think that it's so important. I love the POLST forums. I think they're just an outstanding tool, but I think that oftentimes the process of filling them out is very checkbox you know we've got this form we're here to fill it out today let's start at the top let's ask let's get this first question answered and it becomes then rather than discovering the goals of care first it becomes this checkbox exercise where oftentimes the boxes are checked before anyone's really even contemplated what the goals of care are so then there's a mismatch between what is on the POLST forum and what's really important to the family yep uh absolutely uh sometimes we get overly focused on the task the form right that's my goal today um i need to get that pink sheet done um rather than the focus um really ought to be uh on the conversation on the discussion uh and and i think many of us are just task oriented people um and i think it's good a reminder on that uh to take a step back you know let's just take time to talk um and and reflect and and learn from um the patient and their loved one you know what do they really want any other comments um let's see i have a comment here the hospitalization is often a reprieve for the caregiver recognizing uh and addressing this is important absolutely if you have caregiver burnout right um i need a quote vacation i just sent minerva back to the hospital so i can have a couple days off um that is a great comment um so we need to be uh as providers uh be attuned to that uh again taking time perhaps to ask uh minerva's daughter and say you know how are you doing um uh what you know what's it like uh when you know when minerva does go to the hospital um does that make you feel guilty or do you uh do you appreciate the time uh for yourself i'll perhaps ask a question in that way all right uh let's move on we got a couple of minutes and i just uh have a few more slides um uh advanced care planning uh somebody uh brought up uh um uh the post form um there are just a couple of things uh i want to again highlight uh the advanced care planning um it's a continual process you know um we talked about the pulse form you know that is important we do need to get uh some kind of documentation done but sometimes that is not possible uh when we um and i don't want us to look at it as just a one event thing uh similar to prognostication conversation it's an ongoing process and discussion that supports the patient any age any stage of their health uh in in an attempt to gain an understanding of of their illness and sharing their personal value their goals and their preferences regarding future medical care one of the key goal is to get um to provide the kind of care that the patient wants to receive that's consistent with their values their goals their preferences remember dr cornwall and uh and amanda talked about uh one of the four uh four or five m's and in geriatric care uh what matters most uh that's uh often the first m uh that i teach a residence because from that flows your care plan right um um uh yeah i was going to use a tab or procedure uh as an example but we talked about that uh before advanced care planning discussion uh should be proactive should be integrated into a routine visit um and uh it should be periodically reviewed um uh often uh when i get referrals from uh community providers acp discussion has been done as part of their medicare awvs um so that's integrated uh into that particular visit um and acp uh that there we go already uh preemptively uh moved down to my uh i jumped the gun early on my next bullet point there we go next slide please again just the overview of the discussion process is very similar uh to the prognostication conversation um we're trying to get an understanding of their illness and their care preference um and discuss treatment options uh with the patient or their designated surrogate it may result in a complete and a completion of the form um but it is not required uh and again just to remind all of us don't get uh fixated on that uh like you know every time you come and visit me dr chang you just want to talk about the pink form uh again that doesn't build relationship uh which is really important uh especially as they become sicker if they think that you're just there to do the pink sheet all right and finally uh get that uh once the form is completed um disseminate that information um to uh relevant uh providers uh individuals as necessary so everybody is aware next slide please uh there's some example of advanced care planning document whether you're talking about the living will post most um or a health care proxy or agent uh or five wishes document which is the document that we pass out to our patients and families when they're trying to uh establish a poa of health care for their loved ones next slide please the benefits again is similar to the prognostication talk uh delivering care that's consistent with their goal reduce unnecessary medical intervention reduce anxiety and burden um families and caregivers and again the provider as well it can guide how future unforeseen medical condition uh can be uh or should be addressed there's a question um yes how often can you complete and bill uh for advanced care planning to medicare is there a limit on times for reimbursement per year uh brianna do you have an answer to that how often we can build on acp she might have gotten pulled away i will make a note and we will find out thank you for your question thank you for that question i appreciate that next slide please again this is uh similar to the prognostication talk um uh is i won't for the sake of time i'm not going to go through uh all all of that you can uh read through this when you have a few minutes uh later today or sometime uh in the future they do have all slides and then um this should be reflected in your workbook as well next slide please and we encourage um uh our our residents when we do bring them along um on their rotation geriatric rotation with me um to to take the ask tell ask approach uh to conversation you know ask by i uh build trust by learning what matters to the patient assessing their understanding of their condition and their prognosis