Yesterday, I had sent you a blank one should look like this today you have one that's actually got a couple of things filled out just to give you an example of what that could look like for you. This will be resent again today but what this does is allow us to make sure that we are meeting your needs, both for this workshop, and in the future. So you'll just fill this out with some notes and return it to us, and we would be very grateful for that. With that, I'm going to hand us over to Amanda. Good morning, welcome back. I hope your brains are still kind of spending a little bit but you're feeling refreshed for another full day of learning. I wanted to ask, as we came back for all the learners and even the faculty is your brains again we're working over dinner and you're sleeping here. Is there anything we haven't covered that you want to cover today. So we just want to make sure we're really hitting the nail on the head so if you just would throw in the chat anything that you haven't heard yet, or unmute yourself and to chat with us for a few minutes. Can you all hear me. Yeah, April. Okay. Hi. Yeah, so I yeah like I said, everything was such a great information yesterday so I'm really looking forward to the topics for today. learning about the advanced coding opportunities and the procedures today so I can't think of anything that I don't that I don't think I need that's not going to be covered today and I really really enjoyed this workshop. That's a great way to start us off. Thanks. Yeah, I would say I've been doing this now a couple of years and Brianna talks coding, whether the essential element or this course it's a it's a fan favorite and so I always look forward to that too because she stays very up to date on what's going on and will help us all. And the goal of this you know I'm going to go right into value based contracting but the goal of this is, you know, get paid appropriately for the work that we're doing. Well, it takes it takes a lot of different things to do that. Other thoughts. Okay. Oh wait, I got someone. So from I, I know from the speak. I think for all the faculty, what we really appreciate is the sharing knowledge sharing from all of you, and, and any other questions that you might have and really everyone's perspective. I know that yesterday, several times it was said that we all learn from this conference every time we hold it so I'm, I'm just so thankful to be involved and get to spend the time with everyone, each and every time. So thank you. I will completely echo those comments. I was wondering, you know, because we, we build in so many different cases for our live workshops and for advanced applications we really kind of focus on Minerva and I wonder if everybody thinks Minerva is a pretty typical kind of patient that you see, or are there different kinds of patients that you feel reflect more what we see in home based primary care. All right, so Thomas, thank you. She seems pretty typical. Thanks, Bilal. Yep, Minerva, and Dr. Malini says Minerva is definitely our average patient. Yeah, not the most complex. You're right, yeah. If you took essential elements with us, I think we had even a little bit more complex with some of the patients there. Oh, and you see a lot of brain injury and MS patients, but more minority, okay. All right, well, thank you. Yeah, it's good to know we're on the right track, right, Melissa? Yeah. Anybody, bonus points on where Minerva's name comes from? Any other Harry Potter fans as big as me? No, all right, no. Okay, so here's kind of what we're gonna talk about today. Now we'll kind of, again, we wanna make sure you get everything out of this. So it's okay if we don't spend a long time on the review, but as you're going along, if you don't get a lot out of it, and you want something covered, you're like, oh, it should have been in that session. I didn't hear it. You're welcome to message the faculty individually as well to say, can we make sure we cover this? We are talking too, to make sure we get everything you need. Yes, thank you, Sarah. Favorite, favorite. And so when there's procedure time as well, so some may attend a practice management session, and that is Brianna and I, where we have open questions. So if it's like, it doesn't look like it's fit anywhere, I don't really wanna jump in now, we do have this opportunity to kind of ask us open questions right after lunch in this kind of session 15 timeframe. Well, great, I think let's get into it. Quantifying the value of your practice. So as I said, the thing that we all would like to do is we'd like to get paid for the hard work that we've put into this. Brianna's gonna talk about advanced coding. That's not my area of expertise. My area mostly lies in the space of value-based contracting. You know, I do a shorter talk on essential elements, just on the types of value-based contracting there are. So I know some of you have attended that or will be attending that. Jump in if you have questions along the way. Of course, there are new acronyms as we go along. But, you know, again, we're just trying to figure out what is the best way to tie your business case, your mission vision values to the financing of it to create a sustaining and thriving model for you. So next slide. So here's some of the things we'll talk about is, you know, how do you think about your expenses against the reimbursement and your, you know, your cashflow and your capitated payments? How do you think about the strengths and weaknesses in your clinical model to perform well under a risk-based contract? And, you know, how do you think about who do you talk to, especially with payers or ACO partners, key questions, and then the various types of contracts that would be available. Slide. So let's talk about Minerva. Great to hear that Minerva is a relatively average type patient. You know, we see a number of Minervas, you know, we see also quite a bit more behavioral or psychosocial needs as it comes along, but generally, you know, we're seeing someone who is complex, maybe demented or early stages of dementia, and someone who has, you know, at least some family dynamics that need to be navigated through. So next slide. So here's a list of, now again, I'm not clinical. So here's a list of how I interpret Minerva, right, as a case study. So she's community dwelling. She has this long list of diagnoses, right? She has these medications. She has hospitalizations. You know, she has treatments that are trying to be done. So she becomes what I call a high utilizer of healthcare. She's moving in the various areas that either we need her to, or she wants to move here. But from a financial standpoint, let's say she's dual eligible. So Medicare is picking up 80%, picking up the hospitalizations, the pharmacy, provider visits, potential skilled nursing stays after a three-day hospitalization. Medicaid is now picking up, you know, PCA, any DME, any potential meals, any home keeping, anything that she might need, because again, she's community dwelling. So for this patient, can I take one more slide? You guys are going to do the same thing clinically, right? And we talked about this yesterday. You're going to discuss her goals of care. You're going to discuss who's on point here. Who's our main point of contact? How do we reduce polypharmacy and think about deprescribing? How do we start talking about home care? How do we talk about other in-house supports? How do we talk about, you know, DME? How do we say, you know, should you be living at home? Should you be living in a more assisted living facility? Any psychosocial or medical concerns. So that's all that you guys are doing, but you're getting paid for all of the time and all the things you need to do on this fee-for-service model. So you get paid on this kind of widget-based model, or you might have what I call kind of fee-for-service plus, which is still widget-based, but it's not necessarily tied to the successful completion of like a SOAP visit, right? So I still am going to do some activity, and Brianna's going to talk about all these options, but chronic care management, right? There's still some activity that is generated on an individual in which we do this activity a number of times, a number of minutes per month, per whatever, and you get some additional kind of 1500 revenue, $1,500 for that. You get, you know, X dollars for doing that. But you're not really responsible for all of the pieces of her care, but you are, like, if you do all these clinical goals, right, and all the treatments are the same, you start to lower costs. You're lowering costs for someone. You're lowering costs for, again, her dual-eligible plan. So that might be a, you know, a fighty-snip through the state. It might be another type of dual-eligible plan, again, through the state and the federal government, or, you know, she here is just on straight original Medicare and Medicaid, and you're saving someone money, right? Now we're at the hospitalization. Now we don't have drug interactions because we produce polypharmacy, whatever these things might be. And I think that's where the question is, if you're doing all the right things, and you can prove you're doing all the right things, how do you get paid for them? So, slide. So how do you get paid under capitation? And some of you remember the capitation of the 90s, and I would say it's generally not that different than it is today. I call it ethical capitation now, where it's tied to some more quality measures to make sure that it's not a runaway train, and there's not care withholding. But capitation can refer to a lot of different types of arrangements, but, you know, you can get capitated monthly payment for care coordination. You could possibly get the fee for service for the billable visits. You could get a risk or shared savings model for the pool of patients. So maybe Benerva is one of a thousand patients you're caring for, and you're taking risk on these patients. And you reduce hospitalizations, and you lower expense. And so now there's some shared savings at the end of the day with you and the payer. You could have a shared savings in an ACO-like model. I'd love to... So if anybody out there is in an ACO model, how are you getting those shared savings? Let's talk about that. You could have a quality bonus incentive with a payer health system. So maybe it's not tied necessarily to the total cost of care, but it's tied to, hey, we reduced hospitalizations. Hey, we increased the payer star measures. And that was some financial benefit then. We, you know, there's a threshold, a four-star threshold that we've lowered under that amount. So anybody in these kinds of capitated contracts today for your patients, and it could be in anything, just any arrangement that is not just fee-for-service, jump in. Oh, could you go back a slide? Is anyone today getting paid in that just fee-for-service? Usually there's someone who has some financial piece. Oh, okay, yeah. So Julianne says you're involved in a direct contracting program. So you're DCE. So how long have you been part of the DCE? It's still pretty new to us. We've only been involved in it for a couple of years. It's new to us. We've only been doing it a couple of months, and I'll admit that I have limited knowledge about it because we have someone who's been kind of running that program for us within the agency. She's done similar programs with Medicare and before. So it is fairly new, but it's been very interesting learning about it. Yeah, so direct contracting is a program that came out of the Centers for Medicare and Medicaid Innovation, CMMI, and gives individuals the opportunity to create a value-based contract directly with original Medicare. And it's been out for a couple of years. CMMI, just in the last two months, has put a pause, a new entrance to be DCEs, these direct contracting entities. But you can join other ones. So Patrick, it sounds like you're maybe looking into joining another one if you haven't, if you're not in one today, that maybe there's one that makes sense to partner with. I think for targeted populations, especially the seriously ill populations, these programs become really interesting. And in other ways too, like you don't have to work with an ACO or with a payer. You're working with the single, the single source payer in Medicare. And so you're not at risk at having to negotiate every year your Medicare Advantage contract or your dual contract with a payer, or again, even an ACO of how does attribution work. There are all these prescribed rules, as Medicare says, these are what the patients count as, and this is what it's gonna look like, and this is what we're tracking. And so those become, I think, very interesting opportunities. I haven't heard, DC is still so new. I invite Brianna to say too, that like I haven't heard people, this has only been around maybe three years. So I haven't heard people say you have runaway trains with this yet, but the opportunity to continue to partner directly with Medicare through direct contracting, I think will be very interesting. Yeah, I mean, I agree. I mean, I think the performance period just started in April, if I'm not mistaken. So I think there's a lot of learnings and CMMI has just kind of reiterated their commitment to value-based care, but they're just trying to, which I think is a great thing, take their learnings and enhance the model before they open it up. Some of you may have heard of primary care first. That's the other alternative payment model that they did actually just offer a cohort two for. So that's another value-based contracting opportunity through traditional Medicare to get paid that way. So I think we're hopeful we'll continue to see more and more opportunities. Yeah, and I think it's smart to start thinking about these direct, it's hard because direct contracting is a program, but I'm gonna use it in the non-capitalized sense of like these direct contracting opportunities that come out with Medicare. Liz Fowler, the head of CMMI in the last three weeks, again, a couple months ago, maybe two months ago, they announced kind of a pause on some of new entrants to their programs. They'll continue some programs for this evaluation period. But the other thing in the last three weeks she said is, she's used the word mandatory a couple of times in her interviews. And regardless of political affiliation, the heads of CMMI and some of the supporters and influencers within the CMMI realm have said that over the last couple of years, because from a Medicare contracting standpoint, the people who are getting into these programs are self-selecting in because they believe they can be financially successful. So they're not moving the dial as quickly as they would like. And so I would not be surprised if maybe this next round in maybe two years when the pause stops, maybe we don't see anything big there, but potentially in the next five years, this could be a mandatory participatory program where you really need to think about how you're gonna get in front of this. Amanda, to carry on that pace, I attended a value-based care symposium this year and the language that one of the keynotes used was, we have an ethical and financial imperative to move to value-based care completely within the next few years. So I think we're gonna see that continue and not go away. And the government will likely use our favorite term, right? They'll be budget neutral in how they do that. And so what will that look like, right? Because their GDP is fastly approaching 20% spend in healthcare. So I think for those that are popping in the chat here, I'm keeping track here, thinking about how you're gonna get in front of that. And even if you start with some local payers, so when Michael said, Medicare Advantage, exactly, right? Like a local payer that is already at risk for these patients and it's already a Part C program, how does that work? And getting ahead of that clinical model, that would be really interesting if potentially mandatory models are coming down. So a couple of people said they're part of the ACO. For those who said that, have you been part of an ACO long enough to see any financial gain? Like has the attribution piece and the financial piece kind of lined up or is it more just kind of as a referral network and part of a network affiliation versus you're seeing the financial improvement piece? Yeah, Tom Alitti here. We've been part of an ACO probably since 2015, so actually quite a long time. So in our model, we've actually benefited from some of the quality dollars that have been paid out to the ACO. And every year, for our large hospital system, there's a committee who kind of decides okay, what are the metrics involved? And based off of the percentage breakdown, the PCPs get paid a certain quality dollar amount every year. So that does change every year. I think the only downfall in our system is it's geared towards PCPs that aren't necessarily house call physicians only. It's really focused on office-based physicians but to tell you the truth, we've still done pretty well with our quality even though we're being compared to office-based physicians. Oh, fantastic. Anyone else on the ACO side? Also, if you look at the chat, these guys are talking a little bit about, you know, primary care first. If I remember correctly, I think it's only open to like 26 states. So it's not my area of expertise, because it's not been open to Minnesota, but Brianna put some information around some of the financial modeling in there too. I think, you know, again, I'll keep moving us along, but again, I think thinking about these models, what's out there, because I'm trying to make the argument for you, when you do the right thing, maybe in all of healthcare, but certainly in geriatrics, when you're doing the right thing and you're improving the quality of care, you're lowering the cost of care and you're lowering it for someone, the question is who? And so as you think about next steps, you know, like, hey, these sound great. I'd love to have a capitated contract, because I get the idea that I'm saving people money. I put this little box at the bottom that says, you know, too good to be true, like make sure you're ready for it. And I don't mean it in kind of a glib way. I mean it in a, how do we think about what's it gonna take to get you there? Slide. So for me, the clinical model is the foundation of what we do. I think there are a couple of different areas to running a value-based company. I think it is the clinical model, the business infrastructure and value-based contracting. And I always describe it in that order. We often get a lot of attention because of the number of value-based contracts we have. But, and those only come with the right clinical model. Is your clinical model ready? Do you understand your total cost of care? What are your strengths and weaknesses? Do you know, do you understand, you know, however, here, let me put it a different way. Hypothetically, you're doing all the right work. You're paying people on work RBUs or you're paying people on a very aggressive panel size. You know, when we started talking about value-based care and you're talking about the time it takes to manage these patients, you need to say, well, you know, are all the business pieces in order to provide the right disincentives and incentives for the work that we do? Again, I say clinical models, the foundation has to be the most well-resourced, innovative area of your company. Second to that is your business model. Your business model and infrastructure, basically its only job is to not screw up the clinical thing you've just created. So if anybody works in an organization where you keep banging your head on the wall, not because it's not incredible work, but you're banging your head on the wall because there's too much red tape, you know, you may be, again, creating accidental disincentives for your clinical team just by your business infrastructure. And then when you have those things ready, then you go to the payers and you say, yep, we're ready to start doing this work. You know, also kind of as you think this, who do you need to get on board before you're ready? Certainly your clinical team, you know, how are you going to jump into value-based contracting if your clinical team doesn't understand what that means? Your finance team, your base staff, maybe your entire company, your board, you know, it's complicated to make sure everyone understands the importance of everything that they're doing and how you're going to get paid and how to do it ethically. We've certainly seen groups here that sign a risk contract today because they've grown their patient base to some certain magical number that they should now be able to get that risk-based contract or the value-based contract. And then they go out of business because they were expecting this different outcome. And if there are certain things that are going to make you very successful in fee-for-service, and then there's certain things that are going to make you very successful from a value-based contracting component from a clinical expectation. And so, you know, do you have a pulse on, is your organization really ready for that? The chat, any questions for me on that? Okay. Slide. So, you know, really the devil's in the details is, you know, how do you start creating the sustainable business model? What is your value proposition? I always say, if you don't have your two-minute speech, get it. Really, you do need to be able to quickly identify what you do and what you do really well and where you don't have the biggest, maybe the strongest area, and you have to be really honest. And you can do a SWOT, you can do a gap analysis. But once you figure those things out, then you need to create all of your materials and all of your language and all of your people say the same thing. Here's what we do really well. Here's our value proposition. Here's why we're different. And continue to deliver on that and know exactly who you are. It's okay if your value proposition is, you know, you may be very similar to other house call programs, but your value proposition is, we work in this unique area. You know, we take care of these unique types of patients, or we have this very different clinical tool that sets us apart. Whatever those pieces are, what are they? Can you drive them down? How to think about the area within the larger healthcare system. So, you know, a lot of you are tied to bigger healthcare systems. How are you promoting that model? I mean, the same thing is true. Find that value proposition, but how do you push that within the larger healthcare system? And how do you get credit for that? So I don't know if anybody else is in this boat, but there's always a couple whenever we teach this class that say, we have this great business model, but every time we look at the P&L, all we look like is just a series of expense on the P&L. Then we never get any allocation of money. We save the system. And so we never can prove these pieces. And that's why when we earlier, when we were talking about, and when Tom was talking about in the video of the VA dollar save, is you can extrapolate and say, it may not look like on our allocated P&L that we're saving all this money, but if you actually looked at the lower hospitalizations, here is our impact. And here's the shadow P&L that should sit next to this to show the value that we're in within the larger system. And we're ready for more things like this. And then how do you leverage that and with whom? Who are you willing to partner with? Again, if you're saving someone money, the question is, who are you saving money? Sometimes, to Michael's point of being involved in a Medicare Advantage plan, sometimes if it's a Part C program, you're saving Medicare Advantage. You're saving United or Aetna. Sometimes you're saving original Medicare money. And so you need to look into a DCE or a primary care first, or even an MSSP or advanced payment model through MACRA as an alternative to MIPS. So now we start to say, okay, wait a minute, I'm saving someone money. Who's getting that money? And then who's willing to partner with you? What are the things that they want? And how do you become a solution to their problems? Because they have the same problems you have. If your costs, like if you're doing something right, they want more of you to do that right thing. And then what data are you getting from your partner? So how do you formalize this relationship with your partner? For example, with all of our partner relationships with our payers, and so we have local payers here, I build into the contract thresholds for when money like triggers will trigger for money to be paid for a cashflow issue. I built in account reps. We need to have an assigned account rep that will be responsible for these things. And we will meet at least quarterly to discuss these issues. And you build these things in to say, here's what the relationship is gonna look like. And here's what it's gonna take to do this. Because sometimes, you know, with payers or you sit on all this data, but you're not tying it together to move it forward in a meaningful way fast enough for you to make a difference, right? I'm getting claims-based data six months later after something has occurred. Well, maybe that's fine if it's June or July of the year, but if it's December, and I'm figuring out I had an issue in July, I don't really have the information to be able to make a difference. So when do you need that information? And what does that look like? Questions? And, you know, one thing I'd say, one final thing is, you know, don't be surprised if you don't make money right away on this. You know, how do you adjust and move forward? And if you do make money at this, don't be surprised if other people try to come and get more of that money, right? You have a good year, you sign a contract, you say, here's our clinical model. You know, we sign a payer arrangement and it's worked really well. Don't be surprised in year two if they're ready to collect a little bit more on that. So, you know, how do you continue to grow and innovate and how do you align your mission with your partner's mission? And again, everybody's kind of in different spots. Some are starting groups, some are growing groups, some are trying to demonstrate within larger systems where you're at or some are even, you know, we often get people who are thinking about and preparing for sale for a larger group. I think all of this starts, and I just can't issue it enough of, you know, what is your mission, vision, values and your value proposition? How do those things align with the partners you're working with? We've also seen in my market a number of times where someone says, oh, this is a great idea because we have a very similar P&L, right? Like, so we have very similar size organizations and they should come together. Or, you know, this seems great because this one person's really impressive. You know, people aren't married to their jobs. When they leave their jobs and something changes, it makes it really difficult. So is the whole organization behind it or is this one person a big champion? Just some thoughts on how you move that clinical model forward and who do you talk to. Next slide. So let's say you can figure out, you know, who to talk to. How do you build that relationship? And HCCI has a relationship module too that I helped with around, you know, payer partners and who do you talk to and value-based care. And I think it helps a lot to say, what does this look like? But you need a pervasive or persuasive champion on your team to lead the discussions. So who is that? It might be your CEO. It might be your CMO. It might be you. It might be someone else, right? Who is the person that's going to be leading these discussions? You know, we're now a large enough organization where I have a couple of different people that I'll send in depending on what visual I need and what this is going to look like. Sometimes I need, I know I need a physician at the table. Sometimes I know I need a male at the table. Sometimes I know I need a nurse at the table. You know, what are the roles that you need to be able to be successful and how are you kind of leveraging everything you have? And then again, understand what your potential partner values. I start, I know I'm beating the dead horse here, but I always start with their websites. What are their mission vision values? What are their actual goals that they would like on there? And do those line up with yours. We have two payers that probably look to be roughly similar size or have similar missions. And if you actually look at their mission statements, they're very different mission statements. One is completely focused on all of the external stakeholders in the world. Patients are one of them and a growth opportunity. And the other is so internally focused on patients are the key to everything in the entire world. Well, I, you know, I'm going to tailor my message slightly different for these. So, you know, again, what are their goals? And then figure out as in the conversations of what are their pain points? And I always ask, what are your pain points? Like, what are the things you wish you could control? So they're working with lots of different organizations and they're going to tell you, just like all the data we've seen, that the top five to 10% of patients are the most expensive in terms of need. And so you could be like, well, you know, that's exactly what we do is we solve those pain points. Let's just figure out how to financially pay for it. But I'm going to tell you right now, those that's our bread and butter is those five to 10% that other groups can't get a hold of or handle of, their care, we're the best at it. And then how are you going to demonstrate that potential metrics? So if they say, yeah, these are, we need fewer days in hospital beds. We need people more at home. We need people, you know, we'd love for people to die more on hospice and at home. Great, here's how we've been tracking that. And so there's unlimited amount of data you can track. What are your five metrics that you track? Come able to speak to that gap and how you are their solution and continue to be their solution. Connect in that clinical way, that value prop way first, and then say, well, all that's left is to pay for it. So utilize and then utilize all your connections to get in front of the right people to tell your story. If you reach out and you're fee-for-service contracting person at a local payer spot, you know, they're not really the right person. They're the people who get your papers to sign. And then the people that are going to take a 1% increase up the chain, right? You need to find who is the person that I most connect with to move this forward. If a clinical person's at the table, bring a clinical person. Say, I'd love to meet with your CMO. Say, I'd love for the health plan CMO to come with us and we can learn more about this. Say, I'd love to meet with the head, you know, the head of the clinical program of the ACO. Would you like to do a ride along with us? Connect first from that clinical perspective, and then again, the money thing, especially from a business standpoint, those are just details to figure out. Next slide. And then how do you create, again, that ongoing meaningful relationship? Consider creating a scorecard or dashboard for your practice. You may have multiple dashboards or KPIs that you're going to want to track. You may have board level, senior executive level. You may have staff level that you're doing, but when you create a new partner relationship, how are you pushing out information and pulling in information that shows that you're on the right track? You sign a contract and you don't speak to that person again until a year later when the contract's due again, you're not going to find them that interested in doing more work unless you've just printed money for them, right? You need to say along the way, here's what we're doing right and here's what we're not. And I use these as leveraging points for any of my negotiation. Hey, this wasn't working. Here's what we did. We threw the kitchen sink at it and then it changed. Or, hey, you guys weren't very good partners in that. We worked really hard at trying to get this going and it didn't go anywhere. Like, we really need you guys to show up just as interested as we are. And that's just as important of negotiating metric as anything else. And then keep those key metrics that are highlighting your value. So maybe it's not something that you built into your program today. For example, there's no way for the payer to track days at home or something, but it's a key metric for you. And you guys agree, it's important. Maybe it doesn't end up on your scorecard, but you start just keeping track of it. And you say, this is something that's a future metric that we could track together. And this is value you wanna see. I was recently talking with one of our local payers and presenting, we were kind of dual presenting something else, a totally separate meeting. We were dual presenting. And what was interesting was they used us as a highlighted us as an example. And what I could hear in their presentation was words that I had used to describe us repeated back to me and values and quality measures that I had used as key things to focus on coming back to me. And so that was really cool is, hey, what I'm saying is really landing with you. I've said these five things and they're landing in a way that you're repeating them in a public room with lots of people. And then consider tracking your very sickest patients, days at homes and days in the hospital over time. These aren't things that we are