Good morning, everybody. Yep, I'm not on mute. Hi. Welcome to HCCI's Advanced Applications of Home-Based Primary Care. I think everybody's filtering into the room, so hopefully you can hear me. And you have been muted. We do hope that the next two days is going to be fairly interactive, so don't plan to stay off camera or on mute throughout the next two days, because we really do want to hear from you. But welcome. My name is Melissa Singleton, I'm Chief Learning Officer for Home-Centered Care Institute, and I'll be making some introductions as we go through our opening today, but for now, let me just advance here to the next couple slides. We have a fantastic slate of faculty here today, and you're going to hear from each of them as they share their expertise with you. But here's our disclosures, none of them have had any disclosed relationships with any company that's ineligible, as shared on the slide. And you will earn CME credit or CE credit for your participation in this activity. More information will be sent to you after the workshop ends tomorrow, and we do require that you complete your evaluation, and then you'll receive some information about claiming your CME credit. As we acknowledge for all of our education activities, we are proud to receive grant funding for this activity from the John A. Hartford Foundation, and we're grateful for their support. All right, so you all get to be the first participants in our newly redesigned Advanced Applications Workshop. This is a workshop that we added to our curriculum of offerings in what was late 2019, and we've been tweaking it and honing it for really ever since, but we just had some clarity over the last six months to a year of the need for providers and practices to really come together and understand what makes a practice successful in a value-based payment arrangement. And so you're going to hear some really clear guidelines on that. We've come up with six components that are essential to your success in that, and so that's the new focus of this Advanced Workshop. Yes, we are going to cover some of the basics of what makes a program or a house call program successful clinically and from an operational standpoint, but we really hone in on that value-based payment arrangement. So we're going to be discussing what are the value-based payment opportunities that are currently available in home-based primary care. We're going to talk about some recommended practices for staffing and to enhance productivity and efficiency, the use of telehealth, risk stratification, and coordination with other providers. We're going to talk about how to provide high-quality, cost-effective patient care and identifying some of those specific clinical conditions that are really important to be looking at and measuring in a value-based contract. We'll talk about managing transitions of care for homebound patients and then also performing common procedures that are typical in home-based primary care, including G-tube changes, trach changes, joint injections, and wound care. All right, so at this time, I want to make sure you know where to find all your materials and who your go-to is for help with this. We have on our workshop today, Sarah Bridgehue. She's my colleague, and she is available. I know, Sarah, if you want to wave, if people have their video on, Sarah has been, you know, works with our HCCI Learning Hub. You may have already corresponded with her, but she's your go-to if you're struggling to find the workshop materials. Here's some, I'm showing you right now, some instructions for how to do that. You log into the HCCI Learning Hub. If you, you should all have, I know you have a login because you wouldn't have been able to be registered if you didn't, but log in with your username and password. If you forgot your password, you can use that link and we'll send you a new one. You're going to go to the My Resources tab on the left-hand side of your screen and look for Advanced Applications. Click on that workshop title, and once you click on Course, you'll be directed to all of the workshop materials, but Sarah is your go-to if you want to chat with her and ask for some support. She can help. And if you still need help, contact us at the email address I'm showing on the screen. Just be aware, Sarah's doing a lot of things this morning, and she's the one who mans this email, so she may not be able to get back to you right away, but just know that she will before the end of the day. All right, so now I get to introduce our wonderful, wonderful faculty. And so starting with Dr. Paul Chang, and by the way, all of their bios are located in your workshop resources in the HCCI Learning Hub. But Dr. Chang is Senior Medical and Practice Advisor for Home Center Care Institute, but his day job is he is Medical Director for Home Care Physicians, a suburban Chicago practice that's focused on delivering care to medically complex patients in their homes. And I love sharing his stats because, you know, he's really amazing. I mean, his practice has made more than 123,000 house calls, 123,000 house calls to home-limited patients since it was founded in 97. And Dr. Chang has personally made over 36,000 house calls, and that's to more than 3,300 patients in a 21-year career. So he's really amazing. I know you're going to learn so much from him, and so I look forward to having him share his expertise with you. And then Dr. Michael Kingin is a Geriatric Nurse Practitioner with the Johns Hopkins Medical House Call Program. It's known as J-Home. He's been a nurse for over 20 years and has worked in acute, subacute, and community care settings. He was Director in the Quality, Safety, and Education Division at the largest hospital in the nation's capital, is a longtime faculty with HCCI. You're going to hear from him a little bit today and more tomorrow, and I know you'll learn a lot. And then Brianna Plensner is a Certified Professional Coder and Medical Auditor. She's currently Implementation Manager at Medically Home. And you know, she has just deep knowledge and experience in house call practice management. She's focused her career in primary care and home care medicine. And she was on staff with HCCI for many years before moving to Medically Home, but before she came to HCCI, she was a Practice Manager at Home Care Physicians, which is the same practice where Paul is now Medical Director. So she just brings a lot of experience to this role, and I know you'll appreciate hearing from her. Amanda Tufano, oh my gosh, we could not do this workshop without Amanda because the depth of her expertise in value-based care is just huge. She's Chief Executive Officer at Genevieve. She holds a Master of Healthcare Administration degree with the University of Minnesota, and is a Fellow in the American College of Healthcare Executives and a Certified Medical Practice Executive. She just has so, her credentials are just crazy amazing, and she's got a great presentation style, so keep you guys awake and involved over the next two days, I know. And then he's not here today, but Dr. Thomas Cornwell, who's our Founder and Executive Chairman at Home Center Care Institute. He has also made like more than 33,000 house calls and has mentored hundreds of medical students and residents and nurse practitioners and PAs, but now he brings his expertise to home-based primary care, in home-based primary care to Village Medical at Home, where he is National Medical Director. And so he'll be on with us tomorrow, helping out with some of the procedure sessions. I welcome all of our faculty and thank them for sharing their time with us. All right, now this is where I'm going to single out the Illinois House Call Project Champions. You know who you are. There's more than 30 of you, I believe, on this call. If you're not an Illinois House Call Project Champion, that's okay, just bear with me for the next 60 seconds. I want to remind you, you have a full day training session coming up. It's Friday, August 19. It's in person, 830 to 5 in Schaumburg. You should have already received some information about it. If you have not, go to Sarah. Sarah can help you with that. It's really important we get you registered so that we know you're coming and we can plan for you. I've provided the information here on this slide for what you need to do. Please, please, please register. I'm giving you till tomorrow. If you can, please, please, please do that. I appreciate it. And we want to welcome all of our Illinois House Call Project Champions. You are doing great work. This is the second training now that you're attending. You were with us in June and we are looking forward to working with you to advancing that special project. All right. So now I'm going to stop talking and I want to hear more from you. I know our faculty want to hear more from you. But here's the thing. We've got a lot of people on this call. I'm looking at 40 participants right now and I know we have some more that are going to be joining us. We have just over a half an hour before we have to officially start our first content session, which you're going to hear about soon. But so if you were present at the Essential Elements Workshop and did a little video introduction, I'm going to ask you to share in the chat, not on video at this time, your name, your practice, health system or organization you're from. What's your level of experience in home-based primary care? Like any nuggets you want to share about that. And then what are the two things you're hoping to get out of this workshop? Um, uh, if you could share that in the chat, I think that would help. And then we're going to get you on video at another time. Um, and then I'm going to call on people and we'll see how this goes because, um, I got a lot of screens I'm looking at here, but, uh, let me see is, um, I got to find and make sure that we've got people here. Yes. All right. The first name. Okay. Karen Farnham. You're the first name on our list. And I want to invite you to please turn on your video. If you're, if you're able and unmute, um, would you just introduce yourself where you're from? Hi, good morning. Hi, Karen. Hi. I intentionally was without video. It's a really bad allergy day and I was waiting for the eyes to go down a little bit more. So hopefully I'll get an opportunity to redeem myself later today. Thank you. I'm Karen Farnham. I'm a nurse practitioner. Um, I have been a nurse since the early eighties, um, had actually retired for a bit and then returned, uh, back to practice in 2008. Um, really at that point in time, motivated seeing the opportunity with the aging in the United States and not wanting to return to hospital-based work, but more community. Um, I've been doing in-home, uh, collaborative type of practice with a community-based PCP since 2015. And my business unit is really a business subsidiary of the insurer, um, Cigna. All right, well, thank you. And what do you, what, what would you like to get out of the next couple of days? Oh, oh, great. Thank you. Um, so number one, uh, not only am I a nurse practitioner, I'm also the practice manager for our tech, uh, Texas-based teams. And we are transitioning our program from being collaborative to full risk, um, with an ETA on delivering that, uh, Q4, perhaps Q1, 2023, and really just level setting, educating myself and preparing for the, really the staff development that we need to do for that extra level of care. Well, that sounds awesome. Thank you so much. Appreciate your, um, your, uh, introduction and hearing from you. All right. Let me see. I'm going to call on Carrie Mitchell. Carrie? I'm here just trying to get unmuted. Um, so we were actually part of the course last month too. So, um, I'm a relatively new grad nurse practitioner, started, um, in the House Calls program, worked for Carolina Caring, um, in North Carolina. Um, and my other cohort nurse practitioners here with us as well. Um, so we're, uh, our program's about a year old and we're, we're growing quickly. So I think for, for me, some of the important things is how to be efficient, not just with my documentation, but scheduling and as we get new referrals and new admissions and all those things, how do we manage that? Um, and then also we are, we're growing as far as staff. So, you know, what makeup is been successful for other organizations when it comes to, you know, social workers and nurse navigators and, um, how best to use our staff to be once again, more efficient as we were growing. All right, great. And, um, so I apologize if I, um, you know, if you gave this introduction before too, but, um, are you, are you working in, um, any kind of value-based payment arrangement now? We're not now in my past, I've been a part of that, but we're, we're not there quite yet. Okay. But maybe that's the goal. Oh yeah. And so, um, all right, well, I'm glad you're here. You're kind of be ahead of the curve then. And then is your colleague, Melissa? Yeah. Melissa Beaver. Okay. Melissa, are you on, do you want to say hi and what you'd like to get out of it? Hey, I'm Melissa. I'm Carrie's partner and I was on with her the last meeting, but excited to learn more. All right. Awesome. Well, thank you. We're so glad you're here. Thanks for coming back. Um, let me see Brooke Calton. Hi there. I'm Brooke Calton. I'm a palliative medicine physician. Um, recently transitioned, um, over from UC San Francisco to Mass General in Boston. Um, and I, um, am the director for palliative care for the health system and run, um, a home-based palliative care program. Um, for the health system. Um, and I've been practicing home-based care for about 10 years. Um, I am really looking to get out of this workshop, you know, coming out of the pandemic when a lot of our home services, at least that I was involved in were kind of on pause. Um, just a