and then you know understanding of their condition and their prognosis and if additional medical information is is desired again some patients don't want to know uh and then also uh ascertain the goals of care and then it's our time to tell or explain the condition uh to discuss uh future uh opportunities or potential complications and then uh go back to ask again ask if there are additional questions ask for the understanding about what i just told you ask if they need more time ask if they need more clarification and so forth so it's a continuing ask tell ask uh approach next slide um you know a prognostic information is really essential uh to help with prognostication discussion and advanced care planning uh decision so use some of the tools that we've referenced uh early on in the talk and have at least some reference ranges as you get into a difficult conversation with your patients and their loved one focus on preparing patients and surrogates for in the moment decision making and also finally improve your skills by practicing the ask tell ask approach and consider um using available guides or checklists and that is it thank you so much dr shang and leading us through those last three sessions uh was a lot of work on your part and for our learners that was a lot to take in and i've been monitoring chat there's fantastic dialogue going on brianna is back with us uh brianna you could answer in chat perhaps about how often one can bill for advanced care planning i am on it right now here we go wonderful thank you um so i have that question answered in chat and we are ready for amanda for session nine our last session of the day self-care and avoiding burnout i'm gonna stop my share for a moment and i believe melissa's gonna pick it back up so we're ready when you are amanda in just a minute okay got it i was gonna say you know i'm i'm i'm the one that's supposed to be landing the plane today so if anybody wants to turn on their camera or you know do the pilates that you've been wanting to do uh that paul was talking about like this is the time to do it okay so let's let's end this on a high note there is so much information in these two days that is shared it's hard to know where to even kind of start and stop and and the thinking components um but i i so appreciate your time so let's talk about what we will talk about today from a learning objective standpoints is oh there we go uh is let's recognize some common stressors facing practitioners, but that includes clinicians, that includes your staff, and let's identify coping strategies. And then we're gonna talk about, you know, operational administrative strategies. So, you know, when we talk about stress and burnout and how we recognize things and how we think about recognition, this is that time. And so I would love a high level of participation so start getting some of those thoughts ready. Paul mentioned we're taking care of people and I couldn't agree more. This is now how we take care of, how you take care of you and how you take care of your staff as well. And it just extends to the stressful part of the job that it sometimes is while rewarding. It can be both rewarding and stressful and hard at times. Slide. So this is, so this is a 2019 Medscape survey and I pulled out internal medicine and family medicine here and says, which physicians are the most burnt out? And it's just almost 50% from a specialty standpoint of generally the practices in which y'all are coming from. I would extrapolate this. I think it's an easy extrapolation to do this for internal and family APPs as well. So I certainly think that it's all workers are experiencing stress and burnout, but especially in traditional primary care and now home-based medicine or kind of clinic-based medicine where you still have these like lower reimbursement components, lower paid positions than other specialties. Slide. So let's talk about the top stressors and guys jump in the chat or unmute yourself if there's other things here that we want to talk about. But, you know, mediating patient family conflicts. This can be incredibly difficult. I can't tell you how many times providers have come back and they've said, you know, the patient isn't as complex as the family member. And sometimes my job feels like I'm taking care of the family member right now and I'm walking them through this. Absolutely. The electronic health record and paperwork complexity. There was a, there was an article a couple of years ago about just like the death of EHR. Do you remember Brianna? I talk about all the death of EHR or death by a thousand paper cuts or something like that. It was like death by a thousand clicks, I think. Yeah, I remember. And it's, and it talks about how, you know, best of intentions from a legislative and policy standpoint as we were trying to, as they, as we, they, as a society are trying to put in place health, electronic health records, that they just continue to put things on top of other things. And so the convoluted process that it is, especially from a policy and legislative standpoint, sits on top of each other and doesn't really interact with each other. And so now we essentially try to take a paper, a very complex paper system, make it electronic, introduce and make it through our, you know, political system. All these things come together and it just doesn't feel right. And you can feel that in working on it, right? You know, when you're like, why would this piece of information be, you know, single directional and not bi-directional, you know, relationship? Oh, well, you know, the incentives weren't at the time to create a practice management system. At the same time, you create an electronic health record. So nobody did. And then someone bought one of the other and then they tried to put them together and the system doesn't work. And I feel it every day. I think there's a financial pressure, this inadequate funding for the complex work. This is a lot of what we talk about. And we'll, we'll open with tomorrow is how do we talk about value-based care and how do you really launch your business off the runway here is getting other people to understand that it's an incredibly complex