necessarily tracking today. I'd love to see if anybody in the chat is tracking those things, but track those things and report those back. Those are gonna be financial savings. And I think in the next five to 10 years, those are things that we will all get used to saying. And so we'll stop saying ER days per thousand or maybe we'll keep saying them, but we'll also say days at home, dying at home versus days at hospital. Stop me anytime you guys. Okay, slide. So types of value contracts. There's certainly alternative payment models. APMs came out of the MACRA legislation a few years ago as an alternative to MIPS. And so sometimes the MACRA was part of legislation, of course, but there are some programs in there like comprehensive primary care that come under the alternative payment models. There's this augmented fee-for-service or fee-for-service plus again, and Brianna will talk about it, but transitional care management, care management codes, even advanced care planning. These are things that require you to do something, some activities, some widget-based work. Someone is doing something and we're billing it through the typical program and then we're getting some additional fee-for-service dollars. And so it's kind of a pro-fee way of getting paid for some additional care coordination like things. Then you can have per member per month or per enrollee per month or per beneficiary per month. And so you may have seen some of this language here where it's just a flat fee. They're enrolled with you for some solution, right? Maybe care management, some quality measures, and you're getting additional dollars to offset that fee. And the basic pieces, you may have some general ideas that you have to do, but if you don't do them, you still get that fee as long as they're enrolled with your program. For example, you might have a care management program where you say, we get a hundred bucks per member per month to manage this patient. And the management of this patient, the goals that we're hoping to achieve are lower hospitalizations. And maybe it's a program that has like a three-day waiver, utilization of the three-day waiver, this quality measure will improve, but you don't have to do those things each month to get those things. You just, those are the goals of the program and you're getting additional stipend for resources to do that work. You could get fee for service. So typical fee for service, plus kind of this care coordination component. So you get one, you get other, you get both together. You could have kind of a shared savings example would be kind of the track one, MSSP, right? Is where we're all in this together. If we perform over a certain threshold, then the government takes some or the ACO takes some of the money and then we get allocated our percentage based on our allocation of patients to our attributed model, our attributed patients to our model. And so it's really shared savings. If there's no, if there's money lost, we're not, we don't have to owe any money back. It's just, if there's positive money, we might get some of that. Quality bonuses are kind of paid for performance where a big thing is set, especially a few years ago, but the idea of like, oh, well, we're going to have just certain metrics. We don't, maybe it's other things don't matter as much, but these things, did we do the eye exam and did we get the breast cancer screening? And those things, if we do those things right, we get paid for that. Then there's really, we kind of go into gain sharing. Well, let me jump to one. I'll do the bundled payment first. The episodic, the episodes of care payment or bundled payments, you can go on CMMI's website and go to your state and see what other bundled payments are out there. But they make a lot of sense for very discreet, you know, procedures, you know, total knees make this very popular. Heart, you know, heart interventions make this very popular. We say, you know, here's the start of care. Here's a really clear start. Here's a really clear end. And here's where there's a lot of waste in healthcare. So if we could bundle all of this together, we'll give you a lump sum to manage these patients. There's some like built-in disincentive, especially for example, with like orthopods. So hypothetically, you know, or not hypothetically, in reality, I guess, from an orthopod standpoint, what we're seeing is these bundled payments. And so then they're doing so much screening on the front end for who's the right total knee replacement individual that sometimes people are being screened out, specifically people who have, that are morbidly obese. And so for an obesity screening, or a BMI is going to pull someone out for being a good care. And then they need to find another orthopod because they don't even make the screening to go through it. Because they're like, well, this person's going to be too expensive. So some disincentives, but done right, it definitely makes us rethink, you know, these episodic moments of care. And then gain sharing and full risk, right? So someone, we're at total risk. Someone is collecting all the revenue. Someone's collecting all of the expense. At the end of the day, there's money in the bucket. There's, you know, money in the net income line, and we're going to share that. We're going to split it 50-50 if the patient population got better and we spent less on them. You could have full risk capitation and say, well, it's, you know, whether it's positive or negative, we're going to share in that risk. It's going to be 50-50. And maybe there are floor of ceilings added to that. Like there might be a floor of saying you can't lose more than a million dollars, but then usually it comes to the ceiling if you can't make more than $2 million or a million dollars in this arrangement. So those get into more kind of the total cost of care structure. I'm going to look at some of the chat here. Okay, Brianna, did you handle all the chat or should I? Are there any questions for me in here? You're good. I was just putting some of the resources you're mentioning in there. And let's just see. Anna did say, interestingly, many of my homebound are completely homebound or underutilized, so their number of hospital days may look good, but doesn't reflect their health and improved outcomes. Sure, absolutely. And so, you know, I think that's from a system. I think the system of healthcare is still very interested in low hospitals. Low hospitalization days may get you into the room places, but then you may say, you know, you may say I'd be a great fit for, you know, metrics tied to low hospitalization, but I'm not a great fit yet for some of the specific quality improvement components. Or you may say, hey, I'm happy to keep people out of the hospital, but it would be great if I have another resource to help me with these things. Would you be willing to help me with these things? And so one thing that we've been thinking a lot about and starting to build some models off of is what if we started going to payers and said, you know, we're at risk for something or we have some incentive here, or maybe there's some grant money, but we'd love to try just a couple of, like a resource. We'd love to try a resource that could focus on specifically transitions and these scenarios. What would that look like? How could, could you help fund something like that? Because we're seeing this come down to, you know, maybe it's not hospitalizations, but maybe it's, you know, a quality of life component. And, you know, we have a quality of life measure and we think we can improve this, right? And you say, oh, maybe that's kind of interesting, you know, and the state is specifically good. Like states are really good at putting out kind of performance programs too. And so to talk to them and say, hey, do you have some grant money for a specific intervention I'm interested in that maybe doesn't line up perfectly with the saving of money in the traditional sense, but could save it in another area, if that's helpful. Other questions for me? Okay, just a couple more slides. One more slide here. So hopefully I've made the argument that, you know, start with, as a clinical model is your foundation, make sure your organization is ready for that change piece. You know, figure out who is it, your partner and your financial partner in this. Who's saving money? Who could you partner with? Where does it make sense from a value perspective? Then build that relationship, build it into the contracting, build it into your time and your energy and then deliver on those results. And I think being able to tie these pieces together in that order starts to open up a lot of doors. And then I have one slide that always just sits here is all the abbreviations. So, you know, you may see some of these as well in your day-to-day life that go along with value-based contracting. And I think the key takeaways, one more slide, I've kind of delivered, but, you know, I look forward, especially in the one-on-one session, if anybody's interested in asking us more questions about any of these pieces or getting more specific around, you know, this is really what I'm trying to do. And I just can't find anybody who's, you know, selling what I'm buying. We're happy to help spin some of those, or yeah, who's buying what I'm selling. We're happy to help spin some of those things for you and talk more about it. Because I think the general idea is always the same. Again, you improve the quality, you're lowering the cost and how do we get paid to do that? So thank you. Thank you. So we have an opportunity here with some time. Do we want to have a talk about some of the things that we've just gone over and maybe do a little consult, share some stories? We can do that in the chat, or we can turn off slides and turn on the video and have a conversation. What are your thoughts, Amanda? I mean, I will do whatever the group wants us to do. If they want us to keep going or if they want to talk specifically on stuff, like absolutely. Okay. So I may be, this may be an individual conversation and not for everybody, but as I'm in the very beginning processes of setting up my practice, and is there any specific models that you would recommend that I try to model my practice after? Because even before this, I've kind of been doing some research on the different models and kind of my thoughts were kind of the fee for service and adding in the chronic care, the transitional care stuff. But being that I'm going to be the only employee of my company until I start making more money, my time is gonna be needed to see patients, to make some money before I can hire people. So are there any suggestions as I'm starting this maybe? Yeah, and you guys jump into, I mean, you guys have been in this spot, but so my first job actually at this company was director of business ops and the company had just started as a joint venture. So it'd been around a while, but it was kind of getting into this next iteration. My job was to bring all of the things that required to stand up a company and make it a standalone company instead of kind of a spinoff from another company and so it was like HR and payroll and the business and purchasing a malpractice. And it was a long two years to stand up a company by itself. And so I wish you the absolute best and a lot of your energy should be on that, is how do I think about and bid malpractice? How do I think about my corporate insurance and some of the things that I have to do here? So for me, I'd probably just, I'm gonna be interested in other's thoughts, but I would probably say, focus on how do you think about fee-for-service? My guess is, and you can hear a lot of these guys, is you're going to have quite a bit of success, right? Like there's the market is there for you. So how do you start thinking about how do I capture the revenue today that I want and how do I do it in a fee-for-service and a fee-for-service plus way? And so Brianna, the advanced coding I think will be very interesting for you because you guys will become just best friends because you can say, okay, now I'm gonna do some kind of total cost of care stuff. And then I think you pick a couple of quality measures that aren't that hard to track, that would make sense that you've heard other people interested in, but like days at home, hospitalizations, and just see, even if you're doing it, we've done this at different times for different programs, just on a piece of paper, an Excel document of like, here are my patients and here's the intervention and the quality piece. What we find is, you don't need a lot, you need three to five measures. So just find a couple of things that are easy to track, maybe your EHR does it, maybe you're on paper, a couple of things to track and then create a narrative story. So early on, you're gonna find these moments where you're like, oh, I intervened and the patient didn't go to the hospital, or I intervened and I helped get the patient an air conditioner so that they didn't go into the hospital. Those moments, when you're sitting in the ivory tower of being a payer, you don't know that's how anybody lives, you don't understand that world. And you are being in this position of power of being invited into their space. And so start the narrative around those stories that then you kind of tie to people's home, you tie to your data. So say, the things that I do are, I do joint injections in the house, they don't have to go out. I do, I've brought in air conditioners, sometimes they need help moving or whatever this is, and I find services for other people. I talk to someone at 5 p.m. on a Friday, so they don't feel lonely over the weekend and they don't go to the hospital. And then say, and you can see that in my lower hospitalization rates, right? And so you've tied this narrative together with a quality measure. And then you get a big enough patient base and I think it's probably at least 500 patients, and then you start shopping around for who do you want to pay you more money to do that work. Thank you. Yeah, other thoughts? Greg, your passion and I think just how thoughtful, I had the opportunity to chat with you with Betsy on all your planning is really, I think, gonna help you in a lot of ways too. And I'm amazed, I mean, I just feel so privileged, especially not as a clinician. I'm sure Amanda would agree, like if I can help you with the business of medicine, like that's what gets me passionate to wake up in the morning. But I'm amazed with how many, so and we have a lot of them here. I'm sure the solo providers on this call can share a wealth of knowledge and hopefully connect with each other because I'm thinking of one nurse practitioner or two that I've had the privilege of talking to for like the past three years. She just started, you know, she was still working another job, just learned a lot every day, was drinking from a fire hose. You know, she still, you know, she started small and didn't go above 60 patients while she was still kind of getting everything set up because it was just her. I've also seen some practices start with like virtual medical assistance part-time, which can be a pretty low expense and still just help you. Like there's so much paperwork, like the DME and the prior authorizations are just doing callbacks for your patients. So, you know, you definitely don't wanna hire staff too early, but I think you can also get creative with the support because I'm amazed how much people are using virtual MAs now. And it's been, you know, obviously they're not gonna be driving you. They're gonna be, you know, kind of back office support, but that could be huge and a relatively low cost, especially if they're part-time and contracted. Brianna, I agree. And Greg, really inspirational to us. We're talking about a lot of you who are small practice or solo practitioners this morning. We really wanna help you. Of course, we wanna help others as well, but support you in whatever ways we can to get your practice going and take wonderful care of your patients. A couple of comments I'll make. I agree with Amanda. Brianna has become, or has been, and becoming more so of my best friend, especially with this billing and coding. And I want, with her talk, I hope you can get as much revenue from the work that you are doing already. And that's what I tell my nurse practitioners. It's not like I'm telling you to do more work. No, no, we don't want to do more clicks and, you know, do more stuff, but you are already doing this. What can we help you with to get the revenue that you deserve? Not Amanda. Brianna's gonna talk about transitional care management, how you can get reimbursed for that, non-face-to-face, prolonged services. As you're reviewing the patient's extensive chart, you know, we get these records from outside institutions, like 120 pages. You can actually get paid for doing that. You are going to review it anyways, because you're gonna be out there delivering wonderful care, and you can get revenue for doing this. And those phone calls and those pictures of a rash that happened, it's not much money, but, you know, fight for every dollar, and we're gonna try to help you in whatever way we can to support you under fee-for-service as you get your practice going. So, yep, those are my comments. Thank you. Does anyone else, because I know we have a lot of people that, a few of you that are super experienced, like thinking back to when you first started, you know, how did you approach that? Or any pearls anyone wants to chime in with? I know it's early, we're trying to, we'll all wake up together here. Okay. So I, my first exposure to house calls was with another healthcare, large healthcare system in the mid-Atlantic region. And I had to leave that job for, to take care of my mom. And thankfully I was able to join Hopkins when they had a need to expand their house call program out to a more rural county. Well, a county with a core of high density and then the surrounding area was rural. So speaking as an experienced house call provider going into a new house call role, expanding the territory, I couldn't figure out for the first year why I was always in the weeds and, you know, why everything was taking me so much longer and why I was working so late at night. And I mean, I kind of had a dingbat moment like nine months in, and I'm like, well, Michael, all these patients are brand new to you. So I guess my first bit of advice is, you know, no matter how experienced you are as an advanced practice provider or otherwise, that give yourself the time to learn the role. It is very different than office-based or an acute care setting or long-term care. As most of you know, it's you in the bag. And then when you're new to the role, you're learning these complex patients and it just takes several visits, I think, to become familiar with them. And we all want to do a great job. And, you know, our immediate instinct is try to cover everything on the first visit and that's just not realistic. So that's kind of a bit of advice that I had to be reminded of a few years ago. Thank you. And just to piggyback on what Amanda said, think about your practice and your EHR and what quality metrics you can fairly easily get without having to do a lot of analytics and so on. Things that may be as simple as, you know, flu shots or Pneumovax or now COVID vaccination and depression screening. And fall risk assessment. Those may be easier for you to obtain than say 30-day readmission and hospitalization if you don't have access to more extensive data. My final comment is this, is once you have the data, you can certainly have your elevator speech then ready. Amanda talked about that. Have an elevator speech ready. Tell them about what you do. Show them the data and the quality that you're measuring. And the final thing is always have a patient story. Always end with... So numbers are important, of course. End with a story that shows the impact of your intervention in the lives of these patients and the caregiver. So those are just some comments from me. Yeah. And, you know, just from an over, you know, not necessarily specific to Greg of starting, but, you know, when you're trying to start something with a payer, like these things don't go quickly. I mean, they take, you know, two years, a year to get in the door and to have the conversation and to, you know, to get someone to shadow you and just to even get off the ground. So they're not always quick conversations, but I think they're worth having and trying to find the right people and kind of staying at it too. I love what Amanda shared in the chat about building relationships too. I mean, sometimes just talking to a peer or, you know, are there other people in your area? Because similar regions are going to have similar challenges, you know, or, you know, or just friendly people in other states. You can learn a lot from your colleagues. A lot of times what I hear is most valuable to people is just the sense of community. Like, hey, I'm not alone. There's other people that have done this or there's someone that has been struggling. And so just like this opportunity here to net with your colleagues and peers. And, you know, I think that that's just priceless to have that opportunity to just know you're not alone and build that sense of community. So thank you, Amanda, for those comments. This conversation has been fantastic. The supportive storytelling I think is just unmatched. This group has so much to offer one another. So I just want to remind you, if you haven't already put your contact info in the chat. If you would like to connect with colleagues later, if you have LinkedIn or a website, email address, phone number that you're welcoming of people reaching out to you with, please go ahead and put that in. We actually have time to take a little break, which I think is very welcome for everyone. And then we will begin again at 945 Central Time with Brianna and Dr. Cornwell will bring us through hierarchical condition category scoring for house calls. So looking forward to that wealth of knowledge. So take a breather. We'll see you back at 945 Central Time. Thanks. Thank you. Bye-bye. Bye. Bye-bye. Okay, if you're in the sound of my voice, please return soon. We're going to get started in two minutes. I'll be sharing my screen momentarily, Dr. Cornwell and Brianna, so I will cue you up and you can let me know when you're ready to have me start bringing us through. Janine, I was maybe just going to give it just another minute or so. It looks like it's about 9.45 now. I'm sure people came back from break. All right. Good morning, Dr. Cornwell. We have Tom with us today, excited to co-present with him. Welcome back, everybody, for our nice little brief break that I'm sure was appreciated as we started our morning. So we're going to be talking next about HCC coding. And so building on Amanda's value-based care talk, there are certain aspects, like we'll talk about later, of coding that are important for fee for service. HCC is one topic that's very important, especially when you're thinking about value-based contracting and being able to show your value, because it's really talking about, in Medicare's eyes, the complexity of the patients that you're caring for, and how much financial resources, why they're so sick, what additional kind of revenue and support you need for these patients. So Dr. Cornwell and I will be tag-teaming this conversation. Tom is always, you know, jump in any time. But we can go ahead and advance to the next slide. So our learning objectives, and maybe share in the chat, those of you, I'm curious how many of you are familiar with HCC coding. Do you feel like you're, you know, pretty successful at this in your practice, or kind of is this a brand-new topic for you? And everyone's going to be at different stages. So completely fine if you haven't heard of it. That's why we're covering it today. But we're going to talk about what that risk score calculation is, and why, you know, it's important, and the impact. And then we're going to try and give you some practical tips when you think about workflow, so you can figure out how to do this, and how you're making sure you're assigning the appropriate ICD-10 codes that have an HCC risk adjustment weight. And then what kind of strategies do you need to follow that with? Because any time you're coding something, you also need to be able to support it from a documentation standpoint. So we'll talk about that as well. Next slide. So some of you are familiar, Laura, especially with your ACO work, no surprise, and some brand-new. So that's great. We usually always have a mix. So, and there's a pop-up, Janine, if you want to click one more to have the reveal. There we go. So what is risk adjustment? Essentially, it's a methodology that CMS determined, and it started with being most important for Medicare Advantage payers. What they're trying to do is, it's predictive modeling to say, what's the cost to insure? What's the cost of healthcare for Medicare beneficiaries over a year? And it's tied to how the Medicare Advantage plans are paid for their premiums. But there's so many different models now. It's used in PACE. For all of these new alternative payment models and value-based contracts that we talked about earlier, they're using your patient's average HCC scores of your population to determine what your capitated payment amount is. What is your PMPM based on how sick your patient population is? So that's why it's becoming growingly important, but, you know, it really comes down to a predictive modeling methodology. They're trying to say, okay, more complex patients obviously need more financial resources and support, and so you should be paid different if you're caring for that complex population, whereas a true office, you know, primary care practice that has more healthier base would be, you know, not as sick, not as high as that capitation. So that's why it's really important, and you're going to have a lot more leverage when you're negotiating those contracts that you heard Amanda speak about this morning. If you can say, hey, my average HCC score of my population is 2.0 or above, you know, that's if you can see on the little graph here, which we'll come back to on another slide, that's a high HCC score, and that's a typical HPPC patient. These are your patients, but unfortunately, it comes back to your ICD-10 diagnosis coding. You have to tell CMS that. Next slide. So just a little bit of background. You may have heard of some different models. They're, you know, they take all of the ICD-10 coding categories, and they create kind of major categories of diseases that are similar, and then they break that down into the specific ICD-10 code. So not every code risk adjusts. They're trying to say which certain chronic conditions do we associate with having high cost, and just to kind of give you a little breakdown. Next slide. So those of you who might have ever heard of a RAF score, so a risk adjustment factor. This is per the patient. There's things that go into this that affect your HCC scores outside of the patient's chronic conditions. For example, their demographics. So if they're an aged Medicare beneficiary, or because if they're aged, they're on Medicare, or if they are on Medicare due to a disability, that's going to go in and affect, you know, their RAF score. Of course, obviously, the diagnosis, there's things called interactions, and when they updated the model in 2020, because they are taking their learnings, they said, hey, any patient that has four or more chronic conditions, four to 10, that are considered HCCs, we should add an additional risk adjustment weight for that, because those patients for multi-core morbidities are obviously more complex. So now, they used to call it the APCC model. Now they're just calling it the CMS HCC 2020 model, lots of little acronyms there, but this is how a RAF score is calculated per the patient. Next slide. So just an example, again, interactions are not something I would expect providers to memorize or really need to pay, you know, too much mind for, but just so you know what they are, like if, you know, diabetes and congestive heart failure, again, that disability status. These are just some examples of what those interactions are. Next slide. And the full list for you. Again, nothing you can do. Where this comes important, and we'll talk about this a little bit more, is getting comfortable with using combination coding. So, right, so if your patient has, you know, chronic kidney failure due to, or congestive heart failure due to, hypertension due to, getting more comfortable with not those unspecified ICD-10 diagnosis codes, but really telling the full story of which diseases impact one another. Next slide. Dementia, surprisingly enough, when they first introduced this model in 2017 didn't have a risk adjustment weight. Thank goodness now it does. So that's always good news. And then all stages of pressure ulcers were, but an example, if you coded mild cognitive impairment, rather than actually saying that patient has dementia and Alzheimer's, that the mild cognitive impairment does not risk adjust. So you have to be specific, especially for, I know we have at least one palliative provider on. Sometimes you're so used to coding signs and symptoms, you really need to code confirmed chronic diseases. In the outpatient world, which includes the home, regardless, even if you're a palliative care provider, if we go to our ICD-10 diagnosis guidelines, if there's a confirmed condition, you have to code it, rather than the sign and symptom. You may be there supporting their symptoms, but if it's a confirmed chronic condition, that's what you want to code. Next slide. And then again, just to show you the, kind of how they tie the one to, or the four to 10 additional HCCs, again, all these decimals are mathematically figured out on the back end, but it's just kind of showing you that impact and how it gradually increases, the more chronic HCCs that a patient has. Okay. I'm going to let Tom kick this over to just, this is a nice slide about the financial impact. Well, thank you. And, you know, I saw that, you know, some of you said, oh, this is new to me. Others said, oh, I'm familiar. But, you know, there's always, you know, more to learn. And, you know, now that I am steeped in value-based care and the work that I am doing, from a return on investment, there is nothing more important than being good at showing Medicare the complexity of our patients, because that is your revenue. So under fee for service, your revenue is all your volume. Everything you do, your revenue under value-based care is showing Medicare how much money to give you to take care of these sick patients. So this is critical. And here's just a simple example. The first column, the example is a patient that comes into, for a URI, which is more complicated than when I did this in the past years, because now we got all COVID, but they come in for a URI. They're double-booked. You have no time. They haven't been in for six months. You have no time to do anything else. You take care of their URI, and you send them on their way. And from a value-based payment, your risk-adjusted factor, if you look down at the bottom, would be .692, just for their demographic information that you have on them that Brianna told you about, and you get $6,600. Okay? For about every point, it's about, what, $9,500, Brianna, roughly, the conversion. And so let's do the same patient, but instead of being an add-on, you actually had an opening. So you have 15 minutes. So you say, oh, let's, you know, well, I'll deal with your cold, but boy, you haven't been in for six months. You know, you haven't had your A1C done. You know, let's, you know, I want you to take a good listen to your heart and lungs and order some electrolytes because of your heart failure medicine. And then I add the diagnosis of just, you know, diabetes, no complications, because I don't know HCCs, and it doesn't matter to me what I put down. But then you look down at the bottom, and because now I've added two HCCs, the diabetes, no complications, even though the patient does have a history of circulatory problems you're going to see in a second. And then I, but now I'm up $4,000 in that 15 minutes. You know, that's a pretty good return on time. But now let's go to the last column. In value-based care, AWVs are critically important. So a lot of times when patients come in for routine blood pressure diabetes, they actually are what we call flipped into doing an AWV plus the office visit because a medical assistant can do a lot of the work. And so we do an AWV, and we capture everything on this patient. So we capture that their diabetes is not just no complications, but with circulatory complications, which gets you .2 points more. And again, it's almost $10,000 a point. You already had the congestive heart failure. And I just realized, Brianna, because this is an old slide, we have not put in for Alzheimer's. And so we're going to need to do that. But now Alzheimer's was not in HCC. Now it is. And so we would get more for that. There's disease interactions. And I tell people, don't worry about the disease interactions. Just code appropriate codes. And it's kind of like icing on the cake if it happens to also be a disease interaction. One of the things that, you know, Brianna, you know, drives home is that you start out cured of all your problems January 1 in Medicare's eyes. You don't have any HCC scores January 1, even if you had an amputated toe. You have to not only resubmit the codes, you need to document that you're taking care of them. And Brianna will talk to you about that. This patient also is on antidepressants. She's got major