refresh, particularly as it pertains to value-based care, um, and what might be new or different. And then, um, the second thing is I would be curious to understand, um, recommended staffing ratios, particularly if you're thinking about, um, including telemedicine, um, or other healthcare, um, clinicians like community health workers. Fantastic. Well, thank you. We're, um, we're glad you're here and, and, um, that introduction that's helpful for us as we go through faculty, you know, the faculty to hear that so that we can make sure that we're addressing the things that people are interested in. So thanks. Um, all right. Let me look for another name here. Um, all right. Suzanne Dease. Hi, um, I'm Suzanne. I go by Susie. I'm a nurse practitioner. I work with, uh, with, uh, Northwestern at Payless Hospital with, uh, community-based medicine. Um, and I've been with them about six months. So I have a lot to learn, but I'm coming along. I've been a nurse practitioner for about five years in internal med in a private practice before I came to the home-based care. So I'm hoping to learn more about the value-based medicine. That's really my, my biggest, um, you know, learning that I'm looking for. Um, right now I manage probably about 150 patients. So, um, it keeps me busy. We have, um, 12 of us out in the field between palliative and, um, SNFs and home-based care. So, um, lots going on. So yeah, yeah. Thanks Susie. Nice to meet you. Nice to meet you too. All right. Let's see. Um, Joanne Soltis. Hi, good morning. Um, thank you. I am a, um, palliative care physician as well with a relatively small community-based organization in Connecticut. And I had been doing just inpatient palliative medicine for about seven years prior to embarking on trying to get a community program in place. So we currently just have a palliative medicine, palliative care home-based program in place for the last few years. And I'm most interested in trying to expand it into a primary care, um, program, of course, to try to improve and increase our, our ability to touch so many more patients. So since we're really, you know, somewhat limited now, um, I'm really interested in learning about value-based care models and how to approach, how to form a business model. I've been sort of, um, asked to come up with a plan moving forward to see if we can get better support, um, for staffing and to, to hire moving forward. So I know all the pieces are there and I, I've been, you know, I, when I heard about HCCI, I was so excited because it seems like this is finally the one organization that sort of brings everything together and hopefully will give me what I need to, to make a good stance for, for, for getting more support for our program. So I'm super excited to be here. Thank you very much. Thank you. I love hearing that. And, and, you know, you know, I was talking about our Illinois House Call Project Champions, but every one of you has the opportunity to be a champion in your organization to, um, you know, to take what you're learning over the next two days and bring it back to your leadership or bring it back to other decision makers to, um, you know, to, um, advance your program, to serve more patients. And so thank you for, um, the investment you're making to be here. Um, and we hope to make sure we deliver, um, on that for you. Thank you. All right. So let me, um, uh, so the next name I have is Yuting Wang. Am I saying it right? Oh, yeah. Yeah. Hi. Hello, everyone. My name is Yuting Wang and I'm from WellBe Senior Medical. I'm kind of new with the home, home, home-based, um, practice, but I, I just been with the company for six months. So very glad to have the opportunity come to learn today. Very good, thank you. And can I ask what geographic region you're in? Oh, I'm in Illinois, yeah. Oh, you're in the Chicago area? Yeah, Chicago, Illinois. Oh, great. Well, thank you. And is there anything specific that you're hoping to learn over the next two days? I want to learn more about managing dementia and other complex medical problems like in the home-based care, yeah. Right, great. Well, yes, I'll go over the agenda here in the next couple of slides, and you'll see how we'll be addressing those things. So thank you, Yuting. Thank you. Erin Sanders. Good morning. Hi, good morning, Erin. How are you? Good, how are you? Good, I'm Erin Sanders. I'm in the Columbus, Ohio area with Wellbe Senior Medical. I've been with them for about seven months, but I've been in healthcare for 17 years. And I'm really just hoping to expand my knowledge because this is my first year in home-based primary care. All right, well, fantastic. And yes, we're going to cover the gamut, and you'll hear more about that, but welcome. We're glad you're here. Thank you. All right, Imani Rasheed-Williams. Are you here, Imani? Yes, I'm here, good morning. Hi. Hi. So yeah, I'm a nurse practitioner with Wellbe. I've been with them maybe the last three months, but I've been doing home-based home care for the last four years. So this has become my passion. So I look forward to gaining additional insight so that I can expand my knowledge, do things better, so forth and so on. All right, great. I know you're with Wellbe, what geographic region? Oh, I'm sorry, Atlanta. Okay, that's fine. I was sort of familiar with the regions that Wellbe serves, and so we're glad to have so many of you here from your different regions. And I love hearing that this is your passion. I mean, in general, we know that the providers and professionals who do this work are really missionaries. I mean, they are passionate about providing this kind of care to the patients that need it, these vulnerable patients. So I'm so glad to hear you say that. Absolutely, thank you. All right, Nadia Applegate, are you on? Good morning. Sorry, I had to unmute. No worries. So I also am a nurse practitioner with Wellbe Senior Medical. Currently working as a change management project manager, because I'm based out of Phoenix. Okay. What I would like to get out of this is the knowledge and skills and some tips and tricks to take out to the field to help all of our field-based nurse practitioners who are in the home. Okay, great. In our communities, yeah. Okay, fantastic. Yeah, so to help disseminate some of, you know, some of that learning to others in your organization. Okay, great. Great. Well, thanks, Nadia. Glad you could be on. Is Nancy Zaner on? Nancy? Nancy? All right, we will come back to Nancy. How about Alina Galitskaya? Good luck. Hey. Hi, Alina. I'm sorry I didn't say your name very well. That's okay. So my name's Alina. I'm with Anytown PCP. We are based in Wheeling, Illinois. We have home health, hospice, and palliative care services that we offer. And we just expanded on home-based care within the last six months to a year. So I've been in healthcare for a long time, but there's something that's very new and just trying to get like tips and tricks and unscheduling. I think that's one of the big questions, you know, how to better manage my nurse practitioners and providers and clinical staff. I know that that's a concern somebody else brought up. So I think scheduling is a big piece of management. And also as far as value-based programs, I know there's different programs available. There's Medicare, Medicaid, the Meaningful Use or MIPS program. So I'm actually very interested to hear for home-based providers, what programs are available for them because the clinical measures and some of the reporting guidelines might be a little bit different. So I'm interested to hear about that. All right. Yes. And we will. And, you know, Alina, I know you're an Illinois House Call Project Champion, and I'm not sure if you got this from the Essential Elements Workshop. It was recorded for you. I know Brianna goes into a lot more detail in that workshop about scheduling and route planning. But so if you don't find what you need here, you can also go back to the recording and see her sessions on that. I just want to make sure you don't feel disappointed like we didn't get into a lot of the scheduling pieces. Oh, no, that's okay. Yeah. Thank you so much. No problem. All right. So April Odom, are you here? I am. Good morning. Good morning. So I'm April Odom. I'm a Family Nurse Practitioner in Illinois and Flossmoor area. I've been doing home-based primary care for about two years in my own practice. I am here. I was working with Rachel a lot, and I am really trying to learn the operations component, more of how to be effective in our day-to-day practices, how to obtain more referrals, and just run a very efficient system with me and my staff. I have a staff of four, but I really want to make sure that we're able to see the patients continue to provide excellent care, but be more efficient in our scheduling and our planning and things like that. Okay, great. Well, thanks. We're so glad you're here, April. Sarah Brubrocker, are you on? Yes, I am here. Good morning. Hi, Sarah. So I'm a Family Nurse Practitioner, working in a mix of office-based, home-based up till now, but just in the process now of trying to get my own business off the ground, specialty senior care. So I'm really looking forward to building some relationships and getting some tips from the others who've been doing that a little longer, especially the business piece of things, because that's brand new for me. I'm in the Chicago area, but now we're Northwest of Chicago. All right, that's awesome. Well, welcome. And we know that nurse practitioners, I mean, for those of you who are nurse practitioners, you know this, that you have been like driving the growth in house calls across this country. And so when I hear about someone like Sarah starting your own program, we talk to NPs around the country that are doing that. And so kudos to you. Thank you. I'm looking forward to it. Yeah. So then Alicia Rose-Bedek? Are you on? Alicia? Oh, you may not be on. Okay. How about Nicole Hartley? No, I don't see Nicole either. Okay. So is there anybody else whose name I didn't call that would like to kind of, even if you said something at the beginning of essential elements that you'd like to, you have a burning question that you came to this two days and you wanna make sure we know. All right, well, let's move on. And you know what? I wanna just also say, don't be afraid to use the chat too at any time. Our faculty are monitoring the chat. And so if you have questions that come up, yes, we have designated times during our sessions when you can ask questions, but I don't also, I have an aging brain. I sometimes will forget my question by the time at the end of the session would come. So don't be afraid to just put the question right there in the chat. And it may even be answered within the chat if we don't get to it at the end, so at the end of that session. So thanks, Tony. No burning questions, great. Well, welcome everybody. And thank you for sharing your information in the chat. Let's move on. So here's our agenda overview for today. We're actually gonna probably get started a little early, which is good. We've got a session to set the table on home-based primary care being the future of value-based healthcare. We'll talk about how you quantify that value when you're working with payers or other stakeholders. And then I know a lot of you mentioned this, just trying to understand the current advanced payment models. It's sort of an alphabet soup out there. And so we have Amanda and Brianna that kind of will break that down for you. And then we have a whole block of sessions where we're talking about clinical care today. And specifically, how do you provide the most, the highest quality clinical care, but in a cost-effective way? So medication management, dementia, congestive heart failure. So we'll cover those right around the lunchtime there. I do wanna point out, if you downloaded the agenda before this morning, we did have to do a little bit of tweaking of our times. And so we will take breaks and lunch. We'll have a break at 11 a.m. Central. All of these times are in Central time. But then we have a 30-minute lunch break that isn't until 1255. So if you're kind of needing to plan other parts of your life, please keep that timeframe in mind. All of our sessions will be recorded and you can refer back to them in the HCCI Learning Hub. Give us until next week sometime to post the recording, but it will be available for you in your resources section for this activity. We continue the day following our afternoon break with another session on working with specialists. How you make that decision about, okay, when are you gonna treat? When are you gonna consult? When are you gonna refer? What's the best way to be working with those specialists? And then we have a session on managing care transitions in a value-based world. And then we wrap up today with a session that kind of blends self-care and avoiding burnout with how you hire the right team and then retain that team. How do you support them? Because we know this work is very isolating and this work is also not for everybody. I mean, and that's kind of an important thing to acknowledge and so Amanda's gonna finish us up at the end of today with that. I wanna call your attention to your HCCI Learning Plan. If you've attended our workshops before, you're familiar with this. It's one of your resources that you can download in the HCCI Learning Hub, but this is an important tool for you and for us because we want you to record sort of, what are the light bulb moments that you have over the next two days? So, what are the topics that you hear about? It's like, oh, I wanna read more about that or I wanna learn more about that. What are some action steps that you wanna take as a result of what you're learning here? What are some specific things you wanna remember or some people or resources