work, right? You're doing it in this space. You're doing it for a reason in someone's home because they don't have the means of transportation. They don't have the mobility function. It just makes total sense for the family dynamics to be in someone's house. And, you know, in many ways, while it shouldn't seem like a new idea and it's well, it's not a new idea, the complexity of what goes on in the home is not well known. And so you're constantly trying to fight an uphill battle to get paid for it, to get the recognition. Patient adherence with care recommendations, right? Especially promoting patient self-care. How many times have you said, here's what I'd like you to do, and then it doesn't work. And you're like, you're banging your head against the wall. I don't know why, you know, this is what happened. And I think Paul and our clinicians and all of you probably do a very good job of meeting someone where they're at, but sometimes where they're at can be hard. And you can kind of see some of these pieces come together. How many times have you walked in on someone with oxygen who's also sitting there smoking a cigarette? And you're like, we see the conflict and it's hard for us to take in as care providers. The scheduling and the logistics of providing care in the homes, getting all the supplies and all the people and all the right things to align at times can feel like a mountain. And then this, just this unsupported feeling of being in the field. So, and there's a wide range of individuals on this call, but it's sometimes it feels, especially when you're going by yourself into a home or maybe with one other, that you're on your own island. And so that can be a lot. Other stressors here. Let's see, I'm taking a look to find this. Other stressors might be, you know, too much time at work. So anybody find themselves during the pandemic at all? Everybody quit at five during the pandemic or everybody was feeling like, when am I gonna get a break? And when am I gonna see my family again, even though it's in my house? And I didn't think I'd bring all this, all of this work home every day. Some lack of respect, again, trying to gain the traction you're trying to get, government regulations, lots of things that can provide stress, certainly. And some are specific to healthcare and some are specific to home-based primary care. And then there's this intersection of the two. Slide. So stress, especially since I'm speaking to so many clinicians, stress is this natural body reaction to change, right? It's this physical or mental, emotional strain or tension. It's the sweaty palms, it's the fast heartbeat. It's something has happened here. But from a burnout standpoint, there's really no agreed upon definition. And as I like to describe it, I kind of use a combination of these. It's this long-term stress that results in this exhaustion, depersonalization, apathy, lack of belief that you can make a difference. It's where you have this energy balance that all of a sudden has a negative balance, but it's over time. Burnout doesn't just happen to you. Stress might come and go throughout your day, but burnout is something that is cultivating it inside of you for a very, very long time. And it's a public health crisis that really urgently demands action. When we were talking about that specialty review and the 2019 Medscape article that we were talking about, of the physicians surveyed, 80% had not thought about suicide, which means that 20% had either thought about it, tried it, or were not willing to answer the question. So if we're talking about one in five clinicians that you're interacting with might not be able to definitively say, I have not thought about suicide because of my work, this is an urgent public health crisis. So what are some of the outcomes then of stress and burnout? Slide. There are three areas I'd ask you to kind of look at. One is this individual health outcome. Depression, exhaustion, dissatisfaction, depersonalization, again, apathy, higher rates of addiction. So it's a failure job, a career change, suicide rates. So individually, that's how we start to see it in someone. We start to see a disconnect of, I just am not part of the change. I am not, you know, I'm punching a time clock here. From a patient outcome standpoint, right? Now we're gonna talk about the bigger people around who we're touching. And you as employers have to think about this, right? If your clinician, your staff is feeling that individual burnout, it's gonna come out in lower patient satisfaction scores, potentially lower quality of care, higher risk of malpractice claims. And then there's a systemic issue that comes through where it's like, the system is never gonna get better. I'm not part of the solution. And if we keep going like this, it will never get better. The students become unprepared and untrained for the real world and innovation is solved because I can't think of new ideas when I can't feel like I'm part of the change. And so there are kind of two ways to think about this talk. The first way is to think about, you know, and where can I go? The first way is, hey, the work that we do is a solution to this. And the second way is you're always at risk for this in any job that you do. You're always at risk for feeling an intense amount of stress that can eventually lead to a burnout of what you're doing. And so you just have to keep an eye on it. So a couple of slides we added during COVID were around kind of grief and loss, slide. And it's just part of working with healthcare, right? You're not, it's not like you work at 3M or you work at General Mills and you're pushing off cereal off the line, right? Your widgets are people who have experiences that you get very attached to and you are invested with them. And at some level, every business person and clinical person gets invested in another person, whether it's in their success clinically or in their success in a professional way, we start to feel those human connections and we need that. And I love me some virtual world, but we need that connection piece. And so everyone experiences loss, trauma, grief in their own way. And we've all seen that come out. And how many of you have