depression, which is mild, has had a colostomy. And so the colostomy is always there. But again, you need to re-document that it's there and how it's doing. And all of a sudden, all of a sudden now, by doing this AWB and capturing all these codes, the risk adjustment factor has gone from the first column of, let's just say, 0.7 up to over 3. And again, it's $10,000, almost a point. So now you're up to $30,000 of revenue because you have shown Medicare the complexity of this patient. And so, Brianna, I'll hand it back to you. Thanks. Yeah, and I was just looking at Anne's comment about is it true that you only need to capture the codes only one time a year. So your patients are reborn. So yes, so, and it's not just one provider, too. We should emphasize, I mean, you want to do your due diligence. You're the primary care provider. You're probably treating all of those conditions. But Medicare is going to look at claims data for that patient for the entire year. So like Tom mentioned, if you do a really good job, we'll talk about some implementation considerations later in the year. But if you do a really good job of doing annual wellness visits as the way you're going to take time to document and capture your HCC scores, you've done a really good job of telling Medicare those chronic conditions. So yes, Anna, to your point, I mean, I wouldn't, you know, totally one and done it. You want to kind of be consistent because the other thing that we'll talk about later is, yes, you could code the 20 diagnoses that the patient has and submit it. But then I would have to go to your assessment and plan and look for meat, which I'll explain later and say, did you really meaningfully assess all of those conditions and were they active at the time that you coded it during that one specific encounter? So yes, you really only need, you know, it's about getting the code submitted at some point throughout an entire calendar year. It doesn't have to be, you know, this extensive every single visit, every time. But you do just want to get in the habit of saying, being as specific as possible. And then, you know, I always say prioritize your assessment and plan. You're focusing, like we talked about, you can't solve for everything the patient has in one visit. What are you really focusing on? What's exacerbated? You know, what is the problem at hand that you're really taking care of that patient for? And then use those as the, you know, the first list of diagnosis. Because claims also only have, you know, the, gosh, I think it's the first 10 for quality that they'll consider and go to CMS of the diagnosis. So even if you put 15 or 20, that doesn't mean that they're all being captured and accurately reflecting your patient's HCC scores. And Brianna, if I could just quickly add to that. There's certain diagnoses. Now, Medicare doesn't know home-based primary care very well. There's certain diagnoses that they consider only happen in the acute care setting, like hip fracture, initial encounters, and heart attacks. And they don't realize that there's these home-based primary care providers that will sometimes on an end-stage dementia patient do an X-ray and find an acute hip fracture, have a goals of care conversation, and the family desires just to keep them at home and keep them comfortable, and we can actually bill for that. But the point is, is those are generally added, the hip fractures, the acute MIs by the hospital, not by outpatient setting, because they're usually taken care of. And I should add, and Brianna, I don't know if you've heard this, but I just this week heard about an Office of the Inspector General, OIG, that are really starting to redo audits. There was a pause during COVID. And one of the major audits they're doing is looking at these acute care diagnoses that were billed in the outpatient setting. And Humana and Blue Cross Blue Shield got huge fines because one of them, it was like 90% error rate using these acute care codes. But, you know, I'll stop there. Yeah. One last comment before we move on about the medical assistance, too, because I think that gets into a good point. You know, we want, you know, our clinicians and our providers to do what they do best and provide patient care. So how can you use your team to help you with these complex? Tom, you mentioned the medical assistance. Do you have them help at all with setting up kind of diagnoses or doing anything, or do they have any role in that? Right. And so, again, I'm working for a Valley basis. So they actually have coders that tee up, like they looked the last two years. But, you know, I don't want to take, you know, too much away from all the great information that you have coming. And does that answer your question? It does. We'll move on. Yeah. Go ahead, Amanda. This is Amanda. You know, we we actually have RNs who mine the charts and tee up the visits specifically for it. So it might be the last, you know, five years, two to five years if it's a brand new patient, and then it's the last year if we risk adjusted them the previous year or two. And so we found a lot of success with an RN kind of, you know, conceptually elbow to elbow. And so the provider doesn't have to memorize all of them, all these codes, but they know what to clinically look for. Yeah. Thank you for that. So just another model. You know, for me at Home Care Physicians, I actually am the one that's populating the problem list and reviewing the charts and putting in the ATP code or diagnosis, I should say, because it's important for me not only for for reimbursement standpoint, as Dr. Quarles mentioning, but also for patient care. I need to know what am I dealing with? What am I need to address? And so on and so forth. And Brianna is going to talk about the meat documentation. It's really important. And just as an encouragement that even for me that I've been doing this for forever, for a long time, I should say that, you know, I had some HCC coaching done through the health system, and they were telling me that, you know, I still need to improve on my documentation for for the meat, for my for my visit, for my HCC codes to go through. So I'll just stop there. Great. Thank you. We can go ahead and move on to the next slide. I just I think all the practical examples and kind of how you you wrap your head around this are helpful. So our theme of the conference, our Minerva case, as you could see. So you you all have her case. What I did is just go through her case, you know, looking at her diagnoses and her assessment and plan. So these would be all of the diagnoses that Minerva has or not all of them. I'm going to ask you, as you can see my cue, but the ones in bold are the ones that risk adjust. So, again, and just to clarify what the Alzheimer's and dementia thing from an ICD-10 coding guidelines perspective, you code both if the patient dementia and the Alzheimer's, but only one of them counts as the HCC. So that's why the dementia is bolded and not the Alzheimer's, just so that doesn't confuse anyone. But these are the ones that carry a risk adjustment weight. And I'd be curious if you all have the Minerva case kind of readily available. Is there anything else that you think is missing? Anything that's not coded here from Minerva that you think could be a potential HCC or anything that could be more specified? And Laura, to your point, yes, 100 percent, most EHRs have become advanced in this, so they generally will have a feature where you can highlight or show the provider which ICD-10 codes carry a risk adjustment weight. So that's generally just a module that you have to ask your EHR to turn on. But if you went back to your EHR vendor, the question would be, hey, do you have an HCC module or an HCC enhancement that will help me tell what diagnosis codes carry a risk adjustment waste? So let's I was just giving everyone a chance. She does have behavioral disturbance. The code need to be changed. Exactly. That's a great one. Bed confinement status. I believe that ends up being a Z code, and it could be a frailty code from a quality perspective, but not necessarily an HCC. I'd have to look up. Is the UTI with altered mental status, does that change anything? She was hospitalized for the. For UTI with altered mental status. Yeah, you know, Tom and I were just talking about some of that, too. It really has to be a kind of like a complication. Again, I think more of the hospital, like if there's an implant, that's a complication. Alterment status alone doesn't. There's some, but that's getting like real specific with what the complication was for and things like that. So just the altered mental status in the history of UTIs. Unfortunately, anytime you see Z codes, those are really just like history codes, which obviously still are important to kind of tell your patient's story. But generally, you know, Medicare still learning with this with this HCC model. But you guys put some great answers in there. The other one that someone told me last time is senile purple, which is a HCC that we could potentially have missed in stage four. Yes, Dr. Atkins, thank you. I purposely was trying to leave some of these things not coded to the top of just to kind of give you some examples. And Brianna, you can correct me if I'm wrong. I think UTI related to a indwelling foley catheter does carry HCCs. Yeah, but Tom and I, I have to look at that code a little bit more. It does in some ways. But if you like look at the full ICD-10 diet definition, I have to I'm going to look up before the end of the conference and get back to everyone on that one. All right, we can move on to the next slide, please. So go ahead and advance one more, sorry. There we go, if you think back to how I was saying 2.0 or above is generally a high HCC score, and actually this grid that you see right here, this is not all contracts. You can have a lot higher PMPMs. This is primary care first that we mentioned a little bit earlier. So again, primary care first is one of the newer alternative payment models for advanced primary care practices. Certainly not exclusive to home-based primary care, but they're very well suited because you're doing this work. So you can see the difference. What Medicare is going to do and Medicare is going to do this. This isn't on the practices. They're going to take a look back period. They're going to look at the past. I think it's 12 to 18 months of all of your Medicare, traditional Medicare patients that are attributed to your practice. And they're going to take the average HCC score for those patients. So it's always a look back period. And they're going to say, okay, if your patient population has an HCC of above 2.0, you're going to get that higher $175 PMPM. So Anna, to your point, if for whatever reason you're, you know, maybe your diagnosis coding, this is new to you and you weren't focusing on it, was in the group two, yeah, $45 PMPM is not going to support an HBPC practice for, you know, these complex patients. So this is why it's important. Minerva's risk score as coded, even just on the previous slide, would end up being 3.163. So again, just kind of trying to tie back how this has financial impact for our practice. You know, generally, yes, it's the payer and things like that, but why it's important for you. Is there an HCC? Yeah, and I'll look on the indwelling catheters, because there are some codes that do, but I just want to make sure it's not like one of the complications where it'd really be more like an inpatient setting. But I will get back to everyone on that. Next slide, please. So again, when we're thinking about what we can do better, and I realize, you know, sometimes I, you know, the pressure on the providers is extensive as it is. So yes, this is another thing that you have to do, but you can create efficiencies with this. We talked a little bit about workflow efficiencies yesterday. In addition to your EHR highlighting diagnosis codes, create a favorite list. Don't look for the same specified ICD-10 code every single time. You know what your patients have. Star those diagnoses, and then you can use it, because if you just tell me that the patient, excuse me, has depression unspecified, no HCC score for that. You tell me they have a major depressive disorder, could be recurrent, in remission. That's going to carry an HCC weight. COPD does risk adjust, so I don't want you to think it doesn't. But again, talking about how can you take it, especially if you're in value-based contracts, those of you affiliated with ACOs and things like this, I'm sure this is some of the education you get. How can you tell me it's emphysema with chronic respiratory failure with hypoxema? You know, those are two different codes that would carry a risk adjustment weight, that chronic respiratory failure. I know Dr. Cornwell and Dr. Chang are really good about capturing that, too. So, are you coding that when your patients have chronic respiratory failure? It doesn't even maybe have to be this advanced. And then, are you one that always tells me it's hypertension unspecified? Or, you know, if I look at your note, too, the other kind of coding trick that I wouldn't necessarily, you know, wouldn't expect a provider to use. But if I'm looking at a documentation and I see hypertension with. With, in coding terms, means due to. So, if you had an HCC coder, they could say, you know, you said hypertension with chronic kidney disease and heart failure, and you told me the stages, they could assign the more specified diagnosis code because you used that language. But without that, we, as coders, are reliant on what you put in the documentation. So, that's why it kind of ties to this cause and effect relationship. And then, again, both diabetes and chronic kidney disease, you could use those codes alone. But if they have complications and if they have stages, anytime there's an opportunity for a diagnosis for you to tell me the stage or the severity, you always want to do that. What would be even better? Type 2 diabetes with chronic kidney disease. And then, you know, again, just get in, you know, tell me what kind of heart failure, rather than just the unspecified heart failure. And then, again, you know, just anytime you can be more specific, that's what you want to do. And any of you that have kind of like tricks of the trade, if you will, because I know we have a bunch of ACO kind of affiliations and things. Are there diagnoses that you guys, you know, use and you're like, oh, wow, or I've started doing this, love all the resource sharing that's going on in the chat. So, please feel free to chime in with your experience. Next slide. So, Tom mentioned earlier, this is a big one. I can't go over all of them in this talk, but I will frequently see CVAs coded in the outpatient world and in home-based primary care. Again, this goes back to an ICD-10 coding guideline rule. You can only report a CVA when the patient's inpatient and receiving active treatment. When they go home from the hospital, what you're coding is the history of the CVA or if they have hemiplegia or hemiparesis, that's an HCC and that's a late effect of the CVA that you can code. There's a resource here too. It's really quick online tool, icd10data.com. You can, you know, put things in or tell your practice manager about it if you have one. You know, that's kind of a nice tool to use if you're not sure what diagnosis. But the reason I like to hide the CVA is to Tom's point, this is something that CMS's when they do their risk adjustment audits, when they see things like this coded in the outpatient setting, is really looking for because it's just not appropriate to, you know, when it's not in that initial stage of treatment. Yeah, even if you called the hospital and see they, it's only, you know, inpatient. So, there's, not to get too deep, but there's like letters in their stages to say, hey, this was an initial encounter or, you know, things like that. But CVA actually has very specific language with the ICD-10 coding guidelines that says it's only when the patient's receiving that inpatient treatment for it. And it'll be coded. So, you'll get credit for it. Yeah, exactly. And again, it's not just you. It's not one provider. You know, it's not like they're not going to know your patient had a stroke. So, again, just remember, yes, you want to do your due diligence, but you are not like the only HCC provider for your patient. They're going to look at everything during that calendar year. I love the app too, Caitlin. Thanks for that. Next slide. So, again, this comes down to quality and cost savings. But you really do have to support it through your documentation and do things like, you know, understand your average HCC score for your patients. And then are you even taking that further? From a clinical model standpoint, are you risk stratifying? Okay, which of my patients really have the top tier highest HCC score? And what kind of resources am I giving them? And doing those kinds of things. And again, this is great, you know, food for thought when you approach those partnership conversations like Amanda mentioned. Next slide. So, this is the acronyms. I'm sure all of you are familiar with SOAP, right? We all know what SOAP documentation is and that acronym that's been kicked around for so long. In risk adjustment, we use a term called MEAT. And it stands for Monitor, Evaluate, Assess and Address, and Treat. So, what this means is I'm going to, if you're coding these HCC diagnosis codes, I'm going to go to your assessment and plan and I need to see that you actively evaluated or you're monitoring and you're treating that condition. You can't just say, you know, let's just say, you know, you have all these different diagnoses and maybe there's dementia, but there's no treatment plan. And it didn't really talk about if the patient's on dementia medications or what's the status of that dementia. It's just very vague. It's just noting it. That's not supporting that diagnosis, that it was meaningfully assessed, monitored, evaluated, or treated during that encounter. So, again, even if they're kind of a pitfall that I see with this too, is especially when there's a specialist involved, and I'll see this more in palliative care where they'll like put cancer and it'll just be like, you know, followed by oncology. I can't give you credit for that. But what I can give you credit for is your role. If you just change the words you use, what's your role in the cancer? What's your role in the chronic kidney disease? Even if they have a nephrologist, just be very meaningful with the words that you use in your documentation. And, again, from at the end of the year, all these patients are reborn. They literally like erase any HCC that patient had last year and it starts over. So, you have to do this for your patients throughout a calendar year. Not, you know, not one visit, not every visit, not just you, but all HCCs need to be reported at least once throughout a calendar year. Tom, were you going to say something? Nope. Okay. Next slide. Sorry, I'm typing. I'm answering someone. Oh, that's okay. Thank you, because I'm not looking at the chat. So, what might that look like in your assessment and plan? Again, Tom, be meaningful. Are you telling me the status of each condition? So, when I go down to your assessment and plan, I want you, you know, you think about in history, you know, you're getting some information from how the patient and caregiver thinks that disease is going. When you're down to your assessment and plan, you've now done your exam. You tell me from your clinical judgment, what is the, you know, the status of that patient's condition? And, you know, avoid the stable, continue, stable, continue, stable, continue, you know, is it mild? Are you, you know, monitoring their effectiveness on a certain medication? Or are you ordering tests or referring to home health? You know, you have to take the time to document that things that also help with your medical decision-making to support your overall level of service. But again, you don't, you don't want to just say, you know, unchanged or stable, continue all the time. Tell me the status, and then what's your treatment plan? Or what are, what things are you doing to consider that diagnosis and take care of that patient? Next slide. And, Tom, I'll kick this to you. Hope you're on mute. Let me send my note here, and then you can rejoin it and tell me if I'm right. Oh, I didn't finish it, but I'll, I'm going to go over this. And so, and so one of the things that, and we're kind of at time, but this is just so critically important that I do want to go over this, the, there's a handout where, you know, there are 70,000 ICD-10 codes, 10,000 that map into these HCC categories. And we went through all of them, knowing what home-based primary care providers see to find the ones. And so it's, it's like six pages, but it is well worth your getting to know. And here's just some ones that are kind of common. You know, our patients are the ones, you know, our patients compared to like an office-based practice have many, much more G-tubes and trachs. And, and you need to at least once a year document, you know, how it's doing and code for it. So you get this, you know, again, $10,000 per point. So this is like over $5,000 for having that. Going down to protein calorie malnutrition, just so common for our patients to have low albumins and to document that. Secondary hyperparathyroidism, really important for our chronic kidney disease, stage three, four, five to check for a parathyroid hormone so that you can find it if it exists. So you can capture that added cost risk, but also so that you can treat them with, you know, vitamin D or analogs plus phosphate binders. Functional quadriplegia. This is something that in my own practice, I've caught numerous times where patients have like ALS and MS, but our patients with those tend to be functionally quadriplegic. You know, well, obviously, and that gets you like, like close to $13,000 added costs for that patient going into the second column. You know, if a patient's sober for 20 years, they're proud of that and you praise them for it. But then you also put down that they are an alcoholic with in remission opioid dependence. Somebody put a note in that last case Minerva saying, well, if Minerva takes opioids consistently, she has opioid dependence that is uncomplicated. Brianna went over a major depression. One of the things is we have the end stage COPD and CHF patients that are on oxygen. If you are 88% or lower, that is chronic respiratory failure with hypoxemia. They need oxygen. They are in respiratory failure. And that again, gets you another 0.3. Brianna talked about the hemiplegia. We don't do the acute diagnosis, but we put down the sequelae and that does get points. And then again, the amputation gray tail we talked about, it reappears every year according to Medicare. So we have to document it every year. And even, you know, some said that they know HCC scores, but they can always learn more. One of the ones I recently learned is AFib. Our CHA2DS2-VASc scores are always, you know, elevated. And so we are putting our AFib patients on anticoagulants because they have a hypercoagulable state. Well, that is an HCC score. I have not done that at all, but that is just another one. So we're constantly learning. And even I just heard, Brianna, that there's new immunodeficiency HCCs that I'm adding, you know, to the list. I just need to confirm this. But again, these things are constantly changing, and this is just critically important for everybody to know. And that's all I have to say, Brianna. Great. Thank you. Next slide. And I will come back to the chat and look through. I'm just trying to be sensitive of time here. Yep. So I'm going to move us along. But again, the reason that this is important is, yes, okay, let's say a Medicare Advantage. Medicare Advantage plan is going to be the one that's audited because they were paid directly for the HCC scores. But what they audit is your notes, because they look at provider face-to-face notes. They're called RADV audits. These are done annually with Medicare and OIG and CMS. They want to make sure that if they're paying you for patients with high HCCs, that that's supported through your documentation. So again, if you code this, go back to that MEET acronym. You have to be, you know, making sure that you're supporting that during the encounter, that you are coding that condition. You meaningfully assessed and addressed that condition. Even if the patient is somewhat stable and you're monitoring it, what can you tell me about the monitoring? What medication are they on? Has that been effective for them? Are you telling them to check their blood pressure ratings? Just tell me the story of all of the things you're already doing, but it just doesn't always get in the documentation. Next slide. So I'm going to leave you with these implementation considerations. Go back with your teams. It's really helpful to have, you know, a clinician champion. Why are we doing this? Why is this important? You know, what logistically makes sense that we can make this easier and efficient for people using the EHR? You know, really saying, okay, annual wellness visits is when we're going to focus on these. Or we're going to commit to making sure that, you know, our problem lists are up to date and we're doing stages and severity. You know, having someone give your providers annual feedback or, you know, or some feedback and education as you can. It's really important because, again, it takes a team and we want everyone to be working to the top of their scope. You can train other staff to help with this. Even, you know, medical assistants or other people, nurses like Amanda's. How can you use your team to make this effective and efficient without it being too much burden on the providers? So just some takeaways for you to consider. Next slide, please. This is the resource to the top of it that Tom was referencing. It's in your workbook. Sarah, if you could throw that in the chat if you haven't already. That would be lovely, please. Next slide. So again, just be specific. You know, think condition status plan. That's like the three easy ways you could think about when you're putting a diagnosis in your assessment plan. Especially if you have Medicare Advantage and you're not doing contracts or you work with Medicare Advantage plans and you're not doing annual wellness visits, now is a good time to start. And then, again, every condition, every year, and do some internal monitoring and education. And I apologize, we're a little over time, but that's it for us. Oh, you're fine. We got to have a break right before you. So we're going to take another five minutes. We will get started, actually, seven minutes. We will get started again with Michael, who is going to bring us through wound care instruction starting at 1115 Central Time. So we'll be back soon, everybody. So go get refreshed, and then Michael, when you're ready, will get you going. Hi everyone. Melissa is going to start sharing our slides. Michael, you look ready to go. We're going to go ahead and get started with our wound care session. Just a moment. Okay, I'm ready. I'll go to the next slide. Today, our talk is really focused on specific wounds of pressure ulcers, although some of the content would be interchangeable for any wound type. We'll discuss wound care goals within the seriousness of illness, thinking about the Minerva case study, describe appropriate interventions to manage your pressure injuries, and review primary preventions of wounds. Next slide. So first, just a real quick overview of the skin and the underlying structures. I really talk about this just to remind everybody that the epidermal and dermal layer are really not very thick. The epidermal layer is really only three to five cell layers thick, and the dermal layer can be pretty shallow as well, depending on the anatomical location of the skin. So wounds or pressure ulcers in particular can very quickly become full thickness. Remember that the epidermal and dermal layer have no active blood supply, so they passively receive nutrients through the skin layers with no active blood supply. So the lower layers of the skin structures are much more susceptible to pressure, friction, and shear. Pressure largely because those lower levels have a higher oxygen demand, like the muscle and underlying structures. So you'll see that those underlying structures will die before you see changes at the skin surface. And then for our staging consideration, you see how far down the subcutaneous layer is in this cartoon. Next slide. So just briefly, the functions of the skin, they provide protection from the outer environment, thermoregulation through perspiration, tactile sensation, excretion, synthesis of vitamin D, and of course, body image by giving us all our own unique appearance. Keep in mind that the skin is the largest of our organ structures, and it is its own specific organ system. Next slide. So there's special considerations to think about the skin as folks age. There's prolonged epidermal turnover leads to epidermal thinning. So typical epidermal turnover is sort of how often you refresh that outermost layer of your skin. At birth to about age 20, it's about 21 days. And after the age of 21, that starts decreasing. By the age 30, it's really almost double in time. Collagen bundles shrink and cause wrinkles. The collagen sort of provides the plumpness to the skin, and the underlying structures in that plumpness also provides protection from injury, especially friction and shear. Subcutaneous tissue and sweat glands start to dry up. You'll see that causing the external dryness in the skin. Decreased sensory receptors, so their tactile sense is diminished. Also combined with delayed refractory time, they may be more at risk for a thermo injury. There's loss of subcutaneous tissue, specifically thinking about areas of pressure. Loss of that tissue can make those bony prominences more severe. Decreased immunocompetence of the skin. There are laghorn cells that are on the skin surface that actually provide the first level of immunodefense, and their use starts to wane with age. We talked about the decreased blood flow to the skin surfaces in the earlier slide. Overall, a decreased inflammatory response. The inflammatory response is important because that's the first stage of wound healing. That decreased response is common in age, as well as the overall decreased immune response. And then the fragility of the capillaries. We see this a lot, especially on patients on antiplatelet medicines, where those already fragile capillary structures leak easily, especially when on platelet therapy. And that's why we always see the bruising. Next slide. So thinking about wound assessment, this really goes for assessing any type of wound and documenting. The first thing that you really want to assess is etiology. That's not here because we're specific to pressure, but whenever you can, you want to think about what the etiology of the wound is. If it's pressure, venous, arterial, neuropathic, or diabetic in origin, you really want to know what that etiology is because that will have an impact on your plan of care. You always want to include location and pressure ulcers because that really gives you a clue on whether this is pressure or it's something else. Talk about that on the next slide. Stages generally only required in a pressure injury. I say only really because skin tears can be staged. No other wounds are generally staged. And to be perfectly honest, most people don't stage skin tears either anymore. Then next, think about the dimensions. And I always think about dimensions lengthwise and head to toe fashion, width at the widest point, depth at the deepest point. And then is there any undermining or tunneling present? We'll talk about that with the model. I'm going to try to be quick through these slides so we can spend time talking about the model and some common treatments that you might think about using. I'm sorry, go back one sec. I want to talk about exudate. So exudate is the fluid that the wound is draining and that may be clear, purulent, cloudy, cirrus, cirrosanguinous or sanguinous. And then you want to describe the quantity, scant, small, moderate or highly exudated. That's important for Medicare to pay for some of your wound products. And then the wound bed, what are you seeing in the wound bed? If you're not sure at the minimum, you should describe what you're seeing by color and percent. So 60% pink granular tissue with 40% yellow stringy adherence slough. And there they add up to 100%. Next slide. So this is sort of a general definition of pressure ulcer or pressure injury. The latest definition is pressure injury. We all hear all of the terms decubitus ulcer, bedsore used interchangeably, but the most current acceptable term is pressure injury. And it's really any injury that's caused by unrelieved pressure that results in damage to the underlying tissue. It's usually over an area of bony prominence where there's either a high pressure over a short period of time or low pressure over a longer period of time. The other exception is when there's medical equipment used that's medically necessary, that's commonly tubes and drains, endotracheal tubes, PEG tubes. Pressure ulcers can occur from urinary catheters are usually avoidable. So those are the things that we think about life extending equipment that causes a pressure injury. Next slide. So here, this cartoon shows you all the possible points of pressure. Remember when you're sitting up at 90 degrees that the majority of the pressure is on the seating surfaces. And when you're lying flat, pressure