that you realize you need to be able to achieve your goals in your own practice? So, this learning plan is designed to help you do that. So, I would encourage you all, if you haven't yet, go to the HCCI Learning Hub, download this form and keep it open on your desktop so that you can make notes as you go through the next two days. And then what'll happen is, we want you to send this learning plan to us. You can send it to us at the end of the whole workshop or some people prefer to do one learning plan for day one and one learning plan for day two. Whatever you wanna do is fine, but share that with us because we can help you be accountable. We can help support you. Our staff will reach out to you based on the learning plan you submit and we can recommend resources to help you so that you're not kind of on your own after the workshop ends, all right? So, any questions on that, you can feel free to open up your video and unmute. You can put it posted in the chat if you prefer, but you're gonna hear us remind you about your learning plan throughout the next two days. So, thank you. All right, now it is my absolute pleasure to turn this over to Amanda Tufano to take us through home-based primary care, the future of value-based healthcare. Amanda? Hi, thanks so much. Okay, so we get to kick off with just a few objectives on a super cool video. Can I get a slide? Okay, so we're gonna talk about the shift of home-based primary care towards value-based care and the socioeconomic drivers for the business case. This will naturally go into then our discussion about how do you continue to make that business case? And then how do you think about these quantifiable terms for the program? And again, just start the beginning of your HCCI learning plan. I referenced it a lot. I took the course many years ago and now I'm privileged to teach here, but it's one of those things that you go along and you're like, oh, I remember this, but I put it in a note somewhere and I don't know where I put it. If you have it all in one spot, it's super, super helpful. Next slide. Okay, so let's talk about just some of the basics just to kick us off. And this is about an 18 minute video. So I just wanna warn everybody going into it. It's about 18 minutes long, incredible content. And I think we'll provide a nice foundation for how we start our day. Here we go. of access to primary healthcare and therefore often must rely on calls to 911 and visits to the emergency room to receive even basic care. And this group is growing exponentially with 10,000 baby boomers turning 65 every day. And those aged 85 and over projected to quadruple by 2050. This group is also part of the 5% of high utilizers who consume 50% of Medicare's $800 billion budget. The good news is there is a solution. It's called home-based primary care, also known as the modern day house call. With this type of care, physicians, nurse practitioners and physician assistants provide ongoing healthcare to patients in their homes. These visits can include lab tests, EKGs, x-rays, ultrasounds and more. House calls not only improve outcomes and the quality of life for patients and their caregivers but also reduce the overall cost of care. Currently, however, only about 15% of those who need this type of care can get it. That is because there simply are not enough providers and practices offering longitudinal home-based primary care. Experts agree that due to the increased prevalence of value-based contracts and Medicare Advantage, not to mention the impact of the current global pandemic, demand for home-based primary care is predicted to grow at a rate of 10% annually for the next 10 to 20 years. The Home Centered Care Institute is a national nonprofit organization focused on scaling home-based primary care and bringing it into the healthcare mainstream through four main focus areas, education, consulting, research and advocacy. HCCI is an authoritative source for clinical and operational best practices. Clients can count on HCCI to answer questions and conduct market analysis to inform their business decisions and help them assess opportunities for starting or expanding practices that offer home-based primary care. Dr. Thomas Cornwell, founder and executive chairman of HCCI, explains the impact home-based primary care has on patients, their families and caregivers, clinicians and payers. So what is home-based primary care? Home-based primary care brings providers as well as modern technology into the homes of mostly homebound patients in order to improve their quality of life, the lives of their caregivers, while reducing healthcare costs by enabling them to stay at home and avoid hospitals and nursing homes. A perfect storm of forces is fanning the sails of the modern house call movement. Just some of these include the aging population, advancing technology, increased home and community-based services being funded by the government, the value of house calls, and payment reform. The first force is the aging of society and the cost of increased chronic disease burden. The extremes on this graph are surprising in that the least expensive 50% of the population consumes only 3% of total cost, but conversely, the top 5% consumes 50%, and the top 1% consume an astounding 21% of all the cost and an average cost of over $100,000 per patient. These high costs are caused by our fragmented healthcare system that is not set up to care for the sickest patients who are often homebound. Bringing home-based primary care to these patients has been shown to dramatically improve their quality of life and, again, the lives of their caregivers while reducing these healthcare costs. Advancing technology is another force. I like to say that house calls are principally high-touch primary care in the home, but we also have the high-tech capability to provide quality care in the home. Just some examples are smartphones that can do rhythm strips in seconds. They have numerous apps now that I can do vision testing, drug databases, decision support, and much more. Portable x-rays and ultrasounds can be done in the home. Labs can be done in the home, including point-of-care testing, as well as we can draw blood in the home and spit it down in the car in a centrifuge that's plugged into the lighter. Modern technology has enabled me to do more in the home than most primary care practices can do in their offices. The third force is increased funding of home and community-based services. Government funding of long-term support and services are made up of institutional care, nursing home care, and home and community-based services. This graph shows that back in 1983, 99% of all funding went to nursing home care, so your only option if you needed help was to go to a nursing home. Over the past two decades, there has been a remarkable shift in funding, where now over half of all the dollars goes to home and community-based services, and this enables nursing home-eligible individuals to remain in the community. These individuals create an increased demand for home-based primary care. Recently there was a study in the Journal of the American Geriatric Society showing how integrating home-based primary care and home and community-based services delayed nursing home placement by 13 months. A major force has been the data that has come out showing the value of house calls, but before getting to the data, I wanted to share a couple stories illustrating just how valuable this care is. Our first story is about Amanda, who when I met her in June of 2017, was 34 years old, suffering from type 1 diabetes that she had had since she was a child. She had kidney failure and was on renal dialysis. She also had coronary artery disease and already had had four stents. She also suffered from chronic pain. In the four months before we saw her, she had been in the hospital 30% of the days. We were able to dramatically reduce that over the following seven months of 2017. In 2018, she was so much better that she did not spend one day in the hospital and sent me this wonderful picture of her at an art festival in the fall. In 2019, she did go back to the hospital because she had gotten so much better that she now qualified for a kidney transplant, and she had a kidney and pancreas transplant, which cured her of her diabetes and removed her need for dialysis. What a joy to be able to give someone their life back like this. Elsa was born in Germany in 1921 and came to the United States after World War II. I was called out to see her to fill out nursing home paperwork. When I met her, I learned she was no longer able to get out to see her doctor because of her right foot being amputated and her left leg being amputated, and had been in the hospital six times over the previous four months because of multiple chronic problems, including heart failure and diabetes and pressure sores. The patient shared with me that part of the reason she lost her legs was from frostbite caused by cold winters in a concentration camp. Through quality home-based primary care, we were able to quickly get her heart failure and diabetes under control. We ordered home health that she was previously not able to get because there was no doctor to sign orders. We got her a hospital bed and enabled her pressure sores to heal. She got so much better that we were able to arrange and pay for transportation to an outpatient rehabilitation center where she got new prostheses so she could actually walk again. Over the next eight years, she only went back to the hospital twice. Besides powerful stories, we also have compelling data, such as from the VA's Home-Based Primary Care Program, which is the largest home-based primary care program in the country. The program's director, Dr. Tom Eades, about 2005, was told to cut the program because they were spending $11,000 more per veteran sending doctors and nurse practitioners and physician assistants, mental health workers, and others into the home than usual care such as home health. Dr. Eades asked to have all the cost data reviewed, and they went back to 2002. And what they found, I think, even surprised Dr. Eades. They found an 87% reduction in nursing home use, 87%. They found a 63% reduction in hospital use, an overall savings of $9,000 per veteran. And when you multiply that by the 11,000 veterans in the program, it came out to $103 million savings by giving them $11,000 more care in the home, by giving them what they wanted. As a result of this data, the VA program has grown to over 30,000 veterans, and would serve even more were it not for the shortage of providers. This data also led to significant support for home-based primary care on Capitol Hill and at CMS. The last part of home-based primary care's value equation I would like to discuss is cost-effective quality end-of-life care. The last year of life is the most medically expensive, consuming 25% of all Medicare dollars. 70% of Americans say they would like to be at home at the end of life. Only 33% died at home. Homelessness use markedly increased over the past decade from 22% to 42%, and is now up to 50%. But also over the last decade, ICU stays in the last month of life increased to 29%, and hospitalizations in the last three months of life went up to 69%. End-of-life care at the House Call Program I founded, Northwestern Medicine's Home Care Physicians, is much different. A quarter of our patients die yearly, and over the past five years, 76% have died at home, 77% were on hospice, and the median House Call length of stay that they were on our program was 1.3 years, and so we covered them during that costly last year of life and dramatically reduced hospitalizations. One side benefit to this is because we have so many patients pass away at home and less go to the hospital, we actually were able to help reduce our hospital's mortality rate, which is another selling point to health systems. The last force we will discuss, which is helping to expand home-based primary care, is payment reform. Medicare has increased fee-for-service payments to better support House Call providers. This includes payments for advanced care planning discussions and chronic care management, where practices can be reimbursed monthly for the non-face-to-face care management time that occurs for patients with multiple chronic conditions. Medicare has also increased the amount it reimburses for transitional care management, which provides services during the handoff period between the inpatient and community settings. Research has shown programs with a formal transitional care program reduce hospital readmissions by up to 30 percent. Additional fee-for-service revenue opportunities include prolonged services before or after visits for reviewing extensive medical records and discussions with family caregivers. While increased fee-for-service payments help, new value-based payments are creating the economic engine stimulating the national expansion of home-based primary care. Value-based payments reward quality outcomes instead of the volume of services. Value-based organizations take on different levels of risk, including full risk, and then are rewarded when they improve care and drive down costs. Home-based primary care dramatically improves the care of the sickest and costliest patients, and this includes quality end-of-life care. And under value-based payments, these providers are financially rewarded for the reduced acute care utilization. A great example of value-based payment reform is the highly successful Independence at Home Medicare House Call demonstration that began in 2012. There is an ongoing effort to expand it into a new Medicare program. Its greatest benefit has been to inform Capitol Hill and CMS of the value of home-based primary care. This has led to the creation of other models that benefit or incorporate home-based