loved ones when someone dies, they're not gonna talk about it. They're not gonna talk about it for the next 10 years, right? And how many of some people, and maybe you're like this, where you're like, all I wanna do is talk about it for the next 10 years, right? And so how do you recognize the five stages within yourself or others? And again, us as employers, leaders, clinicians, how do we think about denial and anger and bargaining and depression and acceptance? And I know you know these five, but these stages are really critical to watch in others and it is important to get through them. And so what you wanna look for is that someone stall out at some point and can't move through them. So a couple of questions, I'm gonna pause for group participation. How do you move yourself through these stages? What is your kind of movement here? It's a good question for the end of the day, isn't it? Anybody in the chat? Especially, I mean, you guys, you could keep, you could think about when your favorite patient died or your favorite patient returned to the hospital. Sarah, okay, great. We have weekly team meetings where the first thing we bring up is anyone we've lost. Yeah, recognizing, processing that together, talking about it. Some people might be closer than others and have a few more words to say. Patients, oh, Nicole, I love that. Absolutely, this last year has been incredibly hard. I describe it as I'd like it to be a blip on the radar. I'd like it to be a really hard blip, but I'd like it to be in the past and on a tiny blip that we debriefing on decision-making. I like that, Caitlin, absolutely. Like, how do we think about the stages that got us here? And what are those operational pieces? And some people are gonna need more operational pieces and some people are gonna need more of that touchy feeling and how do you kind of cater to those things? If you go to the next slide, then we talk about how do you find meaning? How do we acknowledge that grief and loss is, again, is a part of working in healthcare? So if we all experience it differently, then we all find meaning in a different way. And so how do we find this meaning, move away from the grief as personal and we go to this individual timetable? And again, we recognize how someone's working through it. There is a lot of research on how people find meaning, especially in healthcare, with being able to process grief and loss. And again, this is something to look for in yourself and in others. And not everyone, you know, recharges the same way. So just a couple of things, but there are universal supports. I've done a little bit of reading on this and find it to be fascinating and do a talk on stress and burnout and these things over and over again. I love talking about it, but universal supports are, you know, how do we find and express gratitude? How do we lean into our community? Faith, family, and friends are typically kind of the three Fs we're leaning into. How do we create action that points around, hey, now that I know something, I'm going to move something forward. And how do we display love and acceptance? Not everyone recharges the same way. Not everyone gets their mission the same way. And not everybody has their value set as the same or in the same order that you have. You know, I just finished a diversity, equity, and inclusion in the workplace certificate. And one thing that came from that is recognizing that your lens is always your lens and you interpret your lens. You don't think about it consciously, but your lens is always correct in moments. And so as you're viewing other things through your lens, if it's not the way you would have done it, then it's not correct. And how do we kind of push away that to support others where they are? Let's see if there's some... Oh, yes, Sarah, weekly creative writing workshop for folks in medicine has helped me find meaning. That's great. That is super cool. Thanks for sending that resource on too. I'll take another slide. So who's heard of Pono Pono Pono? These are four steps. It's a Hawaiian practice combining love, forgiveness, repentance, and gratitude. And it really translates in English kind of as correction. It can be used in a lot of different ways. It might be used to move forward again with kind of love, forgiveness, repentance, and gratitude towards a relationship you might have, towards a moment, towards many relationships, towards an organization. It's also used to regain personal strength of self-love. So I was giving this talk during COVID and I just kept coming back to, as an outsider of the clinician world, trying to express the work that had been done of, I'm sorry, and thank you, and I love you. And I was putting those things into the Google and it came back with, these are four components. And these four components, saying these over and over again, and believing these, I'm sorry, please forgive me, thank you, and I love you, even to yourself starts to step you back for the self-connection and healing. So it can be used for others. And again, people or organizations, or it can be used for you as you think through how you move forward. So, slide. As I mentioned, I think the cool part about home-based medicine is I think it's a solution. I think it's, I think home-based medicine is a reconnection to the value set of why many people went into the nursing and the medicine field. It becomes really almost the tool of the IHI quadruple aim of how do we improve the clinician experience? How do we make it vocationally interesting? And so successful positioning of this medicine really, as you've talked about, as you recruit in, as you retain people, right, is it's vocationally rewarding because they're challenging cases. It's not a series of ear infections, right? It's a series of multi-complexity, many people and many partners that I need to connect the dots. And every day I'm connecting those pieces and lines. It requires teamwork and partnership. And I think the hard part is it's, from a reimbursement standpoint, is it's lagging. But many use that sustaining and motivating compensation models. So maybe the reimbursement piece isn't there, but we can directly tie something that is broken in a primary