is more equally distributed throughout the entire body. In each position, it shows you where the common pressure points are. The sacrum is the number one location for pressure injury. Heels are second. And I always say that they're always avoidable by floating the heels, which means you keep the heels off of the surface beneath the heel so you can run your hand. So you can sit on the bed surface and not touch the heel. And the second most common is the back of the head. Next slide. Stage one. So I think if you click again, it will show the definition. So stage one is a red end area over an area of pressure. It typically blanches when you press on the skin surface. And this is really the precursor before a wound forms. And if you relieve pressure on that area, I like to say that sort of cellular CPR will occur, blood flow will be restored, and an injury will not result. Keep in mind, in darker pigmented individuals, stage one pressure injuries often go unrecognized. And in darker pigmented individuals, they may appear darker than their usual pigment or lighter than the user pigment. And you should think about other assessment skills like heat or pain to try to identify those sooner. Next slide. You can go again and again. So stage two is the first stage where there's actually a break in the skin. This would be considered a partial thickness wound. If you want to think in general terms, a partial thickness wound, whatever the etiology always remains in the epidermal or dermal layer. And just as an aside, when you have a blister that forms, it forms at the junction of the epidermal and dermal layer. It gives you a little bit of an idea of sort of anatomy and skin thickness. Stage two is always 100% pink or red in color. A stage two can also be a serous filled blister. Next slide. Stage three is now a full thickness injury. It's gone through the epidermal and dermal layer and to the below subcutaneous tissue. It's commonly pink in color, but there can also be other, there can be slough and eschar present in the wound. You should try not to continue, consider subcutaneous tissue as yellow. So don't confuse subcutaneous tissue as yellow slough. Stage three is what folks tend to get confused on. Is it a two? Is it a three? Is it a four? And I usually like to say, if you're not sure, phone a friend and try to commit to a stage and thinking about hospitalization and all those things. If you're not sure, it's probably better to stage higher than lower. Next slide. So a stage four is a full thickness injury. It often exposes underlying structure like tendon, ligament, and bone. And there's commonly debris in the wound, slough or eschar that's present in the wound. Next slide. Most folks can identify a stage four. Next slide. So deep tissue injury is a relatively new term. Deep tissue injury is generally thought to occur when a patient experiences high pressure over a short period of time over an area of bone prominence. It usually appears as a bruise or a deep purple in nature. Things that you should think about at risk for deep tissue injury would be someone that's found down on the bathroom floor, prolonged transport time to the hospital, those types of things where they could experience intense pressure over a short period of time. That deep purple hue that you're seeing is tissue death that's occurring and DTIs can resolve without any break in the epidermal layer if it's caught early. If it's not, it is possible that they'll very quickly go to a full thickness stage for pressure injury. So you really want to think about those patients that are found down or trapped or something like that and really do a thorough skin inspection looking for a DTI. Next slide. Unstageable is our sixth stage and an unstageable pressure injury is a pressure injury that you're not able to fully stage because greater than 50% of the wound bed is obscured with debris. And by debris, I mean avascular tissue, yellow, blue, brown, black, eschar, or stringy adherence slough. And if you remember my sort of succinct definitions of the previous stages, stage one and stage two never have slough or avascular tissue. So you should know that an unstageable is always going to be a stage three or stage four. Next slide. So I'm thinking about reminding you about Minerva. She has a stage four sacrocoxygial wound, which is full thickness. And here it's described in length as four centimeters and width four centimeters and deepest point of depth is 2.5 centimeters, which is really pretty thick. There's no undermining or tunneling. There's some drainage with 75% dressing saturation. There's no odor in the wound bed, 20% adherence slough. I would usually assign a color to the slough. It helps you when you reassess the wound and then 75% pink granulation tissue. That's generally how you begin to describe her wound. The margins are defined. So that means that you can clearly see the wound edge demarcation. We'll talk about that a little bit more with the model. That demarcation is usually a brighter red in appearance. The surrounding tissue. So sometimes I refer to that tissue as the peri wound tissue. And you wanna say, is that skin intact or is something else going on? If the peri wound skin is macerated, that's a sign that this is a highly exudative wound or that your topical plan is not managing the exudate well or that moisture is coming from somewhere else, which would typically be perspiration or incontinence. Signs or symptoms of infection. That's a whole separate topic, but significant changes in the wound from one assessment, one day to the next would be concerning, a serious deterioration typically. Another concern would be new or worsened pain. Those would be the most common signs that are not systemic that the wound may have reached critical colonization or infection. So that's, I already covered really pain and discomfort. And when you think about pain, you wanna think is the pain consistent with the characteristics of the wound? And if it's not, then you should really be more worried about infection or something going on. And we kind of talked about moisture and incontinence already. Next slide. This is just a cartoon about the ongoing assessment process and evaluating your plan of care. And regarding creating a topical wound plan, I really say there's almost never a right answer, but continuing to do something that's not leading to good results is the wrong answer. So you want to be able to see if the wound's progressing. And if not, you need to say that, you either need to say that their plan's not being carried out or you should change the plan. Next slide. So thinking about assessing the wound and creating the goal is you always want to remove, to heal the wound, you usually wanna remove necrotic or avascular tissue. When wound healing is not the goal, that may not be the goal to remove that tissue. If wound healing is the goal, you always want to maintain a moist wound surface. You always want to minimize the dressing change frequency whenever possible. Every time that you open that wound to, and expose it to the environment, you decrease wound healing by 50%. So if you're changing a dressing several times a day, two, three times a day, you've lost 16 hours of wound healing time because that wound has to heat back up to a healing temperature, regenerate moisture, those types of things. You do always want to try to prevent infection. Manage drainage and odor is really at minimum a dignity thing. And of course, manage pain. Next slide. Next slide. So special considerations, advanced illness, end of life. In this scenario, wound healing is generally not an option. And I do tell my patients and family this. And I tell them that the wound may also get worse. Think about at the end of life, there's specific ulcers that we've talked about, Kennedy terminal ulcers that show up literally overnight. And on the sacrum or buttocks, they typically look like a butterfly. It's really an indication of skin failure at the end of life. Impaired inflammatory process. So here you want to think about wound patients that have immunocompromised. So autoimmune diseases, infectious diseases, chemo, oncology on chemo drugs, on organ transplant patients on anti-rejection drugs, high-dose steroids. Those are all going to impact the patient's ability to heal a wound. And in some cases, you may be able to address those things. In some cases, you can't change those medicines. Wounds are often stalled in the inflammatory phase. So if you think about the stages, the common three stages of wound healing, the inflammatory stage is sort of the second stage. And here you may see reoccurring slough, redness, exudate, swelling. And the goal is really to jumpstart that wound back to a healing state. We talked about age already, advanced age, and the associated comorbidities are going to have an impact to healing. Medications, we really already talked about in the above bullet point. Infection. I do sometimes do swab, wound swab cultures. You really have to get kind of good at it. You do that after you've cleaned the wound and you want to try to get fluid drainage and not the real nasty area that's sloughy because that's just going to grow everything and not give you a lot of meaningful data. And then nutritional compromise. So this is really goes to end of life. In earlier talks, you talked about albumin, forced to lower the albumin. The more challenge you're going to have healing and I would document that. Next slide. So interventions that we can think about is whatever you can do to boost nutritional status. Look at labs, A1C, we talked about albumin. Glucose, you want to try to control it to the best of your ability. Blood count, of course. Prealbumin, I know most people don't use anymore. And really most folks in my experience really just look at albumin. Whenever you can, manage infection or prevent infection, which we'll talk about a little bit more with the wound dressing types. Minimize the medications that impact wound healing. Always talk about the comorbidities that your patient has with them and the family and the challenges that those are going to create with wound healing, particularly things like peripheral artery disease and arterial ulcers or pressure ulcers on the lower limb. Those may never ever heal. And that's what I tell my patients. And lastly, remember what matters most to the patient and family. If the treatments are painful or too frequent, you may have to talk about the risks and benefits to going to a less frequent dressing change or administering opioid pain medicines that may cause sedation or confusion, but may allow them to tolerate the treatments. Next slide. So for Minerva, she's on a daily dressing change. It's being, this I'm gonna actually go over with the demonstration. I'll point out that you should have some reference guides about wound assessment and topical plans of care. But in the box there are some of the generic names of wound types. So we always try not to use brand names because formularies change and one home health agency to another, you know, they never use the same vendor. Next slide. Next slide. Pressure injury. So prevention is always the cure, is always the preferred intervention. So if you're familiar with the Braden scale, you want to try to address all of those risks that increase risk of pressure injury development. It's pressure, friction, shear, moisture, incontinence. And you really want to have a plan in place to manage all of those risk factors to decrease their risk for injury. Teach your families and caregivers about the appropriate interventions. The one that I probably see most common is layering underneath the patient. So all those layers really increase the pressure. If you think about a stack of paper, 20 sheets is a lot harder than one sheet. So they increase pressure and they trap heat and moisture and that's really not a good combination. And it's commonly when I see wounds worsen that they have a high functioning mattress underneath them. It also blocks any therapy that that mattress can provide. It's the one I talk about most. Next slide. So key takeaways. I always remember what matters most to the patient and what are their goals. You want to manage pain to the best of your ability. Always think about prevention first. This is a big one with patient and family education. Always want to try to reduce the frequency of dressing changes whenever you're able. Remember that reason is that every time the wound is exposed to the environment, you reduce healing time. Wounds heal faster when they're covered. So let the air get to it is never good, actually. They always should be covered. And generally you always want to cleanse the wound, fill if appropriate, debris if appropriate, protect margins and cover. And that we're going to go over with the model. Next slide. Okay. So does anyone have a burning question before we go to the model on this and the products? Okay. All right. So this is Seymour Butts. This is obviously the sacrum, can't tell. So down here, these two, this wound right here, let me try turning off the light. Okay. This wound is pink in color. The epidermis is intact. So this would be a stage one. And it's probably at the ischium. So that could be causing the pressure. So that's kind of how, remember in an older adult loss of muscle mass, this could be flabby and it might be over here. But when you think about when they're sitting, would this be in line with the ischium? And then this one here, if you see, it's more beefy red in color and it's kind of shiny. And there is a little bit of depth to this wound. So this is also, is probably over the ischium. So this is a stage two. And when you describe a stage two, length, head to toe, width, side to side, you always want to assign some depth. And usually I say 0.2 centimeters, if it's real shallow like this one is. A couple cell layers thick. So when you think about both of these wounds, if they're not caused primarily by pressure, these could be caused by friction. Friction or shear from scooting, from changing from bed to wheelchair, if they're dragging their skin across the surface. So I just mentioned it because pressure is not always the predominant cause. When an indicator that pressure is the predominant cause is when the wound is round. So if a wound is really completely round, that's really telling you that the primary cause is pressure. When it's oval or oblong or oddly shaped, friction and shear is contributing to the development of the wound. Okay. So this is a trochanteric wound. And this one we see, we, I don't know how to not get the glare, I'm sorry. It's, we'll do the best we can, okay? So this one, this is a stage three and we see multiple colors. So here on the sort of the periphery of the wound, I see some yellow that's really meant to indicate subcutaneous tissue. And then there's some beefy red and some pale pink. This is actually pale pink, it's not bone. And then thinking about, so here are our wound margins and they're, I guess that's, so I would say that these wound margins are closed. So if you remember, I said for the wound margin, you want to see a beefy red demarcation all the way around the wound edge. And the reason is that means that the wound edge is opened. Commonly in chronic wounds, the wound edge will heal closed and in that case, it looks like skin. And in your documentation, you may say that the wound edges are closed versus open when you see that beefy demarcation. The problem for management is, is once this wound granulates to the surface level, if the wound edges aren't open, it's not going to epithelialize to close. So the treatment to try to open these wound edges is with vigorous sort of just rubbing those wound edges with a dry gauze after cleansing the wound and then usually applying some moisture like Vaseline to keep them opened. There's no undermining. No, there is. There's tunneling. There's undermining right here where you see my finger and undermining is like a gully that extends beyond the outermost wound surface. And this area of undermining goes from here to here. So I would say that there's undermining present from 11 o'clock to one o'clock. So I recommend describing undermining and tunneling using the face of the clock with 12 o'clock being the head of the patient. And then this wound also has tunneling and you see tunneling is a fingerling-like projection that extends beyond the outermost wound surface. And usually it's much narrower than undermining. And you usually have to probe with like a cotton tip applicator. And this one, you would describe again by the face of the clock, tunneling at eight o'clock and then you'd measure that. You put your fingers at the outermost wound surface and then you measure what was in the tunnel. This is another wound with multiple colors, and when you think that there's red, some sort of yellowy stringy stuff here, brown here, black here, it obscures probably 70% of this wound. So this wound is unstageable. And for this wound to heal or any wound to heal with avascular tissue like this, all of this avascular debris needs to be removed. So this is unstageable, stage three. We did one, two. And then stage four, most everybody knows because I kind of say it smacks you in the face. The hallmark really is exposed underlying structure. And here there's bone exposed right here at the center point of the wound. Again, there's some black eschar and yellow slough right here, some yellow slough up here in the top part of the wound. There's a large deep tunnel here. See how deep it is. And there's undermining up here, sorry. It's kind of like when you type and someone's watching you mix up your words. An area of dark purple coloration, epidermis is intact. This is a deep tissue injury over the trochanter. And then this wound is showing you a dehist-surgical wound. And the way that you know is you can, there's old suture lines here. You can also kind of tell because it looks like an incision. So this wound you would not stage. It's a dehist-surgical wound. Any questions about staging? Okay. Okay, hearing none. So thinking about developing a wound plan. So yeah, thank you. So I try to keep the staging brief and use key points or words that are easy to recognize when you're in the home. NPUAP.org I think is in your resource guide. They always have the most up-to-date definitions that are very thorough. So thinking about just Minerva and developing a plan of care. The first thing that you should always start with is how you want the wound to be cleansed. And in some cases in the home, you know, that could be water, soap and water. But I generally would recommend wound cleanser. If there's debris in the wound, and by debris, I mean eschar, slough, avascular tissue, gravel, sand from a motor vehicle accident. You always want to use something like a wound wash or a wound cleanser. Wound cleansers have surfactant in them, just like what's in your laundry detergent. And the surfactants are what break down the acid mantle base that causes that slough or eschar to adhere to the underlying granular tissue. The cleanser itself, squeezing the trigger provides a PSI of positive pressure that also can help lift debris that's in the wound bed. Remember that you're at risk for exposure when you're spraying, but in some cases you want to rely on that PSI to help you to clean the wound. The wound wash or wound cleanser in general should soak the wound and sit on the wound bed for several minutes before you remove it. Any kind of topical agents that you're using in the wound bed you always want to remove those before you apply the next dressing. So the next step in your wound plan, thinking about Minerva, she has a stage four. So in a stage four, you always have to fill the void. So you need, in this case, you need a filler dressing. And if you don't fill the void with a dressing, the physiological response is going to fill the wound quickly with debris, slough or eschar. So, and you always want to be sure that the undermined areas and the tunneling areas, that those areas are filled as well. If you don't fill that tunnel, it's possible that the wound could start to heal, but the tunnel does not. And as long as that tunnel's not healing at the same time as the rest of the wound, this could heal and then break down because the tunnel's not healing. So a common filler dressing is a hydrofiber dressing. This is a hydrofiber dressing and they come in plain or silver. And this one's actually silver. It has ionic silver woven into the dressing. And these are highly absorptive. They absorb about four times their weight in fluid. And the ionic silver dressings can stay in the wound for several days, as long as your dressings are not being overwhelmed with exudate. If they're being overwhelmed with exudate, you have to change the dressing. So I would generally fill this wound with a hydrofiber. And the AG or the silver is an option to reduce the bacterial burden on the wound bed and thereby ideally preventing infection. So another filler type is gauze. So the benefits of gauze is it's cheap and it's readily available. The gauze will absorb wound drainage. And when you remove it out, if you take it out dry, you're gonna non-selectively debride the wound. This cannot stay in the wound bed for several days. It really needs to be changed every day or twice a day. And generally we don't recommend wet to dry or even wet to moist whenever possible. A way to reduce the non-selective debridement of the wound bed or removing that healthy granular tissue is at minimum to go wet to moist. The other thing about gauze is these fibers can get stuck in the wound bed. So I generally don't recommend it for a filler dressing. So I bought these at a drugstore. So they are pretty readily available in the drugstore. They can be expensive for out of pocket. Remember if you have a home nursing in the home, the agency has to pay for the products. Remember sometimes they don't choose the best products because they're trying to contain their costs as well. So honey, Manuka honey is also a bacteriostatic wound product. It can stay in the wound bed for several days. It comes in a filler dressing. This is not a filler dressing. So this is an impregnated like duoderm. So this, you could use this on a superficial wound or a partial thickness wound. I don't know why you'd spend the money on a partial thickness wound with honey. But anyway, if this was a filler dressing, yes, I would use it to fill the wound. But in general, I don't see these used in practice. I think this is really probably a gimmick by the drugstore. Okay, so then cover dressings. So we already said that this honey pad is a cover dressing. You can't use Manuka honey from a jar. I've seen patients do it with the jar open and the flies flying all around it. That's not medical grade honey. Duoderm can be used as a cover dressing. The generic name is hydrocolloid dressing. They do provide a small degree of exudate management. They can, it does manage some moisture. It's got a low moisture vapor transmission rate. That means it keeps the wound bed moist. Folks commonly use these as protection from pressure ulcer or for a stage two. If the product stays on the skin for two days or longer, I will use it. But if it's resulting in a repeated change because of incontinence, that continual removal and reapplication of adhesive can cause more harm than good. And in that case, a petrolatum zinc or a barrier cream, like even desitin is really recommended for a stage two. And in that case, you'd cover that stage two nickel thick with the barrier product. Remember the zinc, it'll always look white. This is another example of a cover dressing. Let's see, who's this? This is a Medline border gauze. So it's got an adhesive border. It's got a gauze in the middle and you could use this for the stage four as the cover dressing after the filler. So cleanse, fill, cover. This border gauze, it's soft and fuzzy on the outside. So that tells me that it has a higher moisture vapor transfer rate. So it's not gonna hold moisture in as well as something that's occlusive in nature, like an Aleven, a common manufacturer trade name, Aleven, and it's kind of rubbery on the backside. When you see greater than 75% strike through drainage on your cover dressing, so this square, more than three covers, three quarters has exudate on it. You know that it's time to change the dressing. The products are being overwhelmed with exudate. So if you have a bacteriostatic product in there that can stay in the wound bed for several days, it depends on the product type, three, five, seven days. If that product is intact, not falling out, not over absorbed, you could just change the cover dressing. But so you wanna look for 75. If you have increasing drainage in the wound bed from day over day, that's telling you something is going on. Okay, another type, this is Nepetal, is the trade name. And it's sticky, but non-adherent. So it comes off easy, but there's sort of a tacky rubber texture on the dressing that will stick to the wound, but is removable without causing trauma. The trade name is Nepetal. This you would most likely use for a skin tear. It's more expensive than Xeriform or oil emulsion gauze. That's the Vaseline impregnated gauze. Xeriform has the triple antibiotic in it. Those are fine, and the protective layer goes on the skin tear. You roll the skin flat back. Hopefully that'll read here. And then you apply like a Nepetal or a Xeriform or oil emulsion gauze, and then secure with cling. This we would not use for Minerva. It's to just demonstrate another common wound type product type. It can be used as a cover dressing or a primary dress. Yeah, a cover dressing or the primary dressing. In the skin tear scenario, you wouldn't use fill, and I would not use that for a full thickness wound. And then the last one I have that covers most of the wound categories is a transparent film dressing. And most people know these as Tegaderm. And they're commonly used for IVs. They're good for things like IVs because you can see the site. And really it's almost the only application I would use them for, unless you're in a pinch. So several years ago now, folks used to incorporate these in skin tear management. And it's really no longer recommended because the film dressing has a low moisture vapor transfer rate, and it causes serous fluid to collect on that shallow skin wound. And then that can cause debris to form. So really it's for something like that, a shallow wound, it's more of a non-adherent layer and then a secure layer like roller gauze. In a pinch, I have used these in a full thickness wound where you have a filler dressing that's helping to absorb the exudate. That's really all I have. Any questions about the wound products? You know, while people are thinking about questions on that, we do have a question in the chat. Anna says, it's very helpful. I'm struggling with wounds. Any thoughts on, I'm gonna let you read those because it looks like- Yeah, thank you. So I really try not to send the patient to a wound clinic. And the reason is, is because they're gonna want our homebound patient to come back and come back and come back and come back. So I really, the first thing I would recommend is to get home nursing in. And in most agencies, all the nursing staff have a baseline knowledge of wound care that's good. And they typically have a certified wound specialist when they run into challenges. And I really, that's the first thing that I would recommend. And if and when you're able, if you're really at a loss, think about a punch biopsy or a wound culture. If I want that, a wound culture, I mean, usually I'll do it because there is some skill to it. And I wanna know that it was collected, reliably whenever possible. So the nurses will often recommend it, but it's whether the wound is infected or colonized or otherwise, you're going to get something back in the culture and you're gonna have to decide what you wanna do, whether you're gonna treat with an antibiotic or not. So, and that's the first thing the wound clinic is gonna probably do is put them on an antibiotic, which may not be wrong. Let me see if I can find that question. You can't bill for your dressing change in the home. No, you can't. And I generally don't, we don't even have products and often folks can't understand why we don't have the products, but it's really up to the home nursing agency to have wound products in the home. If you don't have nursing in the home, you can order the products and get them paid for by Medicare. I had a bad patient with lymphedema. So yeah, lymphedema home nursing is generally very readily capable of managing with compression. That's what those wounds need. As long as by applying compression, you're not gonna put them in an episode of decompensated heart failure, or if there's a serious infection in the wound, you wanna be cautious about compression. And then of course, also arterial flow if you don't have a Doppler study. I don't think you can bill for Unubu unless you're in a clinic. I'll leave that up to Brianna. I have never billed for that. There is a code for Unuboot application and there's no place of service restriction. So I have seen that billed in the home and paid. Good. Home nursing will definitely apply Unuboots and usually that's why I've never had to do it. At what point do you think about wound vacs? So wound vacs are most excellent. They've gone a little bit out of favor and I think it's largely because of the costs that the agency incurs. It does require a little bit of work on your part to get the products to the home, but most of the vendors make it very easy for you and they'll help you. The one thing about a wound vac is there should be minimal debris in the wound bed. So less than 20%. It's gonna apply negative pressure to encourage quicker granulation to the wound bed. And you need to still apply the negative pressure to the tunnels and you need to protect the underlying structures. And most home nursing, if they offer negative pressure therapy, they'll know all that. You don't need to remember all that, but it is a good option and it usually requires three times a week dressing change. Sometimes you can go to twice a week. I'm just checking the chat. The one thing I didn't specifically say is a wound is generally considered a chronic wound after 60 days. And that means it's sort of gone off the rails in the typical healing process. Do I ever do mechanical wound debridement in the home? Yes, I do. Sharp debridement in the home and that is billable. Brianna, I think is gonna talk about that. You have to document how much you debrided. I generally will use pharmacological agents like collagenase first. The cost can be an issue for some patients depending on their insurance. And then the other thing to think about is when you use collagenase or even silvadene, you have to do a daily dressing change. Okay, well, that was really wonderful. And it was actually really nice. I mean, I know we've done this talk in person too, Michael, but we get a nice closeup look of the model when you're going through it. And I know that that was really, really helpful. So thank you. We do have one more talk before lunch. We've got Dr. Paul Chang, who's gonna talk about working with specialists in when to treat, when to refer and when to consult. And I'll be driving your slides, Paul. So whenever you're ready. Thank you, Melissa. And I am ready. Let's get this done and we can break for lunch. The objective for this session is to identify home-based medical care providers, unique challenge that contributes to the difficulty in securing specialty care for our patients. I'm gonna describe some logistics around effective care coordination with specialists, as well as I'm gonna bring up two cases for us, all of us to consider and think about how you would manage and discern when it is appropriate for us to maybe treat at home. When is it appropriate for us to refer our patients out to a specialist? Next slide, please. So what are some of the unique challenges for us as we care for our patients at home? Number one, and then I talked about this yesterday, we are often the only provider that goes into the home. I wish there were dermatologists or ENT docs or gastroenterologists or pulmonologists that made house calls that could come alongside myself and take care of these complex patients because as number two bullet point there, they have multiple advanced conditions with what I call competing priorities, right? You got the heart failure, balancing against chronic kidney disease, balancing against polypharmacy, and then you have to consider the patient's hyponatremia, and now the patient's complaining of urinary incontinence and frequency because of the diuretic. So you have a lot of things you have to keep in mind in terms of like, how do I best manage this patient with all of the problem that, for example, Minerva has? The next is a mobility disorder. By that I mean, if I saw a patient who was complex in the office and whatnot, I would say, well, go see a specialist, go see your lung doctor. As Michael talked about, there's a complex wound in the office, it will just refer you to the wound clinic. And our patients often cannot do that. It is hard enough for them just to go down, say, four or five flight of stairs and traveling halfway around town to see a specialist can be very difficult. And that puts the kind of the pressure on myself to say, you know, I got to do my very best because they don't have the capability to leave the home. And the final challenge is that, you know, the goals of care conversation, you know, the first M of the 4M or the 5M that we talked about, what matters most. Some of our patients don't wanna see another specialist. They