primary care, like Primary Care First and High Needs Direct Contracting, which requires only 250 patients to start. Direct contracting entities are required to have 5,000 patients, a number not attainable for house call practices. Several DCEs have incorporated home-based primary care into their model to improve care and reduce costs. The direct contracting name will end in 2022 and be replaced in 2023 by ACO REACH, which stands for Realizing Equity, Access, and Community Health. The programs will be very similar, with ACO REACH having an increased emphasis on social determinants of health and health equity. There are opportunities for smaller, independent programs to partner with these and earlier ACO models to become preferred providers. To drive home how beneficial the new value-based models are for home-based primary care, I will give an example. If a direct contracting entity has 10,000 Medicare lives, you would expect the sickest or 500 to benefit from home-based primary care. If we do a great job billing under fee-for-service, such as 10 visits a year and billing for chronic care management, advanced care planning, time spent before and after visits, and some procedures, we would expect about $1 million in revenue. Under full risk direct contracting, we would get around $16.3 million for these 500 patients. Out of these dollars, the DCE must have the infrastructure to pay all their medical bills, including those to hospitals, specialists, home health, hospice, and DME. The flexible reallocation of dollars gives DCEs the ability to transform healthcare by using money to provide great care in the home that is paid for mainly through reduced hospitalizations. This is the reason value-based and venture capital organizations have become interested in home-based primary care. CMS continues to expand value-based care models with a goal of all fee-for-service Medicare beneficiaries being in a care relationship with accountability for quality and total cost by 2030. With these forces creating a huge demand for home-based primary care, now we need the workforce. Over 7 million homebound and home-limited patients could benefit from home-based primary care, yet less than 15% are being served. In the United States, 3,000 full-time providers make at least 1,000 home visits per year, but we need 12,000 to meet the growing need. Three states—Alaska, South Dakota, and Vermont—do not have even one high-volume house call provider. It's critical we expand the workforce to enable all in need to have access to this wonderful care. Visit the Home-Centered Care Institute for industry-leading experience, products, and services that can help you succeed. HCCI exists to help ensure that those patients who need house calls get them. Because the future of healthcare is in the home. Really powerful, right? I think that is so, so, so cool. Melissa wanted me to let you all know that if in your pitch to your organizations or to payers or partners, that you can request to use that video to HCCI, so you can send in a request to be able to use that video on your behalf, hopefully to continue to grow all of our programs. So there are six top components that we're going to talk about for value-based care over the next two days. Patient identification, gaps in care and quality, managing the cost of care, data and financial considerations, the revenue capture and value-based care model, HCCs, which I think we briefly introduced in the essential elements, we're going to go really deep tomorrow afternoon on HCCs, yep, tomorrow, and payer negotiations. And so they're not necessarily in this exact order. But over the next two days, this is what we're going to cover. And then we'll kind of early afternoon tomorrow, we'll tie this up and go through kind of each one and give examples for each one. So I'll pause for any questions before we move kind of to the next phase. And I'm definitely the type of presenter that will take questions throughout. So just pop it in the chat or send or turn off your voice and ask questions. Okay, so we have one question. Question topic, how to grow your patient population in the practice, where to get referrals for home-based patients that need primary care services. Brianna and Melissa, I think we covered some of that in essential elements. And then we'll talk about some stuff tomorrow around productivity and staffing. But I'm not sure if we go deep into referrals. I think that was mostly essential elements. Yeah, I mean, and I'm happy to take questions to you throughout. I think the nice thing is, even if it's not a formal content, we'll definitely have plenty of time. We know from looking at data from home-based primary care practices, that the number one referral service for home-based primary care is home health and hospice partners and other community providers. So definitely doing your research in your area, networking with them, clinic PCPs, pitching to them that you only want to take care of the sickest of the sick, the ones that really aren't getting into the office, thinking about local area on aging and making them aware of your services. But yes, there's definitely a lot of content that we've covered on that. But community-based partners are really, really important when you think about your service providers. And then also think about communities, senior living communities, assisted living, group homes, even if it's just a new senior living space, just to give you a couple examples to address that question now. Great, thanks. And then Latosha asked about the ACO REACH program. So we are going to cover that this morning, right after break. We're going to go into all of the existing value-based care, Medicare contracting options today. So we'll go kind of deep in that. Just a couple of things, I think as we go through that I really liked about this video, even if you decide not to request to use it. What this video did is it early on, very early on, not the exact first thing, you know, it set a national stage first, but early on it told a patient's story. And I don't know if anybody else teared up. I always tear up when I hear these stories. I always tear up when I hear stories coming out of our practice, because I just think you have such amazing impact. And sometimes when you're day-to-day in the weeds, you don't realize what that impact is and how other people aren't seeing exactly what you're seeing. And so that's what they started with first. Here's the impact we had, here's the quality, and here's the cost impact that then meant for someone. And again, it started with this individual person. And so as you think about, well, I'm trying to pitch this idea to someone, or you're growing your practice, I think it was Sarah, who's growing your practice, right, and you're pitching this idea, start with individuals that you made this difference. And then every time you give an example, people will auto-connect it in their mind of, oh, yeah, that was Amanda. Oh, yeah, that was Elsa. Okay, I'll take a slide. So just some key takeaways here, and hopefully we've talked about them again, continue to throw questions in the chat or unmute yourself, but there's a lot of things that are making the home-based primary care really popular, really important, and we're going to go through and talk about a lot of those, continue to talk about those in depth. And this adds tremendous amount of value for reducing costs and improving quality. I think one of the nice things generally in geriatrics, and maybe it's all of healthcare, but it's certainly prevalent in our work, is when you do the right thing, when you improve quality of care, when you meet someone where they're at, when you meet their goals where they're at, you almost always also lower costs. You know, you can have very specific examples like Harvoni that might cost a lot for improved quality, but you really generally, it really, there aren't that many examples. Most of the time when you improve the quality, you're lowering the costs, you're lowering the transitions, you're lowering the number of medications. So that's really, I think that's really neat for the attention of the work. Sometimes the costs just reduce naturally. And then we're going to continue to talk about payment models, and I think that'll be fun in a couple of sessions. So any final questions? Okay. So one of the first ones we talk about is quantifying the value of your home-based primary care. And so this will be, how do you take even everything you've learned in the last 18 minutes of the video? How do you take everything of your practice? And is there a way to start building relationships and quantifying that value? Slide. So we're going to talk, I'm going to give another example of against kind of the fee for service and capitated payments, kind of how you think about your clinical readiness model. Some of you mentioned in your introductions, you're building your clinical model. How do you build one that performs well under risk? And then how do you build relationships with payers or other partners that will continue to demonstrate your value and talk briefly about the various types of value-based contracts. We're going to go in more depth about Medicare contracting that is available. But if you think about the breadth of value-based contracts, it's pretty, it's pretty expansive. There are lots of different options to get something other than just fee for service. And that's how I'm going to describe value-based contracts for the next two days, is it's really anything other than just straight fee for service on that population. Slide. So I believe in your workbooks, you learn about Minerva. I'd like to introduce Minerva to you. I am not clinical, so I won't be able to do the in-depth clinical review, but if you give me another slide, I'll tell you just a brief overview of when I heard Minerva's case, and I read Minerva's case for the first time, this is what I got out of it. Minerva is a community dwelling patient. She has a long list of diagnoses, medication, hospitalizations, and treatments, but ultimately when I heard this as a reporter, I thought she's a high utilizer of healthcare. She's what we also call as a frequent flyer. She's a Medicare, Medicaid eligible patient. So she has either been on Medicaid for a long period of time or spent down her earnings and no longer has, is private pay. So she's on a dual eligible patient. Her, the 80% of Medicare is going to pick up the, all the medical spend around hospitalizations, pharmacy, visits, skilled facilities stays, her med A stays, and Medicaid's going to pick up any elderly waivered services, a PCA, durable medical equipment, potential meals, or other services she could get inside the home. Slide. So again, as a lay person, you know, how do you impact her clinically? These are probably the things you're doing for all of the patients, right? You talk about what are your goals of care? What, who's the main point of contact? Who do I talk to if something happens with you? Who do I talk to if you no longer can make decisions? And then we talk about all these medications and we say, you know, some of these medications were prescribed because they were just trying to solve a new symptom of A. And so then B got prescribed and then B created all these new symptoms. And so now C got prescribed. And so, you know, you as geriatricians, then as home-based primary care providers, you start to pull apart this work and you say, hey, we can really do some really big med rec here and reduce polypharmacy. Now we say, you know, and you saw an example in the video, how do we provide the right home care services now that we have a provider in the house? And how do we talk about the appropriate living situation? Should Minerva live at home? Should she live in an independent living, an assisted living? What does that really look like? And you start to address medical and psychosocial concerns. Slowly you start to pull back the layers. How do I address all of the concerns that she has? Why is she using the hospital? Are they clinical reasons? Are these social or psychosocial reasons? You do all of this work. And my argument here is you're going to do this work regardless of what payer is paying you. But if you're getting just fee for service, and I did update this for the 2021 fee schedule, you're getting somewhere between $81 and $125 per visit if you're just paid at the Medicare fee schedule for a subsequent home visit. And potentially you might get a fee for service plus, you might get a care coordination or transition management on top of that. But generally you're doing all this work and you're going to do the same work for everyone and you're getting $81 to $125 an hour. Slide. So how do you start to think about value-based contracting? Again, my argument is you're not going to do anything different clinically. All these patients, you kind of dissect their needs individually. But how you get paid under value-based contracts is very different. Some ideas, some things, it's a capitated monthly payment for care coordination. Would you just get a flat fee for care coordinating or medical care coordination? You could also get inside of that, the fee for service billable visits. Sometimes people get a straight cap payment and then they no longer, they bill a zero bill and they don't bill for the fee for service. You can have a risk share or shared savings model for the pool of patients. So maybe you have, it's hard to take risk on these sicker patients, but you could certainly have a shared savings model where you have a pool of patients and you say, I was able to reduce hospitalizations by 20% and that resulted in roughly X percentage and can we share back in that savings? And that could look like, you could have that shared savings with an ACO-like model. And then you could have quality bonuses with