care field, a traditional office-based primary care field, where you're moving, if you've created a financial incentive that moves towards one direction, now you can look at your reimbursement model and say, here's a different way to create compensation and incentive. And that, again, is a solution to a problem that exists in the larger picture of what we're doing. It allows the entire team to feel like they're part of the solution. And I think coming back to that mission work, that's what I do a lot in my job, is say, what is our mission and how do we test our mission against the work that we're doing or the moments that we're challenged? And then it allows for personal flexibility. It's probably a whole nother talk, but I'm doing a lot of work right now on how the workforce is changing and how we need to be on the leading edge of the changing workforce and what that's gonna look like. But flexibility, remote workforce, allowing employers and starting to think about employers that respond and work in which people really wanna live instead of the other way around where you have to live within the constraints as we set up the work system. Those are gonna be really interesting conversations and we're really spurred on by COVID. Oh, go back actually. Is there anything that you guys would add for the solution here? Other things that is like, this is the thing that I tell people and why I love this work. Yeah. So I just think it's important to have that supportive relationship with coworkers where you can share your emotions about things that are painful or challenging or frustrating. But I also think there's that additional piece of having the workplace environment be a place where things are celebrated. So even the little things, the baby shower for your favorite nurse that's having a baby or the workplace barbecue. I know some of those things are sort of traditional and at times maybe not the right fit for everyone, but I think you just need to have that additional opportunity to see people in the other pieces of their lives when they're comfortable with that, sharing that in the workplace. So you can form those bonds that are supportive beyond just the, this is what's going on with these patients. I think that's a great point. And actually I have a couple more slides and one of those Laura is gonna be on, how do we create this culture of support and addressing stress and burnout? And I think that's so, so critical. Sarah put here too, that during times of COVID, sometimes the only other people that providers were seeing were patients. And I've used this, I've described this as the higher you move up kind of in the leadership chain, but I think it would be applicable to just how many people you interact with. Like in some jobs, I think home-based medicine, again, the higher you move up in the leadership chain, there are fewer people to compliment you. And so you have to really figure out how you get recognition internally and from the work and what are the wins that you can interpret as recognition because they don't always come over quite like you would have gotten them in maybe a more typical type of job where you were surrounded by more people with more typical kind of workflows, right? And in so many ways, I describe our work as kind of the wild, wild West where we're just putting it all together and we're trying to figure out what we're doing and we're learning from each other and we're every year, we all just get better and how cool is that? And so this, that kind of community of pulling together. Oh, I love, oh, okay, I love these comments. Nicole said, medicine is siloed. The team's separate in a way that's not just before not because of COVID, it was already happening. Yeah, I completely agree. And I think for us and I love other people's opinions on this, but for us, we're really starting to think outside the box of it's okay if we're not together. You know, like not all of us are together. We weren't before because it was home-based medicine. Like I didn't go everywhere with everyone. I didn't see everyone every single day. But then what are the meaningful touch points when we do come together and what does that look like exactly? And I think we have to maybe rethink about what are the incentives that people will have for that people no longer have the ability or desire to come in for a two and a half hour meeting where they sit the entire time. Meetings look different now and meetings look like, you know, where the individual is control. I can turn on and off my camera. I can turn, I can be wearing what I want. It can be maybe at different times of the day than I was working before because I no longer have travel involved. You know, there are some of these pieces where we start to start individually asking, what does that look like? Okay, let me go to another slide. I have a couple of slides around operational strategies too. So a couple of ways, again, to reduce stress and burnout is, and start throwing in, you know I'm gonna ask it, start throwing in the chat other ideas, but joint visits to manage tension, have separate discussions with family members. How do you see if you can get everybody on the same table at the same time? How do you see if you could kind of clarify in that meeting? Who am I gonna talk to next? Do I have to talk to everybody or can I talk to so-and-so? And then this is how our communication flow is gonna work. How do you document and recognizing the time involved in the paperwork and allowing it for completion of work hours? We heard from Paul, he has an MA and he's doing it on his drive and he's getting those two more visits a day to be able to pay for that. And what does that look like? Have you tried a couple of things to see it? From a financial model, you know, lower overhead is great. I think we will continue to see some pieces of lower overhead. I'm not sure how many practices that are mobile practices will continue to keep bricks and mortar office space just to have, like how many people are we actually entertaining in our office anymore? Team approach to continually educating patients and reinforcing the care plan. How do you make sure that when you create that and it's