don't wanna undergo more testing and more procedures. They want me, they want you to do the best you can for them at home, right? And there's some other challenge which I didn't put on the slide. And I don't know if it's your experience. Some specialists are very willing to help us in terms of they know our patients, our challenges that we face and the complexity that we're trying to address at home. They're willing to help us. Other specialists are like, well, they need to come into the office. They will not offer any advice, give what I call hand-holding with myself as I try to manage these patients. So as you go back to your community, think about, and I'll talk about relationships in a little bit, think about, and maybe perhaps start gathering a list of providers that may be more say receptive to your need and less resistant to say a phone consult or a curbside. Next slide, please. So when to treat at home. So this is, you know, when I give these talks, when I talk to the residents and so on, I said, there's a fine line in my heart between being confident and being cavalier and almost being reckless. And I don't have a precise, you know, people ask me, you know, how do you test for that? I don't have a precise, you know, checklist and say, well, you're confident and now you're being a little bit too cavalier. But I'll give you some considerations for you to think about in terms of, you know, which side am I on, I think. When to treat. I feel comfortable in managing a patient's condition at home if I feel like I have the knowledge and the experience in managing this patient's condition. Often it would be like, you know, congestive heart failure or exacerbation of COPD or talking to them about their atrial fibrillation, about their CHAT-VAS, HAS-BLED scores and so on. So if I feel confident I can do it, then I probably would treat them at home. When I'm fairly certain about the diagnosis that this patient's shortness of breath, I'm fairly certain is related to say pneumonia from aspiration and not related to heart failure or a pulmonary embolism and so on, then I feel confident treating the patient at home. And the final thing that would tilt me towards treating at home would be the patient's preference. Many of our patients don't wanna go to the ER, don't wanna be hospitalized again, don't wanna undergo more tests and so on. And that would favor myself in terms of, let's try to do as much as we can for the patient at home. Next slide, please. I'm gonna give, I'm gonna present two cases. I'm not looking for a magic answer or necessarily the right answer. My goal here is to get you thinking about how you would manage these two patients and what resources you would need and perhaps kind of get a sense of where your own heart is in terms of, if Gertrude was my patient, how am I going to manage her with the following condition? All right, so here we go. These are real cases. Both of them happened within, I will say, the last six months or so. Gertrude is 85. She's got dementia. She lives in a group home and I saw her for the first time a couple of months ago. Her past history, hypertension, AFib, CAD, CKD, hypothyroidism, arthritis. She's got dementia, osteoporosis, and she has this unusual or not common diagnosis of, at least not in my experience, eosinophilic colitis. You can see the medications there. Lodipine, aspirin, metoprolol, statin, an ARB, apixaban, levothyroxine, tylenol, denepazil, and vitamin D. Next slide, please. And on my exam, she looked good. She was pleasant, but she was confused. Her vital signs are stable. You see the exam there. She's got AFib findings. She's got degenerative changes, MINI-COG of zero, and a tug time of 49 seconds. And I thought everything was okay. I put in a plan for the group home nurse with instructions to call me with changes in conditions and so forth. About a week later, the nurse calls me reporting that the patient's having non-bloody diarrhea, no vomiting, no bellyache, no fever. Next slide, please. So I did some blood work. I gave her some Imodium, but the diarrhea continued. The stool studies are negative. She's a little hypokalemic from her diarrhea, but her sodium creatinine were okay. She was not terribly dehydrated at that point. Since the Imodium wasn't working, I prescribed a Lamodel. That's a brand name. Diphenoxylate atropine is the generic name, but diarrhea continued up to eight BMs a day. So I said, well, since these two antimotility agents are working, let me try psyllium or fiber therapy, but that wasn't effective. And then I started thinking, well, maybe she's impacted and only the loose stool is getting around. So I ordered a KUB and there's no obstruction. Remember, she's new to the area. She does not have a gastroenterologist. She relocated from her home, some distance away to this group home to be closer to family. So I did some research in terms of, could this be a flare up of her colitis? I said, well, let me try some prednisone and see if it could help her with her colitis, but prescribing prednisone, the diarrhea got worse up to 11 BMs a day. The family's calling now saying, you're doing nothing for mom. The diarrhea continues and threatening to take her to the emergency room. What would you do? What are your thoughts? If Gertrude was your patient and you're taking care of her, feel free to use the chat box, raise your hands or just speak up. What's the consistency of the diarrhea? Loose, watery, non-bloody diarrhea. And Wyatt, you said stool studies are negative. Which studies do you know? Yeah, and with our whole system, it's called a FilmArray. That tests for various enteropathogens, viral, as well as C. diff, as well as a panel of bacteria. You might wanna consider an ischemic bowel. Okay. The stool, if I recall, it was non-bloody. Okay. No recent antibiotics. Dietary changes, other than the fact that she's in a group home now. And I don't know in terms of what she's eating at the group home versus what she was eating at home. Met list, if somebody wants to see her met list, so if we can scroll back and take a look at the met list. Is she taking fluids? Well, yes, she is. One more slide, I think we, there we go. Full code or not. I can't answer that off the top of my head. I do not recall. If she was in your neighborhood and taking care of her, GI consult. Okay, perfect. Acutely for colitis and GI consult. Any new emotional distress? Nothing apparent to me in terms of when I was at the visit, she didn't look tearful or sad or tearful. She was not anxious or fidgety or anything like that. Cholestyramine, maybe, but then bupredesonide or GI consult. Perfect. Excellent. If she was your patient, again, just think about who is your GI friend. Again, start maybe compiling a list of accessible specialists who may be able to help you with a patient like Ertrude to get you through this bind here before we send her to the hospital and so forth. So, again, just to think of this exercise, again, is just to help you think about what is your own personal disposition and what is your knowledge base and how can when you go home and how can you start maybe developing a plan to take care of complicated and a patient like Ertrude, maybe a little murky in terms of, you know, diagnosis and treatment. And then come up with options for you as you go forward in your practice in taking care of patients like her. Yes, to get prior records. Excellent. Great. Great advice in terms of what was tried in the past and what worked and what did not work. Excellent. Let's move on for the sake of time here. If we can advance to the second case. She's in the pain. Let's give her a low-dose Norco while we get to the GI specialist. Thank you. Thank you for that. Next is Elizabeth. She's 92. And she's typical of the kind of patients we see at home, right? She's got COPD. She's on homo to a fib. She's got half path. She's got hyperlipidemia, CAD, CKD, hypothyroidism, arthritis, HTN, osteoporosis. Her legs are swollen. She's got insomnia, hypomagnesemia. She's got mild dementia, seen at home, living with a paid caregiver, post-hospital for CHF exacerbation. Her meds, she's on O2. She's on a pixivametoprolol, statin, furosemide, lisinopril, levothyroxine. She's on tramadol, denosumab, and a magnesium for her hypomagnesemia. On exam, she's alert. She's cooperative. She's confused. But she still thinks that she's in a hospital. You see her weight, her pulse, and her O2 sat on two liters. Her mini-cog actually wasn't that bad. Her TUC score is 34. She's got no JVD. She's got a few rails in the left base, a little swelling in the leg. And you see her labs there with a little hyponatremia, borderline low hypokalemia, and her creatinine of 1.5. Next slide, please. The caregiver calls you a couple days later. Her legs are more swollen. Her weight is up 135 at your visit. Now it's 140. So you say, hey, you know, maybe this is exacerbation of her heart failure. Let's up her Lasix dose, furosemide, I'm sorry, furosemide dose for the next couple of days. Then the caregiver calls back after a few days, and the leg swelling continues. Her weight is now even more. She's a little bit fatigued, but no shortness of breath. So you decided to increase the furosemide even more and say, well, maybe it's a good idea to check her labs because I'm adjusting her diuretic. You can see that her hyponatremia is a little bit more. Now she's hypokalemic. Her magnesium is low, and now her creatinine is up to 1.9, and her BUN is elevated again. So you're replacing the magnesium potassium, upping her furosemide. And next slide, please. You decided to say, you know, I think it's a good idea. Maybe I should go back and do a follow-up exam on her. I'm just going to pause here for a second regarding, like, you have to think about, in terms of somebody like Elizabeth, in terms of transitional care. In the Naylor model initial study, they looked at heart failure patients post-hospital. Initially, they visited these patients weekly for four weeks and then spaced them out to monthly. Again, think about how you want to handle somebody like Elizabeth post-hospital in terms of the frequency of the visit, whether it should be weekly or more or less. So on a follow-up exam, she's alert. She's confused. Now she's got JVD. Her O2 sat is down a little bit more. She's got RAILs in both bases, and she's got more edema. You say, well, let me go over the medications with the caregiver. The caregiver says, yep, I gave Gertrude, sorry, Elizabeth, all of her medications. And, you know, you told me to keep the salt low and the fluid intake low, and I'm doing all of that. So you do follow-up blood test. Potassium is up a little bit. Magnesium is still low, and creatinine is now 2.0. And the family is now calling and saying, you know, what are you going to do? Her kidney is getting worse. Her weight is up. And as you think about how are you going to address the caregiver and pick up the phone, talk to the family, what is going to be your next step? So I saw in the chat box goals of care. Absolutely. That's important. Consult with cardiology. Absolutely. Again, think about how you may want to do that consultation. Will you have to go back to the records from the hospital and find a cardiologist who saw Elizabeth in the hospital and perhaps give an update to the cardiologist on what you've tried and so forth and see what he recommends? That's certainly an option. Absolutely. Yes. Every time we go, it is, you know, medication, reconciliation, you know, justification, optimization and demonstration. Yep. What we do depends on goals of care. Absolutely. Yep. What happens if the family says, you know, you need to do so? We don't want mom to go to the hospital. Fair enough. But can't you help her with her weight gain and her shortness of breath? Perfect. Switch out the diuretics. Can you do IV diuretics at home? Probably through a home health agency that we're able to do that. Again, there's some logistics involved in getting home health agency in a timely fashion and getting, say, your IV diuretic of choice from a infusion pharmacy. So that could take some time. Switching out the diuretic. Perfect. Whether you switch to a different loop or adding metolazone or xeroxolone in addition to the mix. Again, I'm doing this to generate some thinking and self-reflection in terms of how you would manage this patient. So goals of care, counsel with cardiology, maybe switching to a different loop and possibly adding metolazone. Those are all things I think reasonable and appropriate things for you to consider as you are facing a challenging case like Elizabeth moving forward. Next slide, please. So when to refer or consult with a specialist? Obviously, if your knowledge isn't there, if you're, you know, I don't have a lot of experience managing somebody like Elizabeth with both worsening kidney disease and worsening heart failure. If you don't have that experience, obviously, I think it's a good idea to consult with a specialist. And also, even with my four nurse practitioners, they all have different personalities. Some tend to embrace more of these challenging patients and trying to manage on her own. Others are more quick to say, you know, send a quick note to the cardiologist at the hospital, for example, and get directions that way. So it depends on your experience, your own personal comfort level. If the diagnosis is uncertain, for example, I'm taking care of this patient with very vague physical complaints of aches and pains and so on and so forth. And I didn't think I would find anything on lab tests, but the SED rate and CRP came back extraordinarily high. And I'm not quite sure. And then I ran some additional rheumatologic screening tests and so forth, and they're all negative. So I'm kind of at a loss in terms of, you know, what is the cause of this patient symptom? Then I think it's very reasonable for us to recommend a referral to a specialist. If the patient's condition is not responding to your therapy, and again, if you don't feel comfortable escalating, say, a change in a loop diuretic or adding metolazone, and perhaps that's a time to consult with a specialist. Patient's preference, what matters most, right? If some patients want to see more specialists, want to find out what's going on, see the oncologist or a hematologist for their pancytopenia or whatever, definitely, if they request it, you can certainly acknowledge that. If a procedure is needed, a thoracentesis and interventional radiology or something like that, then it's obviously appropriate to consult. And also consider if a patient like Elizabeth, who saw a cardiologist in the hospital, and the patient is now not doing so well, I think it's also worth considering a follow-up note or a visit, or don't forget telemedicine now, right, with the pandemic, to see if a visit with a specialist, either in person or through a video, might be an option. And finally, as I stated before, start maybe gathering that list of, I should say, I have to be careful what I say, of specialists that you can perhaps more willing to help you with your patients with challenging situations. Next slide, please. So when you're referring a patient to a specialist, I think there are a couple of steps to follow. Let the patient know that you're referring Elizabeth to the cardiologist and the rationale for the referral. You could be talking with the daughter and say, you know, I'm going to refer her back to her cardiologist. I want to see if I can make a video visit because she's not getting better, despite what I'm trying to do. Don't forget to call the specialist if the condition is urgent. And tell them why that you're consulting the specialist, whether in Gertrude's case was for the diarrhea, do I have her on the right medication for her suspected colitis, or with a cardiologist for Elizabeth and say, you know, I've tried what I can, and the diuretics, they're just not working. All right. Think about the logistics for your practice in terms of how does that referral work? Is there a work queue in your EHR that you can just press a couple of buttons and you can send the referral? Or does the referring physician prefer or need a phone call or fax with the questions and what you're looking for from the specialist? Make sure the family know who they're seeing, where the office is, and how to contact a specialist, their phone number, for example. And send your records, send the test results, whether it's the BMP or the BNP and whatever, sodium potassium level, or the stool test in Gertrude's case to the specialist so that they are aware what you've tried, what you're concerned about, and what tests have been done. Just two more slides. Again, it's about relationships. You know, I've talked about this before. Home-based medical care is so much about relationships with your patients and your caregiver. In this case, a foster relationship with a specialist in your area. I talked about the telemedicine option. And think about, you know, what transportation assistance you can provide for your patients and caregiver if they want to get out and follow up or see a specialist for a consultation. In summary, I think it's important to identify any unique challenges that may contribute to the difficulty in securing specialty care. And also to consider some of the logistical factors and clinical factors to think about in order to ensure that the effective care is being transmitted or coordinated with the specialists. And I think that is it. Time for questions. Let me check. Yeah, absolutely. Find out in your area who is offering telemedicine. That's great. Great comment. Yep. Thank you for that. Yes, trust and comfort level. Huge, very important. And especially like for these patients like Gertrude and Elizabeth, the family, they're new patients to me right they the families don't know me from from anyone. I'm just a guy who's going into the home and taking care of their loved ones. They say well you know I can give them all my credentials and whatever, whatever but they don't, it's not important to them. Anyways, so it's so building that trust. It is hugely important. Thank you for that reminder. Sure, it sounds like the cardiology is managing some of the conditions, ordering some labs, and then you're managing pain and COPD in collaboration with CARDS. Absolutely, sometime it is necessary to kind of divide and conquer or be sort of an extension of the cardiologist's eyes and ears for them being in the home. All right, Melissa, I think it is noon. Sorry. Okay. Hi. All right. Yes, we are ready to go to lunch. And we are back here. It's at 1245, right, Janine? 1245 Central. That is correct. All right. Well, we'll see you then. You can stay in the Zoom. Just mute and turn off your cameras. Thank you. Hello, everyone, we're going to get started with our next session in three minutes. So this is just your heads up that will be calling everyone back in just a little bit. We're going to get started with evaluating productivity and staffing with Amanda and Brianna at 1245 central time. See you soon. Okay, I'm going to get our slides ready for our next session. We will get started momentarily. Brianna and Amanda, I will be driving your slides, just let me know when you're ready. Thanks, Janine. Amanda, are you backing with us? Hi. Oh, there you are. I was like, you moved on my screen from your where your video was before. All right, let's see, it's 1245. It looks like we have most people back so I think we can go ahead and get started. So, Amanda and I are tag teaming this session we wanted to dive a little bit deeper into evaluating productivity and staffing, and what that looks like so we want to go ahead and start to the next slide. So right now, our objectives are about we're going to talk about factors about how you develop and grow your team and what that might look like. Thinking about the different types of positions and what kind of signs or kind of flags might let you know that it might be think it might be time to grow or add an additional staff member or position. And also think about productivity standards in your own practice. There's really no one size fits all but we'll talk about some averages and standards that we've seen and give you some food for thought about how you can determine that when you're building your business plan. So, we're, our hope is that we could start with a little bit of discussion. I would love to hear I know yesterday when I asked in the chat there were a lot of comments about the value of social workers. So, if anyone would be willing to share when you started your practice or where even where you are with your practice now if you're more developed. What other than the providers other than the very important clinicians that we can't do this work without what did you start off with what were those position titles or you know licensures. Anyone want to share a little bit about how they started off with or when they did add some sort of clinical support staff or administrative support staff, what that looked like for them and how you came to that decision. Yeah, so last year when I started doing house calls, I started out I just had a like administrative support helping with scheduling. Yep. And then I was doing kind of everything else. And it wasn't until December that I found after doing numerous interviews and looking for various people I finally found a medical assistant in December of last year, who's really great. And then I just hired another for like a part time front desk person also because I do have a brick and mortar location also so. Okay. But I'm looking now for another nurse practitioner which has been a challenge. That's, that's great though and then medical assistant you mentioned yesterday I believe is the one that drives you around to your visits and helps with things like that that's your model. So yes, so she goes with me she drives sometimes and I have another driver some days when she can't go, and then she does the vitals and you know anything we need in the home and follows up on things which helps a lot. Great. Thank you so much for sharing April. I'm so happy that you have that support. Still a lot on your own. One day at a time. One day at a time exactly. I was just talking to someone on break and she's like some days I'm like why do I do this again. So Dr. Melody said when we start off we had one staff member that we were able to wear many hats and able to do both we actually had an MA that became an office manager so that was helpful. Yes, I mean when you start small you really have to think about how you can use positions to do many things. Yesterday in your workbook we alluded to. The care navigator job description and none of these, everyone has different names and titles but the care navigator job description that you all have in your workbook would be a position you could consider if you were smaller starting off with maybe it's a medical assistant but they're also doing scheduling helping with phone calls. You know, maybe they're just your back office support maybe they don't travel with you or maybe they do. So there's a lot of areas of opportunity for flexibility. Anyone else, anything that like a different unique position that you found really valuable or anyone that wants to share? Yeah, I think in the advanced practice I'll pick on you, you have set people that are schedulers, I believe it's like one to two people that you found really beneficial to kind of rather than having a more broad team do that, and scheduling is not as intuitive as it might seem so I think you found your people. Do you have anything to add there? Those people obviously that's not their only job they are also medical assistants who are supporting some of our providers but yes they are doing scheduling for the providers as well. So definitely helpful. All right. We can move on. Let's go to the head and go to the next slide. So, you know, again, we're trying to make this applicable to all different kinds of practice and models and sizes so you're going to maybe start off with some traditional roles maybe it's just you or maybe you have an administrative person that's a little more cost effective that's just doing kind of some office management helping with phone calls all the paperwork, things like that or maybe you have an MA because they're doing that multiple hat roll. And then if you're talking about an interdisciplinary team. It depends on the resources and where you're at at practice, you know, we'll talk about the differences in relationships of what's the benefit of having an RN versus an LPN or a medical assistant. I've even started to hear a lot about community health workers, you know, being a low cost option how can people get creative and use those kinds of roles. And then if you're in more of a value based program. This is definitely still pretty new but, you know, I know Dr. Chang's practice was fortunate enough to do a pilot with a pharmacist to make some deep prescribing recommendations and has a really awesome study actually maybe someone can share the link in the chat about the benefit that that had to his practice. And then as your practice develops you really want to think about how can you, you know, really define roles and responsibilities, use people for their unique skill sets and licensures, and, you know, really do maybe some more systematic care management, or maybe I know someone said they have billing and coding in house that's wonderful maybe you start with outsourcing it through your EMR or revenue cycle management vendor. When does it make sense to bring that in house, or have a, you know, referral coordinator things like that. If you're not sure to one of the kind of activities if you've never done if you do have like maybe a little bit of a team and you've never done some workflow observations or even I know some practices that I've had like working sessions where everyone uses post its to put their, how they think their daily jobs and resource events roles and responsibilities on a board and then they kind of compare and see what the social workers for this to the ma versus the nurses are doing to really have that clarity and make sure there's no. If you're familiar with kind of like the term waste or duplication of tasks and process breakdown and things like that. Amanda, do you want to comment on the transition specialist I know that's something I think you were considering. Yeah, I was gonna mention briefly on the bill or coder piece. You know, especially as you get into value based care. Even though it's not kind of traditional profit billing in that sense somehow it is complicated enough, but that was kind of our trigger point for wanting that in house is you just you really want to know, you know, all do I understand all my contracts, and do I understand where all my money is at all times and do I have kind of control over that. And I think generally that statement is probably true but especially when we get into value care transition specialist yeah we're starting this now. So, we're specifically looking to hire. Well, specifically looking to hire probably an LPN in case we want them to do a little bit more clinical work but yeah how do we think about someone who we have 4000 primary care total patients about 1500 of them would be considered home based primary care like well what, what does that quite look like and what do we need them to do and how much of it is behind a desk and remote and so we're kind of trying to figure that piece out but it's it's an extension of kind of case management to get some of the necessary paperwork and supports put in place as we look at that. I don't think it won't be as involved as the nailer to see you model but, but certainly involved early and often in the transition is the goal. Thank you. And then as far as the specialized provider roles I know again again this is everyone's in a different place but I know some practices, especially more value based that are more advanced that I've chosen to have certain people that all they do is annual wellness visits are those types of comprehensive visits and they're very good at HCC coding, or, you know, hiring a psych and be for your mental health patients or you know thinking about or sending one of your current nurse practitioners that's interested in that to develop themselves to add that value to your team. You know we talked about how challenging dementia can be and things like that yesterday so those are kind of some things that you can think about, you really want to if you're going to add someone, what what different skill set or unique gap, are they going to fill. And we I'd add to that list to like we're thinking a lot about wounds in that space. I think a lot of us think about podiatry but for us we haven't seen. I don't know if anybody does podiatry but you know you have to do so many visits to kind of make that model work. But there are, you know, another number of these we've looked at all of these, and some palliative care roles which many of you have specialties in and wound care, I'd add to the list to. That's a great one I know. Well you heard Michael and the breadth of knowledge that he has, and I know Dr Chang is fortunate on his team to have a wound care specialist too and I can personally speak to how much I value her that nurse practitioner and wound care specialist is is just amazing and a great asset to the team. We can go ahead and move on to the next slide. Amanda and I kind of created this slide because we were getting the question a lot like well what what is an RN's responsibility versus an LPN or an LVN or a medical assistant, and really what are the differences. Now, each state is going to have different scope of practice laws so you need to understand, you know the the licensure laws and things in your own state. But if you think about the differences and that kind of most pure simple form, you know your RN has some evaluative and triage, but, you know, they can without getting provider guidance, give some medical advice within their again within their scope of practice. I know a lot of practices that are using RNs to facilitate telehealth visits or to go out and have their RN do the same day assessment rather than their providers. Obviously the patient and caregiver education piece, you know, and they have clinical assessment skills that you're not going to have with a medical assistant. However, you can still, you know, relay advice and have the medical assistant be the ones, you know, communicating with the patients and caregivers. They still have some clinical knowledge so when they're maybe when they're the ones answering the phone the difference in the kind of information then maybe an administrative person may be able to gather and collect. Certainly their clinical skills in the field if they are traveling with you and doing blood or you know drawing blood for you and doing some helping with some simple procedures. And, you know, obtaining and helping to document medical history for new patients in the medical record talking about saving time for your providers. If you go into a new patient visit blind versus if you spend the time collecting some initial that really good intake and medical history form and then you actually have your medical assistant or someone, you know, prep, update that information within the medical record and collect that information for your providers ahead of time before that first visit. What kind of difference does that look like for your practice? Do you have anything to add here? Yeah, I think of LPNs as they can walk right up to that line but they can't cross that line. Right. And so, from an FLS, from an FLSA standpoint, you want to be really careful when you're posting these positions. From an, again, the RN you worry less about but the LPN and medical assistants again they can do all that gathering information and compile it and bring it to you but the assessment pieces by an RN. So sometimes we see job descriptions that come through that say kind of triage you're going to get yourself in trouble if you were triage and it's posted for an LPN. And so, you know, I mean again know your own state scope of laws but, but, and there's such value in using LPNs and medical systems so I'm not trying to deter anyone from using them I'm just saying, you know, really figure out what is the need what is type of type of licensure look like and then what am I going to need in the future, and do I want to spend the expense today to get the person that might be there in the future or, you know, or do I want to do I have a really idea of the discrete box this person is going to sit in. And, and one of these jobs makes just total perfect sense and we don't need kind of to wait and wait and watch and see so you know I would just be careful to kind of know those things in advance. Yeah, absolutely. And thank you for the comment Dr Malini is he was saying I have an intake staff member now that has increased the number of new patient visits that they've, they've been able to do in a day by getting and collecting and you know updating that information and the medical record. And Michael talked yesterday about how they've actually been doing intake video visits before they go out to the home and and kind of the difference that that's made so you can think about those kinds of creative things to make the most of your time and when you're in the home it really needs, you know, make sure that you really need to be there for that direct patient hands on care. And from an RN standpoint just one way that we're starting to use our answers for some of our patients we use them really for the acute things. So, you get the call. You go out and do the assessment, there may be some instructions that you can execute on site or you, they may have the appropriate skill