a payer or health system as well. And so we'll continue to kind of pull apart all these value-based contracts that are open to you. But what I like to also say is, it sounds really great. Now I'm responsible for the cost of care of this patient. Now I could get some additional dollars, but make sure you're really ready for it. Slide. And what I like to think about is the very first thing before you do anything else is make sure your clinical model is ready. And what I heard a lot in the introductions is people really are ready for value-based care. That's great. And the first thing to do, I think I only heard that comment once or twice, was make sure your model is the model that will actually reduce costs and improve quality. And what are your strengths and weaknesses today? And what do you need or who do you need to be on board before you're ready? Do you need new systems? Do you need new technology? Do you need new processes? Or again, do you need new people? Or do you need to convince the people that are already there that you're ready? If you say, hey, I'm already doing home-based care. I know what I'm doing. I'm just going to sign a risk contract and you expect a different outcome tomorrow. You may not get it. And so sometimes we see some of the work around not doing a full clinical readiness assessment first, and you don't then see the potential that you could actually get on the financial side. If you don't really say, have I built the most efficient boat to be in this speed boat to keep going in. Slide. So the devil's in the detail. And so interpret the clinical model into sustainable business model. What is your value proposition? Sometimes, and I think I heard someone building a practice, you might be the only. Sometimes you're joining a very competitive field. What's your differentiator? What can you prove with that? What are your strengths and weaknesses? And be really honest with yourself because these are the things that you'll have to pitch to someone else. How do you think about the larger healthcare system around you? Is there someone who's already in value-based care? Is there that to Brianna's point around where you're getting your referral systems? Are you getting your patients from someone who's in value-based care or is reliant on you to deliver downstream? What does that really look like? And so then how do you leverage what they are responsible for and whom? And who's willing to partner with you? I was down this last week, or excuse me, at the beginning of this week on Tuesday in Dallas and talking with an organization. It is a different organization than Home Based Primary Care, but they were starting a medical practice in SNFs. And they said, we really wanna get, we really wanna continue to grow our nursing home practice, but, and we wanna talk about our partners. And I said, okay, well, who are the partners around here? And they listed like 10 different nursing homes. And in bigger cities, you're gonna experience that, right? Like Chicago, here's 10 different nursing systems. Here's a hospital on every corner. Here's a home care group. Who's really willing to partner with you? And what are they gonna get out of that? And then if you can figure that out, what data do you get from your partner? And how do you formalize that relationship? Slide. So building this relationship takes a lot of time. And so first you must have the person on your team who is best to champion your work. Sometimes that's you. And sometimes it's someone else. Sometimes it's the lead clinical person. Sometimes it's the lead administrative person. Sometimes it's a combo, but who's the person that can connect the best on the behalf of your organization. And then understand what the potential partner values. So if you're going to the table to talk to a partner, and partner in my mind is truly anybody who's going to help you think about getting paid a different amount of money other than fee for service. So payers are easy examples, but again, it could be health system ACOs. It could be episodic care centers. We do have some home-based practices that focus on certain diagnosis and groups around maybe kidneys. I think we had maybe last year a nephrology group starting up. So think about, again, who is the partner that's going to potentially partner in new ways? What are their goals? If it's a hospital, is it less days in hospital bed? Maybe that's what a payer wants, is fewer days in hospital bed. Does a health system want you to have fewer patients in their hospital? Maybe yes, maybe no. And we have to be really honest about that. And so make sure you come and demonstrate that particular metric. Here's how we're going to be able to implement that. Here's how we're going to lower your days in the hospital. And again, be realistic. And sometimes the hospital systems aren't ready for that. And sometimes they really are ready for that. And that's what they're looking for. And that's why the video and examples and extrapolating data and examples can be really helpful. Take Amanda's story to say, she was in the hospital 37% of the time before we got to her. And a year later, she had not gone to the hospital at all. That's a really powerful story. Be able to speak directly to the gap or the need that you're filling for them. And then utilize the connections to get in front of the right people to tell your story. So HGCI has a great learning module about how to contract for value-based care. This is, again, introducing that idea, but it really talks about who's the right person. So your fee-for-service contract that you signed with your local payer, you were just talking to an account representative. You weren't talking to anybody who has any power. It can take a couple of years to get to the right person that might have that power. And making sure that you have that constant story built out is really, really important. Next slide. So once you figure out who that person is, again, medical director, CMO, how do you continue to maintain that relationship? And so you create ongoing ways to demonstrate your performance that matters to your partner. Typically, I'd say create a scorecard or dashboard for your practice. Here's what we're really doing well. Here's the external dashboard to my partner that I'm doing well. This is the hospitals that I've reduced. These are the days at home. These are the people who've died at home. This is the utilization of hospice. This is the work that we've been able to impact here. And track those measures on something you can physically show them on a regular basis. And that will equal financial savings, even if you have to extrapolate data, right? Even if you have to use the data from the VA and say, yes, you're spending more money on us, but you're saving money in the system. And I'm able to use this data from the VA and say you're roughly per patient saving $11,000 a year because these were unmanaged patient. That matters, right? And reduction in hospitalizations. If you don't have direct data yet, apply it. What I like to do is always try to pick one or two things that you can actually prove and do today. And the rest are more lofty goals of what's possible if you introduce your team and what those impacts could be and look like. And sometimes your payers will come with, your payer or your partners will say, here's the data we can actually give back to you. That's always really helpful. And we really like to see that too. So here are a couple of types of value-based contracts. And again, all of these are kind of under the umbrella of any type of arrangement you can connect to. So if you get someone to listen to you, then you just got to figure out, well, how am I really going to cover my costs? And so alternative payment models certainly exist. Some people are in MIPS. We're going to talk a little bit more about APMs that exist under Medicare in our next talk after the break. Augmented fee-for-service or fee-for-service plus, these are names that kind of come along with the additional fee-for-service-like codes. So advanced care planning, so ACP, TCM, CCM, those types of augmented fee-for-service. They still have to be billed through the 1500 pro-fee process, but they're additional work, but you get additional payments, but you kind of have to check off the list. They can be broad ideas, right? Like, did I complete this? Did I complete advanced payment or advanced planning? Or, you know, did I complete a number of minutes for care coordination? But you still have to do it through the same process. Another idea is per member per month or per enrollee per month. We're seeing these where you just get a flat fee. You provide a service in writing, but you're going to get a flat fee for doing that. 100 bucks, 500 bucks. It depends what you're doing, who's doing it. Sometimes you can get the fee-for-service plus this care coordination payment. Sometimes you can have a shared savings. So like on an ACO track, and we're going to talk about the MSSP, shared savings examples. But sometimes if you can reduce the total cost of care, if there's additional dollars, you're just sharing in the upside. And there can be upside downside, but you have the upside opportunity. A quality bonus, sometimes paid for performance. So in some of our contracts, I do have these built in. So they might be a shared savings, but we still get, if you meet these quality measures, you get a couple of extra thousand dollars, right? And then there's the gain sharing, right? So if, again, if there's dollars at the end of the, shared savings generally is more tied to the Medicare language. Gain sharing is the same idea. If there's dollars at the end of the year in the pool, then you'll get that back. Full risk or significant risk capitation. This is when you're going to, again, you're all in, you're taking total cost of care of risk for these patients. And there's an upside and a downside opportunity. So you could have significant risk. I think of significant risk as really 75% or higher, or full risk, 100% or higher, that you are truly responsible. At a full risk delegated provider level, you are almost the health plan. You could also be the health plan. Some of you larger organizations, as you are starting out of venture capital money or private equity money, you may be also applying to be the risk bearer. And then those can come with what they call floors or ceilings. So, and shared savings is a perfect example of after you get out of kind of a no downside track, then you have, okay, you can earn a little bit more, which is what we call a ceiling. You can't earn more than this, but you are capped on the loss too. So you have a floor. And so those can kind of come together. And then the final one is the episodic of care payments. And episodic care payments, typically you see more with orthopods, a little bit in cardiology. These still exist through CMMI, but there are opportunities to think about those. Generally, and so again, some, I think almost everybody in this group is a general practitioner and not focusing on one disease state, but as we build home-based primary care practices that do focus on one disease state, you wouldn't want to be at risk for the entire population. You'd want to be just, if I do this very well, and what do those quality and cost measures look like, then I can get a bundle payment for that work. And I would get a lump sum amount to care for everyone. So these are some ideas. And again, these are ideas inside of very specific programs. And we'll talk about some of the Medicare programs. And these can be with payers. They can be with ACL partners. Here's some examples of our types at Genevieve. We have some dual contracts that are in the full risk or the significant risk category. They then have some quality bonuses built in. One is a gain-share model. We have a couple of ISNEP partnerships that are in the full risk or significant risk. We have a Medicare Advantage that is more in the shared savings track with some quality bonuses built in. I'm interested in continuing to grow out some of our other contracts that would be more a medical management fee and be paid at the per enrollee per month. And again, all these things are on top of fee-for-service, or again, should at least replace that plus. So I'll stop there for a minute if anybody has any types of questions on this slide or anything I've talked about. Okay, slide. So again, these two dates are really nice because we're gonna cover the full gamut of things to think about. Again, the thing to start with is your clinical model. What do you have in place today? Is your organization really ready to change? And what is that gonna take to get there? How do you find then the right risk partnership and then build that relationship? And how do you continue to deliver results? And I'd give some just small examples of as we think about change readiness. How many of your providers are hospitalists by trade and they've been spent the last 20 years in hospital medicine, or they were ED providers? That's a different workflow than primary care. And I'm not saying it's better or worse, but it's a different workflow. In a hospitalist world, we're moving the patient onto something else. And so we are almost doing episodic care for that moment. Well, now we're talking about longitudinal care. Are your providers really ready to practice in a different way? Can they work with maybe not having or needing all test results in front of them to interpret the situation? Are you paying, like, are your providers part of, have they historically come from, or do you pay them today on work RVUs, right? So if you're paying them to churn and burn, well, now you're asking them to care about a phone call that's not gonna get any reimbursement potentially, or talking to that care coordinator or the home-based community