communicated well, that it's carried through for everyone else? Administrative support, and these are things that we help talk about and we have kind of walked through and we'll keep walking through with you guys around scheduling and routing and how do you cut out some of that red tape? If you're gonna have a clinical model that's gonna get to the heart of innovation and it's going to truly improve quality and cost, don't burden it with a business model that's too heavy with red tape. Keep checking the red tape and say, I put it there and I can take it away. Caitlin, I try to plan one stationary day at home per week to catch up. Absolutely. Drink water with predictable bathroom breaks. That's amazing. Fantastic. I love that. Here are the wins that we have control of, right? Like, yeah, absolutely. Yeah, no longer having to stop at the 7-Eleven. Other thoughts? Some slide, some other thoughts around administrative strategies. And these are the types of things that we think about proactive instead of reactive. How do you handle patient noncompliance? It's easy to see when a patient hasn't followed instructions in their home. So you get first eyes or, you know, either someone you work with or a partner gets first eyes on patient noncompliance. How do you handle that? Is there a line where you won't continue to follow that person? What does that look like? How much energy are you putting out if they're not putting any back for you? How do you handle patient no-shows? It's waste a lot of time and energy to travel if the patient's not there. You know, it's, you know, Brianna mentioned, oh, what if they're in assisted living? Make sure they're in the right room or they didn't go out to lunch or something right now. You know, maybe they did. You can kind of track them down. That only took about 15 minutes, but what if they're not in the building? What if they're not in their house? How many times are you going to make that drive? You know, two, three times? How often do you meet with your colleagues and your team? So there's no one right answer, but it really feels, it's important to be supported by your colleagues that have that expertise and that mission driven just to hear from them. And now we have technology that can bring us together in new ways, but how do you see your technology or how do you see your colleague and your team in that proactive way before we're reactive of like, oh, we're not getting together enough. We need to get together more. Nope, we just have maintenance on this relationship. So think of your role, I think about it, as seeing for the future. You're constantly trying to think about what might be a barrier and you can do it clinically, but it definitely translates to operations too. What's the barrier here and how do I start breaking that down before I get to it? Okay, Sarah says, we have to have management adjust metrics for home-based versus the rest of primary care. We see less patients, but we do just as much work. Yeah, absolutely. Absolutely. That's a great example of breaking down that red tape and saying, you know, the reports that have been coming out, they just don't meet and fit with our work. And so it's bogging everybody down and saying, how do we need to be proactive in that space? Great, okay, I think I'm catching anything, but if I miss anything, either, anybody, y'all let me know. Okay, okay, next slide. So how do we create a culture of support and addressing stress and burnout? I think this is maybe where we may spend a little bit more time, but, you know, like again, in a proactive way, before we get to that spot, I generally think, and I'd love for you guys to tell me I'm wrong, but I generally think when you get to a place where an employee is at the burnout stage, the true burnout stage of apathy, and they just can't see themselves as part of the solution here, there's really no pulling them back from that. What we have is the opportunity to continue to de-stress the situation, find out their concerns, and everybody's concern is slightly different. I describe it, this is not very good analogy, I guess, but I always describe it as all employees, brand new employees start as a whole ball, and what happens is little things chip at them, just time and time again, like, oh, I don't have the right pens, or I don't have a stapler, or I don't have the right supplies, or so-and-so never answers the phone, and it just chips, chips, chips at this, and people don't leave because of one little chip, they leave of a lot of little chips, and then they're sitting there with kind of half a ball that's not bouncing anymore, and we can't figure out why they've left, they seem perfectly fine, and we never really ask along the way, what are the things that we can do to help? And so you really want the individuals to feel as though they're problem solvers, right? You are part of the solution, you are in this incredible work that we're in, you are part of the mission-driven work that we're doing, you are part of the solution that removes red tape. You might create red tape at times to straighten this out, and then if it doesn't work, you remove it. How do you think about an HR department, and as an individual who was HR for a very long time in a very small company because there was no HR, I get the department of one, the employee of one of being HR here, but how do you think around policies that are supportive? How do you encourage paid time off and promote balance? I mean, how many of you guys during COVID took a full week off, right? And if you did, was it because you were pushed to your very maximum? And now that we're kind of getting back into the work, it's like, well, thank goodness it's not COVID, but how many of you taken a week or two off? Let's assume you get four to five weeks a year off, probably should have already, we're halfway through the year maybe you've taken two weeks off consecutively or non consecutively already. How many of you have done it? Check yourself, you're the model for them. What does that time off look like? How do you promote the balance? You send them emails at midnight, sometimes you have to, that's okay. Are you working till midnight? Sometimes you have to. What