set to just execute by themselves on site or queue up a prescription or something and so it for us that's been helpful but it only pays for itself if you do it for the value driven contracted, you know, patients, but yeah. All right, we can go ahead and move on. So, when you're thinking about staffing and you're thinking about productivity and we're going to give you some more, you know, specific averages and things like that but the first point here is does your productivity support the business plan well how do I figure that out right. So, the way that I would offer you to think about this is let's say you're going to think about an eight hour work day, right. Let's say you're going to say maybe six hours of that is direct patient care and two hours of that is going to be left for at least some time for documentation and callbacks and all those other things. How many visits does that equate to and again in a fee for service world the reason that we have to talk about productivity standards it's not to, you know, have an administrative, you know, heavy handed it really needs to be a partnership and you're not going to sacrifice quality you're never going to see as many patients as you can in an office setting. So, what do you need to do to keep your lights on so you know I was talking to Dr Chang about some averages let's say, and this is being generous and new patient generous as and we know there's a lot more time sometimes but let's say your average patient you can do an established patient in 30 minutes and let's say for your new patients you can do that in 45 to 60 minutes. How many new patients per day is your max because your scheduler is going to need to know that let's say I wanted to do two. This is a very lofty goal but let's say you said okay I can do two new patients and six established patients in a day, that would give me eight total visits and then I could think about what total revenue, or you say no you know that doesn't leave me much time for my end of the day so maybe if I'm doing two new patients I'm only going to take four established patients, and that's my maximum per day. And I had Janine upload to the learning the HCCI learning hub for you there's a resource called the HCCI super bill. When you're trying to figure this out too especially if you're an independent practice, you need to understand what's your actual revenue, what are you actually getting paid for the visits. And so, that has the Medicare national fee schedules knowing most of these are Medicare patients for an established patient, the level for 99349 visit is the most common than 100% of the reimbursement schedule would be $129 for that visit. And for physician assistants and NPS you'd be paid about $109 for that visit, whereas a new patient visit level for average would be $181 if it's 100% of the fee schedule and $133 if it's, you know, 85% of that Medicare allowable. So really just understand what you're actually getting paid for those visits and that would be the best way that I would offer about what's right for you, what's manageable for you and what is productivity need to look like for you to be able to provide the best quality care for your patients, but to also be able to keep your business open and provide the support that you need to. So those are the kind of aspects on the screen. I mean, you want to think about quality. These are kind of those warning sides I alerted to, you know, if you're not able to create access, well, that's a problem. Do you need another provider? You know, is there a breakdown in workflow? What's going on about that? And then from an administrative standpoint, can your patients reach you? And then from a home-based primary care, the last thing that patient or caregiver wants to hear is a long phone tree or nobody be able to be on the other end of the phone when they're trying to get ahold of you. So what do you need to do to solve that problem if that's an issue for you? And then we know that this population, a lot of the requests that come in, you know, is going to be different than your traditional primary care practice, meaning they can't wait. There are certain things that have to be addressed same day. So are you actually getting to those things? Are you looking at the different types of messages and baskets or tasks and all EHRs call them differently and making sure that that work is getting done? Or is your team just completely, you know, overburdened where you really need to find a solution or you're going to lose some really good people or even worse, potentially have a, you know, a poor outcome or gap in care? Next slide. So more food for thought here too. Again, it's just a balancing game. These are just kind of some things that you can ask yourselves, you know, and I know Amanda is kind of big on the whole root cause analysis thing, which you're going to talk about, right? You know, are you using those kind of tools? Okay, if my problem is a long wait list, why do I have a long wait list? You know, that kind of fishbone approach or what can I do to stop that? Do you even know how quickly you're seeing new patients or how quickly you're able to get to a post, you know, discharge patient? You know, and what kind of workflow, if you do only have one staff member, what does their day look like? And those kinds of things. And how quickly are your patients getting callbacks on lab results and other things? And we talk a lot about patient and caregiver satisfaction, which is huge, really strongly suggest that you measure that and HGCI has a sample form on our website for that. But what about your staff? What about your providers? Do you manage and measure, excuse me, employee satisfaction? And is that something that you're taking into account? Are you talking with your team and giving them that outlet and that opportunity for feedback? Because, you know, I know April mentioned it's really hard to find an NP. This works not for everybody. You know, you need to find the right people. And when you do find the right people, how are you going to keep those people? Next slide. Amanda, I'll let you lead. Yeah. So, you know, what I like about this slide too is, and kind of leading into this is, you know, here are all the additional things you should consider when you evaluate your growth, right? So now you have growth, which is fantastic. And the number one thing that happens to me, and I'm sure it happens to you too, is something goes wrong, right? Because it does, or someone's stressed out. And what do they do? They come to you and say, we need someone else, we need you to hire someone. And you could be like, oh, okay, what is really going on? And when you ask some of these questions, then it's like, oh, well, you know, the EHR doesn't do this very well, or so-and-so put this policy in place, or this happened, and, you know, this is probably not as efficient, or we're concerned about the future world of this. And it's like, oh, it's not that you need a person, necessarily. And, you know, what I try to tell people to come with is, figure out a way to really understand the problem and articulate the problem. And then what are some of the solutions? Hiring a staff member is a solution. This will keep, again, that productivity piece. And there's, you know, there's kind of this tipping point of, okay, everybody's census is, I don't know, let's say an NP census is 200. And you know what, but when do you hire a new NP? Do you hire them at 201? Now you have 201. Do you hire them at 205? Do you wait until they're 250 and say, hey, you're 25% of the way there, we think we can grow you again? Right? And so that's what these things are attempting to do of saying, here's, you know, here's the thing, you're going to need to hire people. But you need to make sure your other workflow is efficient. And so this is the data. And there is so much data that could be created. And every vendor you have is willing to sell you an extra shiny package on top of it for a low, low price of, starts with, obviously, four digits of this. And you're like, oh, do I need it? Do I not? And so this is, I won't read through all of them. And I'd love for Brianna to jump in, too. But like, what are your call volumes? So how long are you waiting on hold? Do you need it? Are you waiting on hold? Do you have a phone treat? What are your wait times? You know, are your people happy? Are they in tears every day? Have they, you know, is it a drive issue, a geography? We talked about some of the efficiency pieces. You know, how quickly, if you were going to get your own parent in, how quickly could you get someone admitted and in and the provider was going to be seeing them for the first day? Like, is it three days? Is it five days? Is it two weeks? You know, so I think some of those pieces, you know, is billing being held up on the way out the door because of a form, for whatever reason, a guardianship form you haven't gotten back? You know, it's like, well, you're seeing the patient, you're touching the patient, are there some ways to build those pieces in? And so this is just a root cause analysis template, you know, but again, root cause analysis, PDSA, whatever your component would be, come up with a way to find out what's really going on. And this is some good data to collect to get you there. Other data that you guys maybe collect and look at to make decisions? Yeah, I think the reason I like this slide, the only thing I was going to add is, you know, like you kind of alluded to, is if you have a problem, it doesn't necessarily always mean you have to hire, right? Like, is there a process breakdown or something just not working that needs to be corrected? And the resource, you know, that we have on the screen is from the Institute for Healthcare Improvement. They have some free resources. And so that's where this five whys comes from. So again, just really understanding what's your problem and being thoughtful about, you know, do I just need to streamline operations and put some new processes in place or just do some, train my staff? You know, a lot of times, sometimes I talk to people and I'm like, they're like, Susie, you know, is doing this, she's not coming to appointments and I'm talking to Susie and she's like, oh, I was never trained on that, you know? So think about that as well. Yeah, I got a message too around kind of patient attrition too. And so, you know, what, and I think it goes into this next slide really well. So I'll take a slide. You know, what type of growth is your practice experiencing? You know, are you having organic growth? Are you out, you know, merging and acquiring things? You know, at what point do you kind of add services, you know, and how do you truly understand your patient population? Do you, for example, you know, if you have a program that either has enrollment, you know, through an ACO, some other contracting component or payer arrangement that you have, you know, are you seeing as many people die or term as you're getting new every month? And then how do you track that over time to see where you're kind of growing? Again, or you're doing kind of big growth areas like, hey, we've, we've grown to where we are in Florida and now we're expanding to Virginia and that's what this is going to look like. And this is the infrastructure that we need to put in place. So, you know, I think evaluate those budget assumptions you put in place and then adjust as needed. But is your patient, is your practice prepared to take on new patient volume from this staffing perspective? And again, you just have to figure out what your trigger points are. I kind of, I call it step growth where you need to add staff or services. Again, what is the number for you that's a trigger point of, we know that a new provider will ramp up within, you know, this much within, you know, 90 days and this much within a year. So our trigger point is a 25% overcapacity for one provider in one region. Now it triggers a new hire. And that's what this looks like. How long, what is your lead time for even hiring people? You know, ours can be, ours could be pretty long if we're hiring a physician for a nurse practitioner. We, I mean, we keep a list because we have so many people interested. So it's, it's just different. And I'm not trying to rub it in April. It's just, it's just the market the way it is right now in Minneapolis. I think the patient nutrition comment though is great because it's something to consider, like, especially for the new providers. A lot of times what I hear is like, oh, I don't want to market. I don't want to grow. Well, keep in mind the population you're caring for. You know, I think, I know Dr. Chang's practice track, tracks average length of stay. And it's like no more than a year. I mean, these patients, unfortunately are at the end of their life. Most of the time you're going to have patients passing away. And so you have to replace that. So it's really important for you to be able to understand how many active patients you have. Active meaning they're alive. You're seeing them on a routine basis versus how are you replacing that turnover? So I think that was a great point. I know someone called that question out. Yeah, Brianna and I talk a lot about what is the patient data that we're, what you save. And I, you know, like you need to know how many active patients you have. You need to know how many new patients you have every month. You need to know how many patients are leaving. So you kind of need that input and output component. And then from an annual standpoint, I'm always tracking, you know, what is our average monthly census? But then how many total lives did we touch in a year? That measure is helpful for a lot of external relationships and partnerships of saying, you know, we touched, you know, our average patient panel at any given time might be 4,000 patients, but we touched 10,000 patients in Minnesota this year. And that's what this looks like. And those are fun numbers to track. And then finally, you know, are you starting a brand new venture that requires a different business plan? And if yes, you still need a business plan. You just need to rework it for what's your new goal. And it may even need a new staffing model and maybe focus on something kind of different. What can you pivot and put into a learning for that? Slide. So this, I mean, this is one more slide. This is where the rubber meets the road. We have a couple of examples of just different staffing models. So this is a pod system. This is a multi-regional staffing model. It's important to understand the patient volume in each of these areas and the turnover and the growth that you're going to be seeing. And so how do you use historical data to predict some modeling going forward? For us, we have a pretty similar model where we have, we have four kind of around the metro area. So we've split the Twin Cities kind of into four quadrants and we keep a pretty good list of how many total patients are there. What's the ratio per patient? What's the hiring opportunity? If there is a hiring opportunity in which for what position? And then what's the input and output of patients? You know, if we go and we can look at the model and we can say, oh, well, we're going to grow in the northeast pod. We're going to pick up this new site. We feel really great about it. Here's roughly what we put into it. Do we have staff allocated to that area? Can they handle it? Or do we need to start thinking about posting? And you can kind of see in this example, you have some of the external services on the outside that are being called in as needed. And then you have some of the support components in the middle. And those typically are kind of, they don't have to be, but kind of this like office space deployed as needed type of thing. And then you have the actual staffing. And here you see how many people for each pod they've built this. And you can even build it for just one pod. But again, what are your patient volumes and how are they tied to your staffing ratios? And if you can get really sophisticated, and we've talked a little bit about this from some of the geographical scheduling, but I think the next frontier is the proximity away from home. So how do you both balance, you know, how far you're asking someone to drive and where you draw those regions together and where you maybe need to split a region or combine a region. Brianna, would you add anything to this? The only thing you made me think of is the other thing with productivity standards that I didn't explicitly mention is your geographic region is going to greatly impact that. If you're super rural and your drive time, even within close proximity, I mean, that's definitely another factor. You know, we can say eight to 10 visits is great, but you do have to consider your travel time and your geography. And that's when, you know, if you are super rural, can you build in scheduled telehealth visits, especially right now when they're payable. You know, the video visits in between or something like that to kind of offset. But Paul, were you going to jump in with something? I wanted to give you an opportunity. Yeah, I think what I was going to say, going back to what Amanda was talking about, what you were alluding to, you know, we obviously, as you know, we keep track of our death data. We've been doing it for many, many years in terms of the percentage of our patients that pass away at home or that pass away, as well as some hospice data related to that on a separate sheet. We also, so there is, there is, there is, we keep a sheet of what we call unique encounters per year. Those are the number of new patients or the patients that we actually touch per year. And then you have to take into the account about 20, 25% of those patients that you had a unique encounter passed away in that one year. So the census, so if you say, if you have a thousand of encounters per year, but your actual census is probably not a thousand patients, it's likely less because of attrition, as you described. Absolutely, absolutely. Slide. Okay, two more, two more examples here. This is the first one. So this is a practice, real practice, 1,900 patients. You know, how do the part-time physicians split up their time? What's FTE? Again, what's the regionality if you need to split up by region? And then, you know, 12 providers from an APP standpoint, the MAs, the scribes, care coordinator, and administrative staff. And now a lot of these, again, can kind of be virtual. You might have found some efficiencies in this model, too, if some of these teams, the administrative or the office support are now in a virtual model. I would say from, for us, for our practice, we try to hire physicians at at least a 0.5. We have a couple of physicians who do it more at like a 0.1 or 2, and it's really not too engaging. For the APP level, we try to hire really at that 0.8, and then we have a couple of 0.5s, but we wouldn't hire under a 0.5 because the APPs are all MPs, but they're really taking a lot of the first call and information on a patient. So that's kind of, those are kind of how we think about how to think about part-time folks in this model. Brianna, would you add anything? Yeah, the only thing I was going to say that, just because I know it's unique to this practice. First off, if you're seeing these numbers and like, oh my goodness, that's so much staff. Keep in mind, this is when they got to 19,000 patients. This is not how they started off with. So again, just keep that in mind. And I just know the scribes in this practice, it's not a scribe per every provider. So it rotates. They don't all, some providers travel independently, and they get, I think it's like two, maybe three days out of the week, they might get a scribe. But then when they have the scribe, they're expected to see two more visits a day. So again, just kind of going back to that methodology, you know, if you're offering the scribe because it's saving your providers time and documentation, obviously that's a great benefit. But, you know, from a FTE standpoint, they don't, you'll notice they don't have, you know, scribe for each provider. So just kind of another consideration when you're thinking about what makes sense for your specific model. And from, you know, so this is in direct comparison as an independent practice for our next slide, which is affiliated with the health system. There, I mean, there are some things that you may just may get as benefit of being with the health system slide. You know, for example, here, you know, you're going to see a little bit more kind of right sizing from a staffing perspective. But again, you might have some things that aren't necessarily in here. And so Brianna would know best, but like, you know, the administrative person is not like an HR person who's managing all those things because it's coming from a system level or the corporate insurance purchaser or some of those pieces. But this might look a little bit more like some of what you, what you see. Independent practice has to be a little bit more staffed sometimes if you're going to continue that growth. And so here you see a practice, a part-time practice administrator. Like if you were in an independent practice, you might struggle to find someone who's going to do it for, you know, at a 0.25. But if you can borrow someone's time in a larger health system, you'll see that. And then the physician, NPRN and MA levels, this group does not have a scribe. And so the backend administrative support is supervising, scheduling, getting out any, you know, pertinent information or taking any calls for patients, you know, from a kind of a front desk or registration standpoint. Do you have anything, Brianna? No, I was just going to clarify. You're exactly right. The administrative staff, their roles are, they're the ones that answer the phone calls, they do the scheduling, they help with the paperwork and those kinds of things. They're taking the, you know, the calls from patients and scheduling and doing that front office registration intake, getting new patient forms, all of those kinds of tasks. Slide. Okay, let's talk for a minute about productivity. Slide. So why does productivity matter? You know, in all contracts, almost all contracts, in almost all contracts, including value contracts, you do need to keep track of your volume. You, you, you, there really isn't, I guess in the, in a hypothetical world where it's all angel funded or something, then maybe you wouldn't need to do that. You wouldn't, but you really want to make sure that you are keeping a reasonable amount of productivity to kind of have that balance of that, the quadruple aim of increasing quality and lowering costs, but certainly from a patient and employee satisfaction that, that that makes sense. And so, you know, I think it, I think for us from a productivity piece, it really creates your sustainability and you guys know that more than anyone else, but you also, it contributes to your development of your standards of care. You have enough patients to, and you have a breadth of patients and some of that depth to really understand what's your model of care going to look like and how do you, how do you then budget for that and, and track that as it grows. And it creates this partnership between the clinicians and your leadership for productivity of saying, you know, we recognize that the revenue drivers here are also paying for the overhead piece. And then what does that exactly look like? And what does the visit sustainability look like? And finally, it creates patient access. Like if you don't have a sustainable, productive model, do your patients can't get to you fast enough and they're not going to keep coming back or recommend you or the families are not going to be happy. So there's a lot that kind of goes into why pay attention to this at all, but I'll tell you, even from our organization, which gets the majority of our revenue from value driven care, we look very closely at productivity still. So, okay, next slide. So some of the standards, you know, compare costs versus actual revenue, right? What are your expenses? What's your actual revenue? What is your geography? How big are you going to be? We talked about it in the essentials course a little bit more, but from starting up or an expansion, you know, figure out really where your stop and start is of geography. And don't expand to, you know, don't expand that, like really understand in your business model where you're going to generally with this group, because everybody has such big hearts. I'm going to say general, like you need to know where you're going to stop. So you're not driving forever. And then understand what types of visits you're doing and how do you have that balance of visits? You know, you're going to have some of these new, you're going to have some of these annual wellness visits. You're going to have your advanced coding type codes of TCM or chronic care management. And then is there a balance between independent homes, group homes, assisted living, independent living? And can you get some volume consolidation if you go to a couple of sites where you have, you know, assisted living or independent living in some significant volume? And then how do you create that standards of care component? We've kind of talked about that. What's the role clarity? And we've talked about that, of who's doing what, when are they doing it? You know, is it within FLSA guidelines? And then how do you compare to your local peers? This is both from a productivity and from a business differentiator model. And then is there any efficiencies or supplemental care that can help for this work? And so there might be things in your productivity where you're like, we don't have this today, but we could have it in the future. And this would make total sense. And we'll just kind of keep our eye on it as we grow. Or, hey, you know, we've really evaluated the program and we need, we really need behavioral health and we need to look at that as a piece of it. Now we need to figure out how we're going to pay for it. And so at what level can our intervention for behavioral health, whether that's a social worker, a geropsych NP, you know, at what point are we going, like how many visits do they need to see and what does that look like and who's going to kind of be paying for that? And so, you know, really everyone in the organization could benefit from creating a productivity standard of what we're going to be seeing out of their work. Yeah. And then just going back to the scheduling piece, because I know that was such kind of a need for this. I mean, when we talk about type of visits, like, okay, let's say you, you know, five or eight visits per day is your productivity. Well, within your scheduling guide, your, your staff needs to understand, you know, are you going to count new patients or TCM visits as two, you know, or, you know, how does that unit of visits or time for those more complex, longer visits, you know, allocate to, to your schedule? And then, you know, that's something that you should be tracking to, you know, visits per day by provider, by month, by the practice as a whole, because that's really the only way you're going to be able to evaluate your productivity. And your coding levels. Absolutely. Yeah. Slide. This is the one people ask us for more than anything else. How many patients do people see? This is just what, what we see after doing a lot of this and all the data that HCCI has collected that, and we've talked about this, if you're traveling alone or in a really rural space, kind of this five to seven, if you get that MA, that's where you go up to. So kind of that eight to 10 average per day, and then examples per week is around 45 per week. And so it just, you know, these numbers can certainly vary. These are not specific necessarily to assisted living or independent living, you can get higher numbers, depending on your patient population, if you have some consolidation, but if you're traveling appointment to appointment, I would call it a general rule because they're not, you know, five new patients in a day. So this is, this is kind of the overall productivity. And that's where you kind of get this target goal per week is around 45 visits per week, and you're going to have a mix of acuity and a mix of visit types in there. And if anyone wants to share in the chat, we'd love to hear kind of how this compares to what you're doing. You know, if you, if you all are comfortable saying, yep, I see seven patients a day, five patients a day, that might be interesting for your peers to kind of compare what you all are doing in your practice. Okay, one more slide here. What about panel sizes? And so here's an example of the panel sizes. So, you know, a provider might see to have 200 patients per provider, the care manager might have 200 and then the medical coordinator might have 400. In example number two, you've lowered the provider panel. So, you know, they have a higher level of intervention but now maybe a triage MA or an LPN is gonna have a much higher patient volume. And so in theory, you're having your providers do a little bit more kind of high touch and then you're having kind of the supportive clinical model come in and then the patient care manager might be even higher than that. So it's just kind of defining the roles and what makes sense, what are you willing to pay for and what are you getting paid for doing and putting in place and who makes you the most efficient. But I really like kind of two comparative models. I mean, you're just not gonna see a 2000 patient panel group and for, you know, it's not clinic-based work but, you know, around a patient panel if you're seeing 45 visits per week or so a 200 patient panel makes about sense. Let's see, I saw a chat pop in. Yeah, so we see an average of six no scriber traveling in May. Yeah, it'd be interesting, you know, to see if, you know, if you did have someone to travel with you, you know could you put out two more? What does that kind of look like? Is it the stress to have six or is it pretty comfortable to have six? And Nicole said, same thing as depends if newer routine, new patients, two hours otherwise six to seven days of fall routine or six to seven a day of fall routine. So I think kind of fitting within what we've been hearing for sure. You know, upwards, if you're IL or AL I mean, you can be upwards of maybe 15 or 16 in one day, but it's still pretty long day for those days. Well, one more slide. This is hopefully what you guys took away from it. Oh, slide. You know, no one sites at all. We're here to tell you what we've heard and what we've collected of data and HCI has done a ton of work to collect this information too and what we hear from you and we keep learning about what's the different models you guys are doing, but consider your goals and your business model need. We talk a lot about too, if you create a business plan make sure you revisit it on a pretty regular basis of here's what we're seeing and here's what it's looking like. And then, you know, figure out how each team member ties in what their productivity standards are and how they're helping you meet your mission. So thank you. Thank you both for that excellent session. There's so much good information. Again, please, everyone I see you using the chat. These will be saved. All of these resources that are being shared all of the tips that you're sharing with one another will be turned into a little knowledge base from this workshop. And we'll commit to having that up to you when we do recordings in a couple of weeks. I'll send out a notice when they are available. We're gonna move into our next session and we're gonna talk about the data. So we'll move into our next session. And that is where we get into procedural demonstrations. Before we do, does anybody have any questions for Amanda or Brianna about productivity and staffing? Okay, if something occurs to you, please do put it in the chat because they will be checking ahead of our next session, I want to let you know that there will be automatic assignments for the breakout rooms, you will be put in small groups. It will be 30 minutes each for those of you cycling through a knee procedure, trach, and G2 with faculty. There is an opportunity as well to be in the practice management room with Amanda and Brianna. Julianne and Patrick, we have you pre-sorted into there, but you can self-select to go ahead and join after you all chat a while. You can pop yourself into any of the procedure rooms as well. I've left that open to participants. And who is going to queue us up for our procedures? Melissa, would you like to chime in here? Sure. Okay, so what you all are about to participate in are some video-based breakouts. Again, when we do this in person, you know, the learners have an opportunity to work with simulators and actually try the procedures. And obviously, we're restricted through the virtual delivery of this workshop, but we've done kind of the next best thing, which is produce some really high-quality close-up video paired with a step-by-step guide that's available in your workbook with some photos. And then our expert faculty will drive you through that. So, Janine, I do want to make sure we've got all of our faculty on. I see, okay, I see Tom. And of course, we've got Paul Chang and Michael Kingen. And these are our learning objectives. You're going to be going through three rotations, again, 30 minutes each, a trach tube exchange, G-tube removal and replacement, and a joint injection, joint aspiration and injection. And then at the end of it, we will all come back together and Brianna will walk us through how to code and document for all of those procedures we've just learned. And again, these are really helpful procedures for you to be able to know how to do for your patients. It can sometimes save them a trip to the hospital. You know, it can relieve burden for the family to have to transport their loved one to another location to have these procedures done. So, you're doing a great service and there is a way to earn some revenue from it as well. So, why don't we just, what's the next slide, Janine? Or do we just go on to our next slide? I'll bring us to the next slide. First, I do want to say, again, that you can self-select if for some reason you do get kicked, you have a connection issue, you should be able to be, I'll be in the main room supporting Dr. Cornwell. So, I will see you, I will readmit you, but you will end up in Maine. So, you will have to self-select to go to either G-Tube or Trach if that's where you were. Same with practice management. And I know that's a lot of logistics to hold in your head, but we're here to support you. And we're going to make this work together because that's what we do amid this pandemic and everything else. So, we're going to make this a great experience for you all. We are available via chat as well. And with that, I'm going to open all the rooms. You will see that you've been sorted. And we will move you through again in 30-minute increments. Each session is 35 minutes in total, but that just allows us a little time to move you on to the next. And it gives our faculty time to close their talk for each of you. So, we've built in a little bit of squish time. So, here we go. Can people hear me? I don't know when we start. Here, you're good. Yes, we can hear you and I am here to support you. So you have your model, so I don't need to run our video or would you like me to? Oh, no, no, the video is hugely important. Okay, great. I just wanted to make sure. I will grab that link right now and get us queued up. Let me know when you're ready. Oh, yeah. And so just basically, the video is really our leg here. And this is one of the unfortunate things about COVID because it really is just so wonderful when you guys can come live to these sessions and actually practice doing G-tubes, practice doing trachs, practice doing knee injections because you can do it as much as you want. But the video is really what goes through step by step. There is a great instruction sheet in all your handouts in terms of just going through step by step. There's actually pictures along the way. And then another thing that you'll hear about in the video is we have a patient instruction for both the pre and the post steroid injection, information you have to get to make sure it has actually questions for patients. And so this is just a great procedural form to use because it actually can serve as both an educational tool, again, both pre and post that ask questions like, are you allergic to steroids or local anesthetics? Have you been recently ill? Do you have diabetes? Hugely important for a steroid injection that you'll hear about in the video. Do you have a bleeding disorder? And so if there's things that maybe we forgot, it's very standardized. And then also what I've actually done with this is actually put a place for the patient to sign it so that I can actually scan it into the chart. We just do that with our phone. And so it can actually act as a patient consent because it goes through all the risks and benefits and also shows in terms of the patient instructions. And you'll hear about this in the video. But if you can, Janine, tee up the video. I think it's about 10 minutes to kind of show you. And Janine, do you know, do they have access to this video after the conference? I don't know how it is on YouTube or anything like that. I put you on the spot. Are you there? Janine? Can others hear me? Yes, I'm hearing nods. Janine, are you there? And I can take you through the procedure with this, but let me just let them know that I lost. Dana, I see your picture. Are you on Dana? I am. What can I help you with? Um, yeah, Janine is supposed to be teeing up the video. And let me she's not responding. Okay, I'll grab her right now. Let me Let me just see quickly, because I actually have it, but I was told I didn't need to, I apologize. Which video are you looking for? Well, just the knee injection video. She was, I specifically asked her, am I to do it or is she to do it? And she said she had it and would do it. Yeah, because I don't know, I don't know where she went. She was just on and asked if we wanted it to be teed up. Tom, do you need to just give her a minute? She was booted out and just give her a moment and she'll give you the video. Yeah, and let me just, okay, that sounds good. Let me just see. Just a second. Hello, I am Dr. Thomas Cornwell, Executive Chairman of the Home Centered Care Institute. Today, I will demonstrate how to aspirate. So you can probably hear that. Now let me turn it off. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective. Were you guys able to hear that? Yep. Okay, yeah. Hello, I am Dr. Thomas Cornwell, Executive Chairman of the Home Centered Care Institute. Today, I will demonstrate how to aspirate and inject the knee joint. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during your visit. This of course applies to the current COVID-19 pandemic. You'll want to first gather your equipment and supplies for the procedure as listed in the course materials. ♪♪♪ I will now walk you through the procedure step by step. Before starting, counsel the patient and caregivers on the risks and benefits of the procedure. A consistent and thorough way of doing this is by having the patient read HCCI's pre and post-steroid injection instructions or by going over it with them. This useful HCCI patient resource describes the procedure, the risk and the benefits, the contraindications, and the post-procedure instructions. It can also serve as the written consent by having the patient sign it. Verbal or written patient consent needs to be documented in the medical record. A patient safety check should be done prior to any procedure to verify patient identity, the correct injection point, and the medication being used. I always have someone verify any injection I give, whether it be a steroid shot or a flu shot. This is often done by my medical assistant, but if alone, I will have the patient or caregiver read the label to verify. Now let's wash our hands and get started. Injections can be given lateral or medial and superior, mid patella with the leg straight or inferior with the knee bent at a 90 degree angle. We are going to demonstrate the most commonly used superolateral approach. It is preferred because, as you can see in the diagram, it provides easy access under the quadriceps tendon and patella, it is good for both aspiration and injection, and there are no other structures in the area to be concerned about. For the superolateral approach, the patient should be in the supine position with the knee in a slightly flexed position at about 15 degrees. You can use a roll-up towel under the knee and cover with a disposable under pad to prevent stains. After putting your gloves on, mark the injection site one centimeter above and one centimeter lateral to the patella. You can do this by imprinting the pen in the area. Clean the injection site with three povidine iodine or chlorhexidine swabs, applying each swab in a circular manner, starting at the injection site and circling out. Wait a minimum of two minutes. Wipe the medication vials' diaphragms with alcohol. Draw up a syringe of corticosteroid and 4-6 mLs of an anesthetic agent. If local anesthetic is desired, you can apply 3-4 mLs of an anesthetic agent to the injection site and along the anticipated needle trajectory. Alternatively, ethyl chloride spray can be applied from 6 inches away for 5-6 seconds. For aspiration, use a 10 mL empty syringe with an 18 or 20 gauge 1.5 inch needle. A 20 or 30 mL syringe can be used for larger effusions. Insert the needle, bevel up at a 45 degree angle distally and inferiorly under the patella and aspirate effusion if present. Compression of the opposite side of the joint may aid arthrocentesis. Once the syringe is filled, a hemostat can be placed on the hub of the needle to disconnect the aspiration syringe, then connect the corticosteroid syringe and inject into the synovial space. If no effusion is present that needs aspiration, the corticosteroid filled syringe with a 25 gauge 1.5 inch needle using the same technique can be done. When the aspiration injection is complete, withdraw the needle and apply pressure to the site with a 2x2 gauze. Clean the prep area with alcohol wipes and cover the site with an adhesive bandage. I now have my fluid in here. You have to check with your lab, but you want to send the fluid for gram stain and culture RBC and WBC and differential and for crystals. You need to check with your lab which tubes they like. They usually want a sodium heparin green or a lavender tube for doing the test and you can use either a urine cup for the gram stain and culture or you can actually just send them the syringe without the needle on it. Depending on the cause of the knee pain, the local anesthetic should provide immediate pain relief which confirms the steroid was placed in the correct area. Prior to performing a knee aspiration or injection, you need to determine if there are any contraindications. Contraindications include infections such as bacteremia, if a septic effusion is suspected, overlying cellulitis or osteomyelitis. A severe coagulopathy is a contraindication, but being on warfarin with a therapeutic INR is not a contraindication. Injections also appear to be safe for patients taking direct-acting oral anticoagulants. A retrospective study of 1,050 joint injections at Mayo Clinic with patients on direct-acting oral anticoagulants did not have one bleeding complication. Other contraindications include having an osteochondral fracture, impending joint replacement surgery scheduled within days, a prosthetic joint, or poorly controlled diabetes. Patients should also not have more than three injections per year. Additional complications include rare iatrogenic infections occurring in only 1 in 14 to 77,000 injections. Hyperglycemia can occur especially with patients on insulin, and patients should be told to monitor their sugars closely for one week. Steroid flare occurs in 2 to 10% of injections and affects women more than men. It is caused by a steroid crystal-induced inflammatory synovitis. To treat, the patient can apply ice for 15 minutes every 3 to 4 hours and take acetaminophen or ibuprofen for pain. The steroid flare typically resolves within 1 to 2 days. Patients should call if not better in 2 days. Finally, facial flushing has been reported in 1 to 30% of patients. One of the things that I really like about this model is the needle is connected to a box here so that when I go in, it tells me. And this way I can have you do it 10, 20, 30 times if you'd like so that you really know when you're in the right spot. So then you feel comfortable when you actually do it on your first patient. I hope your participation in this video simulation will help you gain confidence on how to safely perform a knee aspiration and injection in the home. When the injection is successful at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also being a blessing for the caregivers. Thank you for watching. Hi, and so do you guys have me on your main part of the screen? Am I big? Okay, good. And so usually when you're talking. And so just, you know, a couple things you can see, I can see the whole, what I will normally do for any procedure is I will go through the procedure in my head before I do it because especially when I'm alone, if you're missing something, it's very difficult to, you know, get it when you're gloved and everything like that. I'll also put it in the order of how I am going to use it and then just kind of walk myself through it. As you heard that this is a towel, my artificial knee here doesn't flex, but, you know, I, you will usually roll up some type of towel. Sometimes I'll use a little pillow in the house, but always put a chuck over it so that you don't get any blood. This is usually a bloodless procedure. I did say that, that, you know, you saw the picture of the knee and it really is a large area, so parolateral, and then you want to get under the patella, but it's a large area just to kind of show you that this is a picture of a knee effusion. And can you see, I mean, this, it's huge, but you can see above the patella, it's just, it's a huge area that you have the joint capsule. And so, and so I'm actually, well, I'm not going to put on my gloves. I act like I put on gloves, but there really is no need for our thing here. We've got our three beta dynes that again, you start in the middle and you work out, you guys have all learned antiseptic technique. And what I said with the, with that pen, what I'll actually do is use some type of like ballpoint pen, but I won't, I won't use the pen part. It's that little circle that you just kind of imprint a little bit with the pen. And it just puts this little circle on that you can then see in terms of marking your landmarks, which is again, is one centimeter above, and this is all in your handout and one centimeter below the patella. So right here. And then, and then you just take your needle. I do have a 20 cc syringe here. And so if this patient had a significant effusion, I would start with a larger syringe to do the aspiration. You already have your, generally I would use one ml of Kenalog Triamcinolone, 40 milligrams per ml. You can use 20 or 40. I would generally for a larger joint use 40 with six or seven mls of 1% lidocaine, obviously without epi. And, and, and then, so in a case like this, you might even use a 60 cc syringe. I will tell you that there was a study, I think that came out in about 2015 from JAMA that, that really show giving more than three injections a year is really not in our patients interest in terms of, of the joint actually deteriorating quicker. This is a procedure I don't do very often because it actually, I mean, it doesn't, it doesn't make the joint better. It just is for symptomatic treatment to try to decrease the inflammation. I do have some patients that really get weeks worth of benefit, but the majority it's only days of, of, of benefit. And in that case, you know, and I talked to them about this, this whole goals of care that we want to improve their quality of life. But if it really is not, if it's only helping for a couple of days, we would say that the harm outweighs the benefit. And so most of the patients that I did with, with this were not ones where I recommended it. It were one, it was patients that had these in the past that, that asked for them to continue. Okay. And so I've done my, my betadine. I have my, my gauze here. I have my, my tubes for the crystals that I have checked with the lab. And even I learned the hard way I was once told, and you only, you only have to have this happen once that what I needed was a green top tube. Well, just let you know, because most of you probably don't know. I didn't know that green top tubes can be either lithium heparin or sodium heparin. And for the test, this lab needed sodium heparin. And so literally the lithium have to do in this procedure and taking out, literally, they couldn't do the test because of that slight difference in terms of the, the tubes, even though they're both identical green top tubes. And so, so I've got my, my lidocaine in here. I'm, I'm marking my, my spots. I've got my gloves on. I already have, have the point here. And then you have the bevel up so that if you do hit the patella, it kind of gets kind of knocked down. It's not a big deal if you, if you hit the bone at all. And so I'm going in here. And there you go. Now you hear it. Okay. So it's, it's, it's quite it really is a quite a simple procedure. Again, I showed you, let me take here. And then when you go to take it out, I have my gauze already. Just pressure. If you, if again, if you are switching tubes, you know, I, I'll usually use a clamp and then just screw it off and then take my, so in this case it would be, I've aspirated. This is now full of joint fluid. I then take my steroid and I'll screw it in and then I'll inject the steroid, take my gauze, put pressure, and then just pull it out. Okay. You know, virtually all, you know, needles now are, have safety caps. This demonstration does not. And so there's my, my cap. Most of the time when I would send this for gram stain or culture, I would just take the needle out. It's a lure lock. And so I would just take the lure lock out and just put a cap in there and, and then send the fluid in the tube for gram stain and culture. The great majority, the great majority of injections, it was for osteoarthritis, meaning that there wasn't an effusion. And so rarely would I ever send. And then obviously I would have a Band-Aid, my Band-Aid, which I moved in the last second. And so, and normally I would even have these partly undone so that I could just, you know, quickly, you know, put it on there after the procedure. Okay. And so let me put this back. And then just, we can talk some, if you guys have any questions. And again, the great thing about this, this model is again, you can practice and hopefully at some point you might be able to get an opportunity. Is this something that any of you are already, are already doing in, in the home? Again, it really wouldn't come up very often. I think feeding tubes and trachs, which again, we're not, we're not super common. We're much more common in our practice than a knee injection. But even though they're not very common, they frequently, you know, prevent patients from having to go to the hospital for something that can be simply done in the home. So are any of you guys doing any knee injections or do you have any questions about this? Yeah, I do a fair number of knee and actually shoulder injections. I guess my question is, I don't know if you've done Hyalgan or any of those other, I didn't know if there's any evidence in this population to do that kind of injection. You know, yeah, it really is poor. It really is poor. And so what he's talking about is hyaluronidase, which is kind of like artificial cartilage. And so the whole problem with, you know, osteoarthritis is that you've worn down the cartilage. And so what you're doing is you're trying to put in kind of like a shock absorber in their, in their knee. And I just really, because most of our patients have quite advanced osteoarthritis, that really the definitive treatment is knee replacement, that most of them are too frail or have too poor a prognosis to be realistic surgical candidates. I also did shoulder injections. The reason why we actually don't teach them is because even in the best of hands, when they research it, oftentimes the target, which with the knee is so easy, the target is missed in general, when they study it 40% of the time it's missed. And so ideally those are done under ultrasound guidance. I don't know if you do that, but generally that's not done in the home. One of the, one of the things I didn't say that's really nice about this is that I said in the video is, is, is that it is something where you do give your patient instant relief because of the lidocaine, the pain is 100% resolved after the injection. And they think you're kind of like a miracle worker. And what, what is more important to us as clinicians is not that you gave them instant relief because you know, it's going to be very temporary for the, for the lidocaine about six hours, max eight hours usually. But but it tells you you, if the lidocaine completely took away the pain, it means you got the injection where the pain is, which means you got the steroid in the area that you want it. So it kind of does two things. The steroid, if you gave it on its own would cause a burning. And so we give the lidocaine for two reasons to prevent them from having discomfort from the injection, but to also tell us that we got it into the right place. I did mention on the video, I have seen blood sugars that were very well controlled and it's mostly diabetics on insulin. I have seen diabetics very well controlled that shot up into the 400s and this can be up to a week. And so it's not necessarily right away. So you really need them to follow their sugars a little more closely. Was that you, Tom, that did that? I'm looking at the names. I know it was a guy. Was that you, Tom, that was doing the injections? And have you found that that sugars just can skyrocket in certain patients? Yeah. Yeah. And you know, it's really, it's unpredictable who except with the exception of the uncontrolled diabetic who the sugar skyrocketed. But yeah, I do find that. Then the other thing rarely is some blood pressures as well. Sometimes I find that those spike. Oh, I haven't. Yeah. I haven't heard. And, you know, the nice thing, you know, and so one of the things is, you know, I have these percentages in here of like, you know, of like, or actually, actually they're not in. So they're in your things, but, you know, the percentage of the steroid flare, and I don't think I've ever in time, you can help me. I don't think I've ever been called with a patient with steroid flare, even though it happens like, you know, around 10%. And, and, but I think the reason why is because this instruction sheet tells them there's a good chance this is going to happen. If it happens, you know, we prefer Tylenol and all of our elderly patients were referred. We prefer Tylenol. But if, you know, you know, Advil helps them a lot more, I'm okay with them, you know, taking a couple, put ice on it, you know, four times a day. And maybe it's because we're being proactive to tell them what to do for it. Maybe it is happening, but I just don't hear about it because I've given anticipatory guidance to my patient, but I've never, I have literally never had a call after an injection of any, any issue. And I don't know if that's been your experience also, Tom. No, no, I totally agree. I've actually never seen that complication. It's just, yeah, but it's in all the literature and, and actually this, this facial flushing is something I hadn't even heard of, but it really, in some studies, it is, it is very prevalent, especially in, in women. And it, and, and it makes some sense in terms of the physiology for those for the, just out of curiosity for those, you know, are you guys doing things like G-tube changes or trach changes or knee injections, you know, besides Tom and because especially I think the G-tube changes are super simple. This pays, I believe about $60 for doing a major joint injection. And so even in terms of the time and stuff like that like advanced care planning, you know, actually it probably takes as long as advanced care planning and just from a dollar cents I think patients get more out of that as well as you get paid a little more about $85 G-tube changes are like $227 and they're so easy. They're easier than a Foley change. And yet they can be so wonderful for our patients. And, and one of the things I don't know if they're going to teach this, but one of the things that I have done for decades is teach my family members how to do the G-tube changes because when they accidentally fall out is often not during business hours. And so I actually teach them. I don't tell them just replace it. If it falls out, I tell them to call me and we'll, we'll walk through it. But I've had a number of families. And if you go to go to YouTube and Google like how to change a G-tube, they're all moms how to do it with their infant kids showing other moms how to do this. And so it is something that I think can really be one of the ways that we can help our patients to avoid the hospital and all that brings. But are we at time? I didn't have one more minute, by the way, sorry about the beginning guys. I was with you the whole time. Zoom just didn't like that. I was doing too many things at once. So if there is a delay for the next one, Dr. Cornwell, I'm here. It just Zoom was not happy that I was trying to do five things at the same time and it forced me into a sequence, but we're going to bring everybody back into the main room. It's going to automatically shut in this room and just another moment. And then we're going to resort you if for some reason, you know, you end up in a room like you're in practice management and you were meant to be in a procedure room. We'll get you hooked up again. You can actually move yourself from room to room or reach out to me in the chat and we will get you in the right place. Okay. So take a minute. If you have any, we have, again, we're counting down 60 more seconds, use the chat and speak with Dr. Cornwell. Of course, he's going to be available later. We will scan back through if something occurs to you. And you do have those resources in your workbook for all three of these procedures. Okay. Any questions? How long do you generally advise people to wait between injections? I know you said no more than three per year, but the relief is so short-lived. I imagine people like ask for another one. Three months. That's a great question. So three months. But if you, you know, you can't do three months, three months, you know, four times. You really have to. And I do that proactively because if they really do get benefit and it lasts like a month and they want it sooner to really make it clear that while this makes them feel better, it really is not the best thing for the joint and can actually make things progress more rapidly in terms of their arthritis over time, in terms of damage to the knee. Got it. Right. Yeah. But like you said, some patients, you know, at the end of life, they really just want. I know. And that's a great point. Actually, I'm sorry. It's going to interrupt you guys, but wait, it's going to close out the other rooms. Everybody will join. You guys can still go ahead and keep talking because we're in Maine. I'm sorry. So everybody's going to join us. Don't be alarmed. We're going to resort. Please continue. And it really is a great question because I'll tell you if push came to shove and I had like a hospice patient that just wanted one more a month later. Absolutely. That's a great point in terms of goals of care. They know the risk. You know the risk, but you think the benefit of a pain control during this, you know, the last months, I would absolutely do it. That's a great point. Thank you. Okay. Everybody's going to start joining us in the main room, and then we're going to do a resort. I encourage you while we are sorting people, it will take just a moment because it is a manual process to go ahead and utilize the chat to talk to one another. Or while we're in Maine, you can go ahead and use your camera to chat, but you might just get cut off. That's my only only caveat. So we will put everybody back in. We'll be switching out momentarily. Bye. Somebody play some music, tell some jokes. It's going to take about two minutes. Where is that house call man video, Melissa? We need Dr. Chang's little, you know what I'm talking about. I don't know why I can never think of the name of it. Racket man. All right. I'm going to pull that up for the next time. I'll have that ready. I actually have some magic tricks upstairs, but I think it would take time. Yeah. I was sharing with Janine that this is the most stressful part of the whole two days for us. You all have to know that. We ask for a little grace in trying to move people virtually through breakouts. I've been teaching during the year with medical students on this, and thank goodness, they have a fourth year who's supposed to be the tech person because I still have not mastered the breakout rooms. I don't envy anybody who has to set up the breakout rooms. Yeah. Yeah. It's a little tricky. Well, there was a little pail of care and empathy. That was very good. You guys are the best. Seriously. I thank you all. One more minute. Okay, we're going to start our sort again. If for some reason you accidentally end up in the wrong room, again, you should be able to switch yourself. Paul's not looking very good. Paul Chang on this, on his picture, he's looking, he's looking not so good. Where is he? Oh, Paul. Somebody help him. Someone shake him. Is he responsive? We're going to send people in to help him right now. I know some awesome clinicians. Here we go. And those of you who are still in the main room with Dr. Cornwell and I, you are going to be taken through the knee procedure. I'm going to pull that up and share my screen in a moment. Do you want to just start with the video, Janine, this time just so that we don't, oh, there you go. Yep. Let's just do that. Yep. I got you. Here we go. Hello. I am Dr. Thomas Cornwell, Executive Chairman of the Home Center Care Institute. Today I will demonstrate how to aspirate and inject the knee joint. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during your visit. This of course applies to the current COVID-19 pandemic. You want to first gather your equipment and supplies for the procedure as listed in the course materials. ♪ I will now walk you through the procedure step by step. Before starting, counsel the patient and caregivers on the risks and benefits of the procedure. A consistent and thorough way of doing this is by having the patient read HCCI's pre and post steroid injection instructions or by going over it with them. This useful HCCI patient resource describes the procedure, the risk and the benefits, the contraindications, and the post procedure instructions. It can also serve as the written consent by having the patient sign it. Verbal or written patient consent needs to be documented in the medical record. A patient safety check should be done prior to any procedure to verify patient identity, the correct injection point, and the medication being used. I always have someone verify any injection I give, whether it be a steroid shot or a flu shot. This is often done by my medical assistant, but if alone, I will have the patient or caregiver read the label to verify. Now let's wash our hands and get started. Injections can be given lateral or medial and superior, mid patella with the legs straight or inferior with the knee bent at a 90 degree angle. We are going to demonstrate the most commonly used superolateral approach. It is preferred because, as you can see in the diagram, it provides easy access under the quadriceps tendon and patella, it is good for both aspiration and injection, and there are no other structures in the area to be concerned about. For the superolateral approach, the patient should be in the supine position with the knee in a slightly flexed position at about 15 degrees. You can use a roll-up towel under the knee and cover with a disposable under pad to prevent stains. After putting your gloves on, mark the injection site 1 centimeter above and 1 centimeter lateral to the patella. You can do this by imprinting the pen in the area. Line the injection site with three povidine iodine or chlorhexidine swabs, applying each swab in a circular manner, starting at the injection site and circling out. Wait a minimum of 2 minutes. Wipe the medication vials, diaphragms with alcohol. Draw up a syringe of corticosteroid and 4-6 mLs of an anesthetic agent. If local anesthetic is desired, you can apply 3-4 mLs of an anesthetic agent to the injection site and along the anticipated needle trajectory. Alternatively, ethyl chloride spray can be applied from 6 inches away for 5-6 seconds. For aspiration, use a 10 mL empty syringe with an 18 or 20 gauge 1.5 inch needle. A 20 or 30 mL syringe can be used for larger effusions. Insert the needle, bevel up at a 45 degree angle distally and inferiorly under the patella and aspirate effusion if present. Compression of the opposite side of the joint may aid arthrocentesis. Once the syringe is filled, a hemostat can be placed on the hub of the needle to disconnect the aspiration syringe then connect the corticosteroid syringe and inject into the synovial space. If no effusion is present that needs aspiration, the corticosteroid filled syringe with a 25 gauge 1.5 inch needle using the same technique can be done. When the aspiration injection is complete, withdraw the needle and apply pressure to the site with a 2x2 gauze. Clean the prep area with alcohol wipes and cover the site with an adhesive bandage. I now have my fluid in here. You have to check with your lab, but you want to send the fluid for gram stain and culture, RBC and WBC and differential and for crystals. You need to check with your lab which tubes they like. They usually want a sodium heparin green or a lavender tube for doing the test and you can use either a urine cup for the gram stain and culture or you can actually just send them the syringe without the needle on it. Depending on the cause of the knee pain, the local anesthetic should provide immediate pain relief which confirms the steroid was placed in the correct area. Prior to performing a knee aspiration or injection, you need to determine if there are any contraindications. Contraindications include infections such as bacteremia, if a septic effusion is suspected, overlying cellulitis or osteomyelitis. A severe coagulopathy is a contraindication, but being on warfarin with a therapeutic INR is not a contraindication. Injections also appear to be safe for patients taking direct acting oral anticoagulants. A retrospective study of 1,050 joint injections at Mayo Clinic with patients on direct acting oral anticoagulants did not have one bleeding complication. Other contraindications include having an osteochondral fracture, impending joint replacement surgery scheduled within days, a prosthetic joint or poorly controlled diabetes. Patients should also not have more than three injections per year. Potential complications include rare iatrogenic infections occurring in only 1 in 14 to 77,000 injections. Hyperglycemia can occur especially with patients on insulin and patients should be told to monitor their sugars closely for one week. Steroid flare occurs in 2 to 10% of injections and affects women more than men. It is caused by a steroid crystal-induced inflammatory synovitis. To treat, the patient can apply ice for 15 minutes every 3 to 4 hours and take acetaminophen or ibuprofen for pain. The steroid flare typically resolves within 1 to 2 days. Patients should call if not better in 2 days. Finally, facial flushing has been reported in 1 to 30% of patients. One of the things that I really like about this model is the needle is connected to a box here so that when I go in, it tells me. And this way I can have you do it 10, 20, 30 times if you'd like so that you really know when you're in the right spot. So then you feel comfortable when you actually do it on your first patient. I hope your participation in this video simulation will help you gain confidence on how to safely perform a knee aspiration and injection in the home. When the injection is successful at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also being a blessing for the caregivers. Thank you for watching. All right. Are we getting rid of the screen? There we go. And so we have a few on here, just looks like three. And so Kaitlin or Laura, and there might be a third person, but it might just be the two of you. Have you done any knee injections or anything like that or, and there's one more, or are you interested in, and Maria's on there now, and I don't know the name of the other person, but have any of you done any knee injections ever? In my past life, I worked as a family physician. And so I did a lot of this type of work, but not a long time ago. So it's all coming back to me, explaining, because I think it's probably been gosh, 12, 15 years. Right. And I, and I really think the video is actually quite well done, but the, the, the nice thing is that your handout really is good. It not only, you know, kind of goes through it. There are, you know, the video, at least my, when I was watching it, the, sometimes the audio and the, and the, the video was a little off, but, but this really goes through everything. And so all the thing about, you know, you do it with a 10 CC syringe and a one and a half gauge, dah, dah, dah, you know, there's no way you can remember that just from a video, but everything is in here. The other thing that is just really wonderful is, and we spent some time on this, is the patient instructions, both pre and post. And the reason is this can act as so many different things. It is, it can be used as a patient consent because it goes through all the risks and benefits. And it even asks them things like, you know, so we try to remember to ask all these things, but it actually has the questions that we should ask things like, you know, are they allergic to steroids or local anesthetics? Have they been recently ill? Do they have diabetes? Have they had a recent skin infection? Do they have a bleeding disorder? Do they have any surgical metal work, you know, you know, in, in, in their joint? Have they ever experienced fainting during a previous medical procedure? And so that's just stuff that is really nice for them to read through it. And it also lists the risks and benefits. And so it really is, I actually on this form have a place for them to sign and actually use it as patient consent and, and then just take a picture of it and we can send it into our electronic medical records. So this is a great resource for patients. I was also saying that it's interesting. And there was someone on the last video of the last breakout that did quite a few of these. And neither of us have like, I've never been called with a steroid flare reaction. So you hear it's like, you know, generally 10%, some studies show less, some studies show more. But I think part of it is this, this tells them what a steroid flare is and tells them exactly what to do for it. So I don't know if it's just good anticipatory guidance that we tell them what to look for. And if it happens, here's, you know, what to do. But if you know, there's problems, always give us a call. But I literally have never gotten a call after a steroid injection. I would probably do about one a month. And so this was not something very common. The issue with it is, is there was a study that came out, I think it was about 2015, but it was in the Journal of the American Medical Association that really showed doing more than three a year was damaging to the knee, and that we should really avoid doing more than three. An interesting question was, what if someone's on hospice, and I, if they're on hospice, may want another one in a month, because it gave them, you know, significant relief, and it lasted at least a few weeks. So there's a whole goals of care conversations that we want them to know the risk benefit. But let me just take you through it. And so one of the things that I always do, when I, when I do a procedure is, we do have our towel here, my, my model here does not, does not flex. And so I can't use the towel. Again, I showed this picture in the, that it really is a large space, unlike a shoulder, we don't teach shoulder injections, I do those. But even in the best of hands to do them blindly, you missed the, you missed the mark 40% of the time. And so it's not something that at least I feel comfortable recommending providers to do. People that do a lot of them oftentimes do it under ultrasound guidance. And the reason I show you this effusion, this is a patient that if I were going to do a, an aspiration, I would probably use a 60 cc, this is a huge effusion, but it's actually not to that point. But the point is, you can see just how high up this joint capsule goes, it goes way above the knee. And so again, it really is a very liberal place for us to get into the knee. As I'm doing any procedure, whether it be a G tube or a trach tube change, I will always go through the procedure in my head with the, making sure I have everything I need here. Usually in the, always in the order of what I'm going to pick up first. And then, so at the end, I would put my joint fluid into the tubes. And so they're at the end, my Band-Aid is at the end here, but at the beginning is the povidine iodine that I'm going to use. I don't think I say this, but usually I'll do the povidine iodine before setting everything else up, because you are supposed to wait a minimum of two minutes for it to kill any bacteria that are on the, that are on the, here's my gloves here, I'm actually not going to put them on. And then again, your landmarks are a centimeter above the patella, and in our morbidly obese patients, that can be difficult. Dr. Chang actually on like a five or 600 pound patient once actually went to our ER and got a spinal needle, which is three and a half inches long in order to make sure that we got into the joint. But so it's one centimeter above, one centimeter below. And what I talked about the pen was, in terms of imprinting, is I actually don't put the, I don't, I don't put the pen out. I just have it, the pen's actually on the inside, it's that circle, and I'll just twirl it and make a little round mark from the pen. I just have found that to be helpful. There's also, you know, markers that are meant for this that you can actually get, but I've never used that. And so one centimeter above, one centimeter below. And if you hit bone, it's bevel up. So in case you do hit it, it'll kind of be knocked, it'll kind of go down. Can you hear it? And so what's nice about this is, again, and you can practice this over and over again if, you know, once, you know, COVID allows you to do it, but you just go kind of under the patella. And so it really is a relatively simple procedure. Again, unlike the shoulder, which is just a more difficult place to hit, it is really under ultrasound guidance for the shoulder that is the best. And so here, let me, one more time, there I hit, there we go, there I actually saw that I hit back and went in. And so then, you know, put the gauze on. If you, I do have a 20 cc syringe here, if it was a large effusion. If I was, let's just say I was going to aspirate, the first needle obviously you put in is going to be the aspirate. I would use a clamp, just take that off, take my other tube and put it on that has a steroid in it. And then I would inject, you know, and then when I'm done, put a little pressure on here. All needles now have safety caps, but this demo does not. And then oftentimes I just, without the needle, but with a cap, will send the tube itself to the lab for Gram-spanning culture. I would put some of it into whatever the lab requires. It is different. I even got burned once that I was told a green top tube, and I don't know how many of you know, but even a green, the identical green top tube can be lithium or sodium heparin, and I needed sodium heparin. And the green tube we had in the office happened to be a lithium heparin, but I only found that out after the lab told me I sent the wrong tube, and your heart sinks after doing this. And then obviously you have your Band-Aid. I usually don't use gauze, and I'll just put the Band-Aid on there. And then to end, what I would do is I would take the patient, you know, beforehand, you know, obviously you're doing an exam. I would do range of motion, the painful area. And because this is so easy, I don't think I've ever not hit the right spot. And the reason why we use the lidocaine is for two reasons. I'm actually going to move this back so you can see me, I can see you. But you use the anesthetic for two reasons. One is because if you don't use it, the steroid actually burns when you inject it. And so it's for comfort. The other reason why you use it is because if the pain completely goes away, you know you've got the anesthetic in the right spot. And if you got the anesthetic in the right spot, you got the steroid in the right spot. As I said, this lists not only things that you need to know ahead of the procedure, if the patient has any problems that we need to know about, it also has the instructions. This is in your handout in terms of post-procedure and things that they should be on the lookout for. And I think that's all I have to say. Are there any questions about the procedure? It pays about $60. And so, you know, the last couple I was even saying, advanced care planning, you know, pays $85. It takes about the same amount of time. And it really, again, it's symptomatic. It's actually, especially if you do them more frequently, can cause harm to the knee. But in our elderly patients that generally have a low life expectancy, oftentimes we are concerned more about the comfort than about the, you know, maybe what's best physiologically for the knee. And the last thing I'll say is I would not do this very often, once a month at the most. And there was a study that came out of JAMA, I don't think I said this on the group, that, you know, you need to avoid doing over three a year. And because of the damage done to the knee, obviously with goals of care conversations, you can always talk to your patients about that. And I think that's what I have to say. Any questions? For those of you who have done it, is this a good refresher? And for those who haven't done it, and this could go either way, it's like, yeah, you know, that looks, you know, not too difficult, but it's not something I plan on doing or something. No, I think I might give that a try. Any thoughts on your guys' parts? Yes. So I had one question around, how often do you find that the super lateral approach, you run into some difficulty with the bone structures as far as arthritis, osteophytes or things like that? Right. So, again, where that, and I just haven't done mid patella, but I would think, you know, the mid patella, like, you know, where the femur and the tibia articulate, you know, that's where you get the osteophytes, you know, there's no, there's no join up here. And it really is a, or over here, it really is a very forgiving, a very forgiving. And so rarely, sometimes if you come in too close to the patella, sometimes you can't get underneath it. And so that I've had a problem, but what I just had to have done is pull out completely because you know, you hit it, you go down, but you just can't get underneath it because you're too close to it. So you have to come out, go down a little lower and then back in. And then, and then I haven't had a problem. I just wondered, because sometimes I do an intramedial, I'll come in at the medial aspect and depending on what the burden of, like, if it's severe arthritis in the lateral compartments and I just, I don't know, sometimes I had more difficulty, I guess, but that, thank you for the refresher. And for the inferior, the knee has to be bent, has to be bent, it has to be flexed at a 90 degree angle. And so that's one thing, pest answering, bursitis, I will sometimes, but that's just kind of superficial. I'll give it a little injection there, but that's not into the joint. You think it's a bursitis there. So any other questions? We have seven minutes left in this room. While you're thinking of your questions, I'll just let you know, we are going to be adding some of these procedure videos to the learning hub. There are e-learning courses in there as well, but for the attendees of this workshop, we're going to go ahead and add those video links to your resources. We'll remind you of how to get to those. The procedure guides that have the corresponding pictures, those are in your workbooks as well. So we will make sure that you have what you need in terms of a refresher for any of these procedures if they are new to you. With that, do you have any questions for Dr. Cornwell while we wrap up? Or anything to share even, your experiences, how it's gone for you, if you have done this before? Or are you changing G-tubes or trachs in the home at all? G-tubes, trachs can be a little nervy if they're on a ventilator, but I've been doing it for 25 years. I never once had a problem. But G-tubes are so super simple. And can be just such a blessing. And they pay $227. And so it's one of those things that the procedure just pays so much and it doesn't take much mental ability. One of the things I said in the last group is if you went online for a video on changing a G-tube, it's all moms showing other moms. So it's not even like doctors or like academic institutions, it's moms showing other moms how do you change these button G-tubes on these infants that required tube feedings. And to that point, I always teach my families how to change G-tubes because when they accidentally fall out, it's usually not during business hours. And so that way, I don't have them just automatically change it. But we do make sure that they have the syringes, everything they need, the KY jelly to change it at home. And we have them call us and then we take them through it if they're comfortable. And I've done that again after doing 33,000 house calls over 20 some years. That has definitely come up. And it's just a wonderful way to prevent a real needless emergency room visit. And even it's amazing in the emergency room because they usually call a gastroenterologist if you've done that. And sometimes there's a delay. And the hole actually closes because they wait for hours. But it is so wonderful to do the G-tube changes. I think more so than the knee injections. And there's an understanding if people are a little uncomfortable doing trach changes in the home. I missed your description of the G-tube changes in the last session because I was on a work meeting. Did they do a video? Yes. Absolutely. It's a very well done video. And so it sounds like those are all, Janine, going to be on the hub. And Dana? Yes. We are going to add those to the resources. And it usually takes us about two weeks to get up the recordings for the workshop. So by the time the recordings are up, we'll send out a little note and say those links are up there too. We'll be able to get those links up pretty quickly though. Great. Great. Yeah. That would be really helpful because I don't do them. A few patients recently end up in the ER. And in our process, they want whoever put it in to do the change. Why? I don't know. So then you have to wait for interventional radiology and whatever. It is amazing. It is amazing. And you know what I just say, and you guys might be able to relate to this, sometimes it's hard to get a Foley catheter into a female because it's sometimes hard to find And I'll tell you with a G-tube, the hole is so obvious. As long as it's been longer than six weeks and the track has formed, it really is. And why they pay $227 for such a simple procedure. And so it's something that is really worth your time. And then we would change them usually every three months. You want to change them regularly. So before they fall out, before the balloon breaks or something like that. And so it really is something where it's $227 on these patients every three months. And we usually have the tube feeding company. We tell them to always have a spare in the home. They'll cover that and charge Medicare every 90 days. And does it matter whether it's a GJ or whether it's just a G-tube? Very good question. I have never, I've had a patient. Yeah, I'd be much more concerned about that. That has been where I've had one, a 17-year-old. It was such a sad case. And these have all been G-tubes. The thing, and I don't have it here. I have the thing that's a peg tube. A peg tube has this silastic. It's about the shape of a quarter. It kind of is kind of shaped like this, but it's all circular. And what you do is if you pull on it, it kind of does this as it comes out. But you really have to kind of pull on it. And that is something that is a little more because you have to put so much traction on it. But you can also with a peg tube. It used to be like in the early 2000s, they might put them in where it has to actually be released by a gastroenterologist. But over the last decade, all of them are this silastic material that is flexible so they can be pulled out. And then you just replace them with a balloon G-tube. Okay. Any other questions? Thank you so much. And thank you for mentioning the family education part. I can share my own experience as a respite caregiver, non-clinical respite caregiver. I have seen families absolutely panic when these come out. I mean, that panic lasts. They become very, very frightened. Because what is to a clinician, a simple procedure to them seems like the end of the world. Oh, my gosh, how are we going to feed them? They just absolutely are not sure what to do next. So I love that you guys are talking about that family education piece. And you remind me of one more thing. Remember I said how I teach them? I'll actually see one, do one, teach one. Once I've taught them how to do it, subsequent G-tube changes, I'll have them do it within there. And that way they just become so comfortable. And, yeah, so that's a great point. So thank you for reminding me of that. Certainly. Thank you all. Okay. It's going to soon close the room. I think we're counting down about 30 seconds. You can choose to leave sooner. Wait, no, again, we're in Maine. I'm sorry. I feel like we were going to put us in a separate room, but then we decided to stay in Maine. That's right. We're figuring it out as we go. You guys are the best. So everybody's going to start rejoining us. And so you're going to see a lot of faces, and then we're going to do our resort. Hello everyone as you are rejoining us again I encourage you to use the chat, share some resources, ask some questions of our faculty because it will take me another minute or two to sort us through your last procedural round. There's a few people, Millicent and Paige, if you can hear me now, tell me in the chat where you would like to go next because we lost track of you. Sometimes as people lose connectivity or we move them around we're not sure we're gonna move them next. So Millicent, Paige, and then of course Julianne and Patrick. April if you would like to let me know where you'd like to go next I will monitor the chat. Okay Sarah I see your note. You're gonna communicate with you via chat Janine? Yes because me staying in Maine like we had Sarah who needed to be moved she was able to get a hold of me in chat so it's it's a good thing I'm here hosting me where I can see everybody. So if for some reason you aren't sorted correctly you should be able to leave your breakout room come back to Maine and write me a little note and we will get you in the right place. I also want to let you know we're gonna make sure you have access to videos and you do have your procedure guides in your workbook and that's got step-by-step with photos a refresher of what you're learning today. Okay so talk amongst yourselves tell some jokes whatever vamp a little sock shoe I'll be with you. Entertainment. Can I do that? Please do. Okay we're gonna try this. Oh wait you know what I gotta go I gotta stop here for one second hang on one second and that's the wrong screen sorry okay all right you guys are gonna be in for a treat. I packed my bag last night pre-drive Zero hour, 8 a.m. And I'm gonna be gone On the road by then I miss my staff so much and I miss my peers It's lonely out on the road On such a mission critical And I think it's gonna be a long long time Till people understand the care I bring I'm not the type that thinks I am at home Oh no, no, no I'm a house call man House call man Bringin' things to take When you miss next house call Home ain't the kind of place to age alone Especially if you're chronically ill And there's no doc there to help them If they need And all this complex care I have to understand It's not just a job, it's compassionate care A house call man A house call man And I think it's gonna be a long long time Till people understand the care I bring I'm not the type that thinks I am at home Oh no, no, no I'm a house call man House call man Bringin' things to take When you miss next house call And I think it's gonna be a long long time Till people understand the care I bring I'm not the type that thinks I am at home Oh no, no, no I'm a house call man House call man Bringin' things to take When you miss next house call And I think it's gonna be a long long time Perhaps it won't be much more time And perhaps it won't be much more time ♪ Perhaps it won't be much more time ♪ ♪ Perhaps it won't be much more time ♪ Okay, so, and that's for all the house called men and women, no gender bias there, so. All right, Janine, how are we looking? We're looking good. Thank you so much for bringing it with the entertainment, Melissa, that was great. Everyone, again, I am now allegedly, I have checked the little box, so allegedly you can leave the room, come back to Maine and ask me to reassign you. Didn't work out so well for Sarah, but this is how it's supposed to go. If you are sorted to the wrong room and you're like, oh, hey, I've already been here, just come back to Maine, write to me in chat, and I will put you where you ask, okay? You should have that level of control. We've checked all the boxes, but you know, again, the Zoom gods hopefully will smile upon us and we'll be a go. I'm about to open all the rooms and I will be staying in Maine with Dr. Cornwell to support you all who are doing the injection. So we'll see you in 30 minutes. Hello, I am Dr. Thomas Cornwell, Executive Chairman of the Home Centered Care Institute. Today I will demonstrate how to aspirate and inject the knee joint. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during your visit. This of course applies to the current COVID-19 pandemic. You will want to first gather your equipment and supplies for the procedure as listed in I will now walk you through the procedure step by step. Before starting, counsel the patient and caregivers on the risks and benefits of the procedure. A consistent and thorough way of doing this is by having the patient read HCCI's pre and post steroid injection instructions or by going over it with them. This useful HCCI patient resource describes the procedure, the risk and the benefits, the contraindications, and the post-procedure instructions. It can also serve as the written consent by having the patient sign it. Verbal or written patient consent needs to be documented in the medical record. A patient safety check should be done prior to any procedure to verify patient identity, the correct injection point, and the medication being used. I always have someone verify any injection I give, whether it be a steroid shot or a flu shot. This is often done by my medical assistant, but if alone, I will have the patient or caregiver read the label to verify. Now let's wash our hands and get started. Injections can be given lateral or medial and superior, mid-patella with the leg straight or inferior with the knee bent at a 90 degree angle. We are going to demonstrate the most commonly used superolateral approach. It is preferred because, as you can see in the diagram, it provides easy access under the quadriceps tendon and patella, it is good for both aspiration and injection, and there are no other structures in the area to be concerned about. For the superolateral approach, the patient should be in the supine position with the knee in a slightly flexed position at about 15 degrees. You can use a roll-up towel under the knee and cover with a disposable under pad to prevent stains. After putting your gloves on, mark the injection site one centimeter above and one centimeter lateral to the patella. You can do this by imprinting the pen in the area. Clean the injection site with three povidine iodine or chlorhexidine swabs, applying each swab in a circular manner, starting at the injection site and circling out. Wait a minimum of two minutes. Wipe the medication vials' diaphragms with alcohol. Draw up a syringe of corticosteroid and 4-6 mLs of an anesthetic agent. If local anesthetic is desired, you can apply 3-4 mLs of an anesthetic agent to the injection site and along the anticipated needle trajectory. Alternatively, ethyl chloride spray can be applied from 6 inches away for 5-6 seconds. For aspiration, use a 10 mL empty syringe with an 18 or 20-gauge 1.5-inch needle. A 20 or 30 mL syringe can be used for larger effusions. Insert the needle, bevel up at a 45-degree angle distally and inferiorly under the patella and aspirate effusion if present. Compression of the opposite side of the joint may aid arthrocentesis. Once the syringe is filled, a hemostat can be placed on the hub of the needle to disconnect the aspiration syringe, then connect the corticosteroid syringe and inject into the synovial space. If no effusion is present that needs aspiration, the corticosteroid-filled syringe with a 25-gauge 1.5-inch needle using the same technique can be done. When the aspiration injection is complete, withdraw the needle and apply pressure to the site with a 2x2 gauze. Clean the prep area with alcohol wipes and cover the site with an adhesive bandage. I now have my fluid in here. You have to check with your lab, but you want to send the fluid for Gram-Stain and Culture, RBC and WBC, and differential, and for crystals. You need to check with your lab which tubes they like. They usually want a sodium heparin green or a lavender tube for doing the test, and you can use either a urine cup for the Gram-Stain and Culture, or you can actually just send them the syringe without the needle on it. Depending on the cause of the knee pain, the local anesthetic should provide immediate pain relief, which confirms the steroid was placed in the correct area. Prior to performing a knee aspiration or injection, you need to determine if there are any contraindications. Contraindications include infections such as bacteremia, if a septic effusion is suspected, underlying cellulitis, or osteomyelitis. A severe coagulopathy is a contraindication, but being on Warfarin with a therapeutic INR is not a contraindication. Injections also appear to be safe for patients taking direct-acting oral anticoagulants. A retrospective study of 1,050 joint injections at Mayo Clinic with patients on direct-acting oral anticoagulants did not have one bleeding complication. Other contraindications include having an osteochondral fracture, impending joint replacement surgery scheduled within days, a prosthetic joint, or poorly controlled diabetes. Patients should also not have more than three injections per year. Potential complications include rare iatrogenic infections occurring in only 1 in 14 to 77,000 patients. Hyperglycemia can occur especially with patients on insulin, and patients should be told to monitor their sugars closely for one week. Steroid flare occurs in 2-10% of injections and affects women more than men. It is caused by a steroid crystal-induced inflammatory synovitis. To treat, the patient can apply ice for 15 minutes every 3-4 hours and take acetaminophen or ibuprofen for pain. The steroid flare typically resolves within 1-2 days. Patients should call if not better in 2 days. Finally, facial flushing has been reported in 1-30% of patients. One of the things that I really like about this model is the needle is connected to a box here so that when I go in, it tells me. And this way I can have you do it 10, 20, 30 times if you'd like, so that you really know when you're in the right spot, so then you feel comfortable when you actually do it on your first patient. I hope your participation in this video simulation will help you gain confidence on how to safely perform a knee aspiration and injection in the home. When the injection is successful at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also being a blessing for the caregivers. Thank you for watching. Alright, so we're almost to the finish line. So there's a lot of information there, like 1.5 inch needle here, and again, this is in the handout. It really is nice both with the instructions as well as pictures that are right out of the video. And so this is a great thing to go through in terms of doing the procedure. And one of the things I think is just a great resource is this patient instructions for pre and post injection, which is also in your handouts. This serves multiple purposes. It can actually be your consent form, because it actually not only goes through the risks and benefits, but it actually, in terms of the quality to make sure that we don't miss anything, it actually asks some questions like, are they allergic to steroids or local anesthetics? Have they been recently ill? Do they have diabetes? Do they have a bleeding disorder? Do they have surgical metalwork? Just to make sure that all those questions, so that we don't have a complication because of something that we didn't learn ahead of the procedure. It then goes into, so that's kind of pre-procedure materials in terms of risk benefit, in terms of being a consent form, but then it also goes into the post procedures in terms of what to do when it talks about the risk of the procedure, such as things like steroid flare. So there's a lot of instructions in here in terms of what to do for it. One of the things that I've said is that you always read, you know, two to 10% have steroid flare that can be quite uncomfortable. I have never been called and either that means none of my patients have had steroid flare, but more probable is that some of them have had some of it, some discomfort, but because in this instruction sheet it has, you know, to ice it, use Tylenol or preferably, or, you know, possibly Advil, that they have just followed the instructions and so haven't had the need to call me. I actually, on my form, when I use this, have a place for the patient to sign and then I actually have a signed consent form, though verbal consent is all that you need. And so I'm going to pull, I'm going to zoom in manually here by moving my computer closer to our knee here. And so, again, as the video said, I have a towel here that normally I would roll up and put under the knee to have it slightly flexed. Our knee does not flex, it has an extensor contracture. This was something you also saw in the, and what this shows is that there really is a large entry point for this. This procedure is very forgiving. One of the previous breakouts, someone had did shoulder injections, but when they've actually studied it, even in the best of hands, blind shoulder injections, you miss the target space about 40% of the time. And so this is kind of hard to miss. This is actually an actual knee effusion and you can just see how high up the synovial space, the joint capsule goes. And so there's just a huge area here for us to, for our target zone. For doing any procedure, I will actually do two things. I will do the procedure in my head beforehand, especially if I'm on my own. I don't want to find out, oh, I forgot something as I'm gloved and ready to go. I will also put it from right to left in terms of, and so here you have what I begin with in terms of the betadine. I'm not sure if I said this in the video, but I'll actually do that before my setup, you know, starting from the middle and working your way out in terms of aseptic technique. But I'll do that because you're supposed to let that set for at least two minutes before you actually put the needle in. And so that's my beginning. And then the last thing I do is have my tubes for doing your gram stain and culture and

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