provider, hospice, home care, again, not gonna get reimbursement for that necessarily, might get some, but not gonna get the reimbursement for that phone call. So, again, how are you setting up your infrastructure and your clinical model and your support model? Who's taking after-hour call? What are your top diagnoses that are going to the hospital? So, again, thinking about those things first before you go out and say, I'm ready for a contract. Oh, I see a note. Okay, and then I'll take my last slide. And we just kind of talked about this, but this is the order in which I always think about this, especially as you go to other people, create your elevator speech for your clinical model, create your one-pager for your clinical model that really says what you do. And if you ask anybody in your organization, it would say what you do, and that's how you start the payer negotiations. Slide. Any final questions for me in this section on quantifying the value of your program? And again, ask for resources, and as we talk about them and you see value in the essential one, we talked, again, about the value that you have, you know, use that data, even if it's not your data yet. It's okay. I think sometimes, you know, CEOs are kind of half, half of what we say is exactly true and half of what we say is a stretch of who we wanna be. I think that's okay with this work. I think it's a little bit out of character for a lot of providers, right? You report the information as is, and that's how it's gonna be, but this is also aspirational, and you have to take business people with you on the journey to say, this is what's possible with this intervention, and so that's one thing I'd like to impart as a final thought. Anything else for me? Thanks, Amanda. Does anybody have any questions? We've got a little time. All right, thanks, Tony. All right, so, well, this is just a reminder. You've got your, maybe use your next, we're gonna have a break here for 10 minutes. Maybe in that break, go find this late learning plan, start to download it and take your notes from the first couple of sessions. Kieran, thank you so much for joining us today. I know it's been a little bit of a long day, the first couple of sessions. Kieran, thanks. She appreciates the final thought. It's essential to be able to communicate value. That is so true. And the patient stories, as Amanda brought up, are so essential. It's not just about dollars and cents. I think you can really personify the impact of what you're doing by capturing those patient stories and communicating them. All right, so at this time, we're gonna take a 10 minute break. Please come back at 1035 Central Time. That's 1035 Central Time. And we will get started again with what you need to know about the current Medicare advanced payment models. Thank you, everybody. All right. Welcome back, everybody. We are going to kick off this next session. Amanda will be back with us, and she'll be joined by Brianna Plensner. So, Amanda and Brianna, can I have you take it from here? Thanks, Melissa. Good morning, everyone. I'm really excited to have you here with us. Amanda and I developed this session when we were revamping the content because we felt like it was important to have a space to really have a little bit of more time to go into more detail on some of the payment models, alternative payment models, that are out there today. We did focus more on the Medicare payment models, the two newest ones, primary care first and direct contracting, which is going to be ACR REACH, because given our populations, generally 80% of home-based primary care is Medicare anyways, and I think they're kind of the most relevant. But Amanda's also going to talk about MSSP and Medicare Advantage, but if you're wondering why we chose that Medicare focus, it's really just because of the population that we serve. We can go to the objectives here. The other thing I wanted to kind of put in your mind is I think it's really exciting that we have different levels of experience here. We have a really awesome, diverse attendee group. Some of you may be much more familiar with value-based care than others, so for those of you that are super advanced, if we're saying something that you think you have a thought or a comment or something that's worked for you, please share in the chat. We always learn as much from you all as everyone else, but hopefully this will be beneficial, whether you're in fee-for-service or you're still trying to get into value-based care or you are in value-based care, just to understand what's out there, how practices that are in some of these payment models are measured, and kind of what those requirements are so you can start thinking about that change management, what would you need to do to get there, or maybe even just how you might want to measure yourself so it aligns better with how Medicare is looking at performance and outcomes and things like that. So we'll talk about what exists today, focus on some of the newer ones and what those requirements are, and then hopefully all of this is going to tie together to help you all start thinking about what do you need to do in your current practice to kind of transform and start being ready for the future of value-based care. Next slide. So if you haven't checked out the CMMI, which is the Centers for Medicare and Medicaid Innovation, has a strategic direction webpage. I just put the link in the chat. It's the link that's on the slide. They came out with a white paper, I think it was last year now, that really just summed up their vision for the future. So you heard Dr. Cornell in the video earlier this morning say that the administration has come out with a really lofty goal to say that by 2030, and I know that seems far away, but nothing with Medicare and legislation is fast, they want to see every traditional Medicare beneficiary have some sort of accountable care relationship. So that means some sort of, you know, ACO affiliation or value-based payment. So we may come to a period of time where if you care for Medicare beneficiaries, you are required to participate in some sort of program. So that's why this is important. Again, whether you're in fee-for-service still or not, you know, Medicare creates opportunities either by signing legislation and making new permanent benefits, or we're going to, the two models we're going to talk about are really demonstration projects, which are generally five to seven years, you know, opportunities for them to trial new payment models and for them to trial things to see if they want to adapt things for the future. But just understand kind of the vision of where things are going, and that this is why this is important, regardless of what state of practice you're in today. Next slide. So again, what's the newest or where are we at today? So ACO REACH, which was for, which it'll become ACO REACH in 2023. And we're going to talk more about that. That was what's currently direct contracting, finishing out its current performance year through the end of this year, through the end of 2022. That's more of a risk-based model. And we'll talk about that. Whereas Primary Care First is an example. It was a little bit more reasonable for a small to mid-size home-based primary care practices. And it's a PMPM or one of that per member per month, flat monthly risk adjusted fee for your patients that are attributed to you, plus a flat visit fee and an opportunity for quality bonus. And we're going to talk more in detail about that. And there's always the opportunity for you to contract with Medicare Advantage plans directly in your area. If you don't know what MA plans, you know, you can, you can find a lot of that information online. So be thinking about who your major Medicare Advantage plans are, because they have so much more flexibility on the supplemental benefits they can offer on how they can work with you to really care for their members. And then Amanda's going to talk about MSSP and kind of forming that ACO relationship. Next slide. So, direct contracting, as it stands today, and the GPDC stands for Global Professional and Direct Contracting. That is the model that the first performance year started in April of 2021. There's currently 99 entities that are currently participating. Some of you who are following the news may have heard there was a big change, and they weren't sure if they were going to continue this model, even after the pandemic. And so, we're going to talk a little bit more about that. They weren't sure if they were going to continue this model, even though it was really, really good for value-based care evolution. So, rather than getting rid of it, they said starting January 1, 2023, anyone currently participating, as long as they're in compliance and can meet the new requirements, they're going to keep the model with just a little few tweaks, and it's going to become ACO reach in 2023. So, just kind of familiarizing yourself with that language. There is no open application period right now. They did open up a new application period for if you weren't in direct contracting to join ACO reach. That has been closed. But what the opportunity would be is for all of those organizations have been announced and published on CMMI's website. Again, these links are in the slides. I'll put them in the chat as well. But they need that preferred and that participant provider network. So, do you understand who these people are? Some of the opportunities that we saw relevant to home-based primary care is we saw even independent small nurse practitioner-led practices were getting approached by these larger entities because they needed a home-based care solution to care for their patients. So, again, we have 99 participants in this model right now. A new cohort is going to be joining that in 2023, and direct contracting goes away and then becomes ACO reach. The difference here is how much risk you're going to take on. So, if you're in the professional track, you have to take on 50% of total cost of care insurance savings and loss, whereas the global, you're accountable for 100% total cost of care savings and loss. So, that's really the big difference if we go to the next slide. And again, I would never recommend if you are new to value-based care to starting with a full risk model, right? You know, that's generally something you want to work your way up to because, like Amanda said, there is a downside, right? It's not all good news. The difference with the different types, so this is all still ACO reach or currently direct contracting, is there's different types of ACOs or different types of entities. The standard, where it differs, is you have to have 5,000 lives attributed to you. So, that's generally a larger organization. Home-based primary care would be joining it as a participant or preferred provider. The new entrant ACO, they gave them a slower ramp up. If you're new to value-based care, you had to have 1,000 lives or 1,000 patients attributed to you in the first performance year, 2,000 in the second, 3,000 in the third, and then growing up to 5,000 in 2026. So, there's still a commitment to growth with that. And then, where we saw a lot of more interest from home-based primary care is with high-needs DCEs or these high-needs that are going to be ACO reach in 2023 because those only required for the first performance year to have 250 patients attributed to you. And then, the next year, by the end of 2023, you would have 500 lives moving up to 750, 1,200, and then 1,400 by the end of 2026. So, it gave them a slower ramp up and an opportunity for those smaller organizations caring for really sick, really complex patients who have social and functional impairments, multiple chronic conditions. These are home-based primary care patients. And the cool thing that we saw, too, is there were a lot, I shouldn't say a lot, but there were some home-based primary care practices that decided, and palliative, for our palliative friends on the phone, that decided to come together and join a consortium of practices. So, they actually created a new entity by combining their practices so they had those patients and so they can make that growth and then to participate in this model together, being accountable for all of those things. So, those are just to give you an example of some of the opportunities we're seeing with this. And, Amanda, I saw you come off mute. Yeah, I was just going to add to that to the point that there were some groups that came together. And so, what we saw this year and what I think we should expect a lot more of in the coming years is kind of TPA conveners. So, people who are doing the third-party administration help to process. They might provide the technology. They'll process the claims processing of the direct information and data from Medicare. And then this allows you maybe to not meet these individual thresholds, but as a group join together and meet the thresholds. But to the extent, and there's quite a bit I know that Brian is about to go into, but there's quite a bit that you have to do on the compliance side, the equity side to keep those pieces up, and the ability for these models to then, again, hire a convener who pulls people together and also acts as a TPA, not processing claims, but all the other functions that a TPA might have. And we saw that rise really happening around private equity-backed ideas. And so, and I think we'll continue to see that. And I think for smaller practices, that's going to make a lot of sense to partner to see, even if you're a large enough practice to be in these, to do all the back-end stuff might be really cost prohibitive. So. Yeah, that's a great point. Because again, if you're sitting here thinking, and we can go ahead and move to the next slide, but there's no way I could participate in something like