does that balance look like for you? And how do we think about work-life integration in this new world? How do we utilize and talk about employee assistance programs? EAP could be very useful for many employees, often they're free and you could offer these programs so you're not paying out of pocket to offer for really small employers, this is a great option for you. I can say from personal experience at my employer that we have had more mental illness and addiction rise up in the last 15 to 18 months than we have in a very long time. And so how do we find the right supports to put in place to move people through that and help support them in their time of need? How do you compensate in line with work levels? And how do you create a model that creates the right financial incentives to do the work that you want to be done? If you are paying on WorkRVUs and you're like, well, we may not be ready for value because we're doing X, Y, Z, like, yeah, you haven't created the right financial incentives here. And so generally there's a book called Drive that my colleagues have been talking a lot about and they've said, generally if your pay is in line with the industry standard for the work that you do, then it comes down to, are you connected to the mission of the work that we're doing? Do you like the work? Is it fun? Is it innovative? And do you have that personal connections of your values and their values? So make sure your comp is in line and be proactive. As a HR department, as leaders, as clinicians, as leader clinicians, we have to say, how do we continue to say I've handled today well enough and I need to think about tomorrow? And show team appreciation. Paul has a great example for team appreciation. I love when he shares his example of all the work they've done, but I'd love to hear some other things for how do you thank your team for showing up every day? You want to go, Paul? Are you there? Yeah, I'm here. A couple of things. Amanda and everybody, you know this. It takes a team. This is really hard work. So take the time to acknowledge the team at your meetings or even just throughout the day. Acknowledge the fact that it is hard. It is hard work. Take time. Me as a leader of the practice, take time just to listen to them. I may not have answers to all of their problems and the challenging patients that we face, but just listen. And when you have an opportunity, make a public acknowledgement of all the hard work that they do for the practice and taking care of sick and complex patients that we all do. There are a couple of things that we do in the office. One is something called in the act. So if we recognize somebody did something that beyond above their call of duty and whatnot, we put a little note and say, you know, I recognize Marybeth for doing such and such for a patient that really brought a smile to the patient and the family. And then we read that aloud at our staff meeting and we give them a little gift like Starbucks or something like that. So there's just one way to give them some token of appreciation. But I think also, I think it's important for us to verbally recognize each other and acknowledge the hard work that we're doing. Look, you know, I just talked about prognostication, right? Taking time for emotions, to recognize that, you know, the caregiver's under duress. Let's not forget our staff. Your staff is under duress. You know, COVID has just been so hard. And I see the chat and it's just such a weird, it's just been so strange, right? But celebrate little things. For example, my staff and I are saying, you know, it's hot today seeing patients at home and it's, you know, 90 degrees and they're not running their air because they have long pajamas on because they're cold, right? We all have patients like that. But celebrate the fact that we don't have to wear our PPEs this year. That, hey, we're not just completely drenched in sweat when we leave the patient's house, right? So that's a little victory. We're moving towards the right direction. We're hopefully coming out of the woods in all of this. So recognizing your staff, take joys in little things and give them some token of appreciation. Final comment is this. My staff knows this. Maybe they don't. I carry this little thing in my pocket. And it's in my pocket. And when I'm faced with whatever, challenges, you know, our patients have a lot of issues we simply cannot fix. And I think I put a lot of burden on myself, just like they think I'm a house call doc, that I come to your house, I can fix everything, right? I don't know if any of you have that experience that I can take out brain tumors, I can do an appendectomy at home and all that. No, you know, but maybe I put that on myself. There are things I can't fix. There are family dynamics, there are troubles, they're in the office or whatever it is. I grab onto this and I just say a quick prayer and say, you know what? I'm gonna do my best. Good Lord, you're gonna help me. I pray for my patients. I pray for their caregivers and whatnot. It's just a reminder to have a moment to recognize my own finitude, to remind myself I'm here to serve my patients. And finally, that I need a community to help pull this off in a good way. So that's just a reminder. That's my coping, it's a rock. Maybe I should throw it sometime when I'm frustrated. Oh no, I'm just kidding. I mean, I think, you know, thank you so much for sharing. I think you do such a great job talking about how you recognize your employees. I've never worked for you, but it just sounds like a true privilege to work for you. It's certainly a privilege to work next to you. So, you know, there are, I don't know if you guys have been reading about this, but it's been called the turnover tsunami or the great resignation. There are more people voluntarily leaving their jobs without other jobs right now. It's almost like, kind of like it's a seller's market for the housing market. It's certainly an employee market. And we were going into that prior to COVID. And I thought, oh, after COVID, maybe the employers will spend a moment kind of being on top and getting a pick of folks. And maybe we slightly did for a short period of time, but now