this. Think about the partnership opportunity. Who else is doing it? There's a lot of those conveners, or think of an MSO, a management services organization that does the management for you, but it's looking for people to join in. So that's really the opportunity for small to mid-size home-based primary care practices. And like I said, we saw a flock of home-based primary care practices getting approached when that last application period was open, and they were trying to build their participant and preferred provider networks, both community-valued and home-based primary care programs. So this is kind of what changed. Obviously with CMMI focusing on health equity, ACO reaches, and starting in 2023, have to actually have a spelled out designated health equity plan, and they have to report to CMS annually what their goals are and how they're working towards those goals. We talked a little bit in the last workshop, there are Z codes, ICD-10 Z codes for social determinants of health data. And right now they're fairly underutilized because they are typically not HCCs. A lot of providers don't know about them, but you could use that in kind of a quality improvement focus. And this is where I think it's going to start tying into some of these payment models in the future, is they want to see impact on social determinants of health data and kind of what you're doing to close those gaps and things like that. So if you're not familiar with kind of thinking about social determinants of health and how you would track that in an actual kind of quality improvement way, I think this is where we're going to start seeing more of that. So they're not typically saying that that's a hard requirement right now, but they are going to expect some collection and attention to social determinants of health, and they need forms of data to do that. So that's where that'll be interesting. Again, with the new model, they just really wanted to make sure that the participating providers, which are the organizations, the provider groups that are actually caring for patients, have governance structure. So that's probably a good thing. The other benefit to participating in value-based care programs like this is additional flexibility. We talked about how you can innovate your care model. So they added one new benefit starting in 2023 for nurse practitioners. Most of you know, hopefully at the federal level last year, because of the legislation that was passed as part of the just ever-changing environment, nurse practitioners can independently sign and order home health at the federal level. Some states are still pretty restrictive on that, but that was put into federal permanent law. Well, under ACR REACH, they're giving nurse practitioners authority to independently sign an order for hospice, which we don't have yet, as well as diabetic shoes. I know Amanda always laughs at that. As non-clinicians, we have to Google what's so special about diabetic shoes and things like that. So some of the other examples of benefit waivers are telehealth expansion whenever the public health emergency ends, post-discharge home visits by other interdisciplinary professionals, maybe nurses and social workers under general supervision, a three-day SNF waiver where your patient would have to have that three-day inpatient hospital stay if they needed nursing home care. So there's a lot more opportunity, again, for you to kind of innovate this and maybe some of the benefits of why you might want to think about a value-based care model in the future. Next slide. So how is this measured? Any model is going to have some sort of quality measurement, right? You have to perform at a certain level. They generally measure you against a national and a regional benchmark, and only the top X percent gets that shared savings or gets that quality bonus, depending on the payment model. So this is specific to ACR-REACH. They're looking at risk standardized, all condition readmission rates, unplanned admissions for patients with multiple chronic conditions, days at home. That has been a huge one that we're starting to see across multiple models. How many healthy days at home was your patient not in a skilled nursing home or not in a hospital? And then timely follow-up after an exacerbation. So these are all things that Medicare is going to measure based on claims data, and they'll give data to practices annually on how they're doing, and that's how they're going to be measured from a quality standpoint in ACR-REACH. Patient experience. CHAPS is the Consumer Assessment of Healthcare Providers and Services. That's just a patient and caregiver experience survey. They're going to, you have to, if you're the ACR or the larger entity, you have to pay an expense to you, a third-party vendor, to anonymously survey your patients, and they ask about things like timeliness of care and provider trust and your kind of health promotion, and those are just some examples of questions that would be asked in that patient experience survey, and then that's part of your quality bonus. But Amanda, did you want to chime in? Well, I just wanted to kind of open it up to around the ACR-REACH before we go into primary care first. Anybody, did DCE move into ACO? Did the research launch in next year? Looking into it, want to add anything to, you know, did we miss anything, but certainly your experience with this? Hey, this is Jennifer Perreur from Duo Health. I'm happy to throw in some experience from a past life. We had a next-generation ACO, which is a part of the, you know, kind of the prior versions of all of the ACOs that are primary care-based. I really think that your advice to join a convener is great advice, because jumping in and taking that full risk and partnering with CMS is really tricky, and sometimes they change the rules midstream and what the definitions of the benchmarks are, and it can be really hard if you don't have somebody whose full-time job it is to manage all of the program elements. So, joining a convener and starting as a participant in somebody else's network is just a great idea. I would, like, second that. It's a good way to start. Yeah, and I would say, you know, there are a couple different things we're going to talk about. The ACO REACH comes out of CMMI, and as we saw, they can change it whenever they want to, right? That is, you know, I mean, it was, what, 18 months, the DCE, and then they transformed it, and there was a long time there before they announced that it was going to be the REACH ACO that it looked like it might just be on pause for an extended period of time. Like, they might just stop it. They might just, they could have grandfathered everybody in, or they could have just closed down the program, because they started closing down some sections of it. And so, I think, to your point around definitely changing the rules, you know, when you're going through the Centers for Innovation, it can vary with administration. It can also vary depending on if they're getting the metrics they really need. You know, Brianna introduced this at the kind of top of the slides here, but, you know, Medicare is funded by the Medicare trust funds, which are running out and are expected to run out at the same time the baby boomers hit, everyone is eligible for Medicare and hit 65 in 2030. And so, I wouldn't be surprised if, in this next seven and a half years, CMMI does a lot of different things, does a lot of tweaks to stuff, adds new programs, adds next generations of programs, because from a cost perspective, we haven't figured out how to really care for this largest population. The other thing that they'll have to figure out is it's not, you know, and I talk about this a lot, but, you know, if you look at the birth graphs, like, we're going to have a 30-year bubble, 35-year bubble of baby boomers, and then we don't have the volume after that. So, it is, you know, how much of our infrastructure are we building and what does that look like? And again, that's not as pertinent, you know, we may all be retired by the time that actually ends. But Medicare has to think really long term of how do you control costs today in the future for 2030 and beyond. So, I think, to your point about what can be changed, certainly a lot can be changed here. This is, you know, I think going to be a really interesting program for many. And the idea of joining together is not a bad idea. The key will be, can everybody who signs on with a convener or an MSO, TPA-like, anybody who signs on, do they have the ability to actually lower costs and improve quality? And so as you think about who are the other organizations you would join up with, this is the type of group to look around and start looking at your friends, right? When you go to the Academy in Florida this year, the AHCM, those are the types to look around and say, who are the people that are really like-minded in looking at this stuff? So just throwing that out there, too. Yeah, thank you so much for chiming in, Jennifer. I think, again, these are pilot demonstrations, right? Not anyone that's participating in these. We're going to talk about primary care first, next. There's a lot of bumps in the road and still a lot of uncertainty for practices. That's why Medicare pilots these things. So it's important to know what you're getting into, and especially if you're not, even if you do have the scale, if you're newer to this concept, maybe you don't want to put yourself and your organization at full risk alone. Maybe you just kind of want to partner or kind of dip your toe in and join. So please, as we go through this, anyone else that wants to share experience would encourage you to chime in. You can raise your hand, too, or just unmute yourself. And the way I, as you are all thinking about your questions, the way I think about it with my board is by 2030, and generally that concept of many, all, most, and now we're due to all need to be in value-based contract by 2030, has crossed administrations. So this is not, you know, a Democrat-led administrative idea that has been going on out of CMMI for years, and now we're in the all by 2030. And so for me, like if you think about the runway of thinking about this program, getting approval, getting into this program, running a year or two, right, if we have seven and a half years between 2030, I can say not an HCCI opinion, but my personal opinion is, you know, try to find paths that are the least risky, financially risky, so you can start learning how to work with Medicare, because if you're required by 2030, you're going to be behind the eight ball because other people have already learned to work with them. And it's not, you know, Jennifer, to your point, like they're, you know, Medicare is a giant organization that by the time they mandate it for all in 2030, it's not going to be really smooth. And, you know, there still might be lots of different pilot projects. And so just understanding the ins and outs of how to work with Medicare, I think is, it's a good test ground and figure out what is the right program that's going to have the least financial downside or the least risk to start. And then you can always morph over the next seven and a half years. Sorry, and I cut off if there are any future questions. So now I'll ask, you know, I'll ask Brianna, any other questions about ACO Reach? The other thing you can do on the Innovations Center website that I put in the chat is you can search by your state to see if there's any state-based programs or what might be going on, you know, around you. That's always a good idea, too. Again, they publish the names of all of these entities. You can find out who they are, who's in your region, or, you know, like the state of Maryland had a really cool total cost of care model that was just for the state of Maryland, for example. So, you know, you can also think about at the state level what might be going on innovation-wise. Okay, so we're going to move on now. We're done talking about ACO Reach. We probably should have a transition slide. Now we're going to talk about primary care first. So primary care first was not nationwide. They focused it on 26 different regions, 26 different states. But they did have two separate cohorts. Again, the application period is closed. Right now there's two cohorts. That makes up approximately over 3,000 primary care practices. And this isn't specific to home-based primary care. This is any what Medicare considered an advanced primary care practice, which is why I really like this slide, because I think they finally put some concrete kind of expectations about what does it mean to be an advanced primary care practice? What kinds of things, again, as you're preparing yourself, do you need to do to be considered a comprehensive primary care practice that can participate in some of these things? And so if we think about even just home-based primary care practices, right, you have to think about all of these things. Medicare actually came out and put definitions around these things. When they think about access and continuity, they said that means having 24-7 access to their practitioner or their care team. That doesn't mean you're going to go make a house call at midnight, but what are you doing with after-hours coverage? Can they reach you? Can they get medical advice in case of an emergency? For care management, and Amanda and Paul have a really great kind of portion on this during the transition session, but they wanted you to attest that you provided risk stratified care management. I worked last year really closely with a couple new primary care first practices, and we had to think about during the application how we could prove the point that they do these things, so that you actually had to kind of have a narrative form, examples of how you're doing all of these things