employees can go anywhere and they're going to start walking with their feet. And so this proactive thing, and how do you show team recognition? How do you show individual recognition is going to be incredibly key. Having mission-driven work won't be enough. It will also be how do we continue to connect to those things for the people who are showing up every day to work with us. One other thing from a tangible standpoint is I've started, I've tried it, you know, we're kind of new into doing this, but I was at an organization once where you had like a sheet and you filled it out. Here's how I like to be recognized. So I've gotten a couple of these back. I've been doing it just in the last couple of months. And it's amazing. I can have two people that seem very similar that are at the same level and they fill them out completely different. I got one that says, I don't want to be recognized in person. I would like absolutely heads up if you're going to say my name anywhere. I don't want to like, and I don't want a big thing out of it. And I got one who's like, yes, it would be great if you take out a billboard on the highway for my name and how great I am. You know, and that is my like excellent level of recognition. And then, you know, it goes into other things. And so as we think about this, sometimes it's really good to ask individuals because not everybody wants to be called out in a meeting. Not everybody wants a gift card. What does that look like? I had an employee try to fill out the form. I was like, I don't really know how I want to be recognized. And I said, well, you certainly maybe know how you don't want to be recognized and how you don't maybe like some things. Tell me those things. So I think we're all going to need a leg up as an employer to continue to stay competitive in the coming, potentially years as the workforce continues to change. One final thought is, you know, the other thing is we have four generations working in the workforce right now. So how do you think about the workforce that four generations are working in? How do you think about recognition? How do you think about burnout? I like to say there's never been a generation in the history of time that hasn't thought the generation after them was lazy. So, and they aren't, nobody's lazy, right? But how do you manage through that when you have a multi-generational workforce? What does recognition and appreciation look like? Oh, let me see, I see a couple of chat comments. Yeah, great. Thanks, Dr. Chang again. Okay, my next slide is a big research and resources, lots of other options too, but here's some for you if you're at all interested in this work like I am. And then final slide for me is kind of key takeaways. You know, home-based medical practice professionals face the same stressors as everyone else. It's not as predictable. You know, there are a lot of increased possibility of stressors. It's also a solution. So how do we think about these kind of key coping strategies and how do we think about operational and administrative strategies for kind of culture change to support our teams as we do this? It's an incredible amount of work. So it's certainly been a privilege of my life to support this work and even the small grain of salt way that I have. So I know we've reached kind of the end of time. I'd love to take any final questions, but I know I'm standing between you and happy hour or potentially for my colleagues in California, you and a nap before the children come home. So, yeah. Thank you. Thank you so much, Amanda. The chat will remain open. And like I said, we're gonna make an effort since there's such great sharing going on. Before Amanda takes us on home and wraps us up, I just wanna remind you, if there are any resources that you wanna share with your colleagues, please do use the chat, use it liberally. It is there for you guys to share all of the wonderful things you know. So we will be saving this. Go ahead, Amanda. All right, guys. Thank you so much for the day. I really appreciate it. We have a slide on kind of next steps. If you could do one more slide for me. Tomorrow we start at 8.30 Central. Make sure to use the second day link. Be sure to complete the learning plan. We're gonna come back to that. Things you wanna continue to learn. As things come to us, we'll continue to send out the resources. I love that we send out all of the chats. We can go back and find those resources. HGCI has been an incredible resource for the physical things. But if I could energize you any more as you go to dinner and hopefully talk about your wonderful day, think about your colleagues. These are the folks in it with you through and through. They will have all of the ideas. They will tell you what works and what doesn't work. They will be with you side by side for the next 20 years if you'll let them. So I have so appreciated today and learned a lot and always learn more than I give from an education standpoint. So it's a true privilege to be here. Thank you. Janine, did I miss anything? No, you were perfect. Thank you. Those are the reminders. I will go ahead in case you misplaced your learning plan. I'm gonna send that with my reminder to you tomorrow with your day two link. So as long as we get that during the time that you're with us, that just helps us follow up with you, provide additional resources, find out what else you wanna learn so we can provide it. So we thank you for completing those, hopefully by the end of day tomorrow and getting them back to us at education, that email address that starts with education at hccinstitute.org. And we really look forward to supporting you further. Melissa, do you have anything to add before we end for the day? No, I absolutely don't. Thank you all. Thanks to our faculty. And I look forward to seeing everybody back tomorrow morning, 8.30 central time. Thank you. Thank you, everybody. Thank you so much. Thanks, everybody. Thanks, guys. Thanks, everyone. See you tomorrow.

patient adherence

socioeconomic factors

health literacy

personal beliefs

educating patients

clear instructions

patient-provider relationship

stress

burnout

healthcare professionals

home-based primary care

grief