when we submitted their primary care first application. When we think about comprehensiveness and coordination, they wanted to see how you were integrating behavioral health needs and access to specialists for your patients. So maybe you have social workers, maybe you made some, you know, telehealth has been great to open up behavioral health access and access to specialists. Maybe you partner to make that service available. I know some home-based primary care practices that employ psychiatric trained nurse practitioners, and that's been really beneficial for their program. So lots of different ways that you can think that, but you actually had to attest to how you're doing all of these things. For patient and caregiver engagement, they wanted to see a regular way that your patients and caregivers had a voice to give you feedback. That could just be annual surveys. Some practices have patient and caregiver advisory councils, things like that where they can get feedback from their patients. And then for planned care and population health, setting goals and being able to demonstrate continuous improvement. So I really like this slide, regardless of if we're talking about primary care first or not, because I think it really just sums up in a nice way. What does it mean to provide advanced or comprehensive primary care? Next slide. So this is why primary care first was a little bit easier for some of these small to midsize practices. Again, there's office-based primary care practices that are primary care first practices, too. This wasn't specific to home-based primary care, but it was an opportunity for home-based primary care practices and palliative. You had to have, well, more primary care than palliative unless you had a partnership, but you had to have only 125 lives or patients attributed to you for primary care first. But your primary care did have to account for over 50 percent of your billing. The demonstrated experience with value-based care, this is kind of where I was leaning on Amanda's comment of, like, how much can you stretch the truth, right? Can you demonstrate, like, when we were attesting to this in the applications, we talked about working with Medicare Advantage plans and, you know, doing some other things that maybe wasn't like a formal value-based contract, but don't, you know, sell yourself short. EHRs, hopefully everybody's using a certified EHR. You know, there's a ton out there. This is why it's kind of important. It gets bundled into these requirements because when we think about interoperability, they want you to have patient portals. They want you to have your patients to have secure electronic means of communicating with the practice. That's why this gets thrown in here as a requirement. That HIE is Health Information Exchange. If you weren't actively using one when you signed the application, you just had to by the start of the model. So there was an opportunity if you weren't, you know, having access to, you know, getting discharge or admission information for your patients and then sharing records for you to kind of look into that, which can be super beneficial. And then again, that 24-7 access, which doesn't mean you're going to drop everything and make a house call, but that you can prove that your patients can get a hold of you for medical advice 24-7. And I was just going to say, I don't know if you, I might have missed this, but like the first trigger point for getting into primary care first is you practice in a state that offers it. So there are only 26 that offer it. Like I'm not in a state that offer it, that offers the option to get in. Again, another program through CMMI, they have the ability every year. Am I going to expand it? Am I going to shrink it? Am I going to pause it? We've seen this one stay relatively flat, but they've not been adding states to my knowledge. So I think, you know, good and bad there. Again, they're not making major adjustments every year to this, and it's not expanded all 50 yet. Yeah, that's a good point. So 26 regions, again, this was not a national model. There was that kind of addition demographic or geographic consideration to even be considered for this. Like Illinois wasn't a primary care first state, for example. But, again, the reason we're talking about this is for you guys to understand what's out there. They did open it up to a second cohort last year, so who knows? Maybe they'll open it up to a third with new states in the future. I think they're waiting for the end of this performance year to kind of evaluate and then go from there. Next slide. So this is just an example of why we have a whole session dedicated to HCC risk adjustment and how your ICD-10 codes pay into this, but this is why it's important in value-based care. Your flat per member per month, so your per patient or PB is just per beneficiary per month payment, is risk stratified based on the average HCC score of all your ICD-10 codes. What is their HCC score for the population that you care for? And if you were generally home-based, primary care would fall into groups three and four, but that's the difference between $100 and $175 PM-PM. And then you've got that flat Mississippi was only about $40. So what that means is you can't separately get paid for things like chronic care management in primary care first because they consider that bundled. But every time you go and do a visit, you still bill for it, but rather than getting the Medicare fee-for-service rate, you get a flat $40 because they're already paying you a per member per month rate plus that flat visit fee. So, again, you're still doing the same thing. You're seeing your patients as often as they need, and you're doing all those chronic care management-type activities. You're just getting paid for it in a different way than fee-for-service. But this is where, again, we're going to talk about HCC and risk adjustment. This is why that's so important before you get into a value-based care model, because I will tell you some of the home-based primary care practices that I worked with that are part of primary care first were kind of sadly surprised when they fell into group three just because they really weren't doing that great at HCC, and they looked back. So they have an opportunity to get into risk four next year. But this is why you really want to get good at HCC coding before you get into one of these models, too, because it could impact your payment tier. And so that's why you want to start thinking about those things now. We have a whole session if HCC is a little freaky or you want to learn more. We're going to talk about that. Next slide. Just another kind of example of how the payment structure works as far as the quality bonus. So the next slide, I'm going to show you what the quality metrics for primary care first are specifically. But, again, you're getting that flat monthly per patient fee plus $40 every time you visit a patient. The other thing that you have to be prepared for is cash flow and having kind of money in the bank and taking on a little bit of uncertainty, because although there's opportunity for a quality bonus, those practices had to wait a year, right? Practices in cohort two still haven't even gotten their quality bonus because they're waiting for the end of this performance year to evaluate that. And it's only the top 50% of practices that were high performing. So did you meet the benchmark? Did you perform well on your quality metrics? Yes or no. And then, again, because they have to make these payment models budget neutral, if you didn't, if you were really kind of below performance, you could potentially have a penalty that's enforced for quality. So there's always a little bit of risk with these models. Next slide. So, again, this is just kind of what we would hope that you do is all these payment models that we're talking about, where is the commonalities with the quality metrics? So, like, what is CMS or CMMI paying attention to in multiple models, and how can you track that in your practice today? So practices groups three and four, what I do really appreciate that they did is they're not measuring us on people who have an A1C or controlling high blood pressure, if you have really sick patients that typically fall in that home-based primary care category. Instead, they're focusing on that, you know, patient and caregiver experience of care survey, advanced care planning, and days at home. So there's that days at home quality metric, again, that's come up. And then advanced care planning, how many of your patients have a documented advanced care plan? You had to test for that, you know, by billing for it or using the quality code that was documented and then addressed in the annual period. So we know advanced care planning is super important. I know Dr. Chang will get into that from the clinical side later. But thinking about these things, pick one to three quality measures, whether they're these or something else, that you can start to track now so you can tell that data story, so you can tell that story of the value of the care that you're providing and maybe get a partnership opportunity moving forward. Any questions or comments that people want to share so far? Questions about primary care first, things that you've, even whether it's not primary care first, things that you've done in your practice. This is Alina. So just speaking from a personal experience, in the past, since 2011, since Meaningful Use came out, I worked for Advocate Healthcare. It's a big healthcare organization in Illinois. And we started to implement MIPS or Meaningful Use known back then to more than 500 physicians. So just like my advice, and that's what I'm trying to incorporate in my practice because we just started, but my experience, you know, we want to start tracking the measures. You know, a couple of, I guess, recommendations from the experience that I have that I would give to practices, whether they're currently reporting for Meaningful Use or MIPS or they're thinking about reporting, you know, kind of utilize what you have now. I think that, you know, we, and I worked with practices in different specialties from 1 to 30, you know, orthopedic physicians. All the clinical measures are different for every specialty, right? Implementation process is hard, right? So, you know, reviewing those reports of physicians, saying what they're doing good, looking for areas of improvement. So when you're trying to scramble and get that data to see where you are and get like your kind of benchmarks, my recommendation would be is use what you have. So if you're using an EMR, especially a certified EMR, something like MIPS is implemented to track those clinical measures. So if you're not knowledgeable enough with your EMR, reach out to that contact who you're working with when you did the implementation. Ask them what reports are available. Sometimes they do charge an extra fee for that dashboard. If you're, what I found from reports, there were a lot of views to these practices because they're independent providers, but they're still affiliated with the hospital system, right? So reach, you should be getting reports from your hospital system or reach out to them and say, you know, what are my metrics? How am I doing? Even for referral process, readmissions, you know, per 1,000, things like that. So you will be surprised at how much data you already have. So you don't have to think that you're scrambling to pull all that information. Also another point, I think the next level, and I don't think you guys, I did not see an agenda that we're going to discuss today, is a program called PCMH, Patient-Centered Medical Home. It's a recognition through NCQA. You can look it up when you have time of what it is. So what we did with our providers in my previous life is after we have tested them, you know, those 500 physicians, we have tested them for meaningful use through CMS. The next step we took with them is implementing that PCMH model. And actually PCMH model is based on the MIPS or, you know, MACRA measures. It just kind of expands on them. So when we're talking back about, you know, what points, what value you can bring to these organizations when you're having these conversations is, you know, some of the physicians who they use that, you know, NCQA, like I'm a patient-centered medical home level three recognized practice. People in healthcare, a lot of people know what that means. And it speaks volume. So yes, it's a certificate you get and it takes a lot of work, but it's the next step after meaningful use. And I would encourage people to look into it because I think that speaks volume. Yeah, thank you so much, Elena. It's funny, I feel like I heard so much about PCMH like years ago and now like the hype kind of died down a little bit. But to your point, if you can say when you're trying to go in with a payer negotiation, hey, I'm a PCMH practice, or, you know, I've done this, that kind of demonstrates your experience and your kind of quality. So definitely, and I can put a link in the chat later to some information on PCMH. Again, it's not a payment model. It's a designation that actually, you know, is a time and cost expense to the practice in order to go through and do. But some people have similar to your experience shared that it makes them more marketable to pay your partners and contracts and things like that. So thank you so much for sharing your experience. And we also, you also have states. So like the states can certify you as a medical home too. And so some state programs. To that point, I do think that potentially states may in the future tie dollars. The idea years and years ago when they created patient-centered medical homes was that federal, and that did actually have some dollars, but federal and state would have dollars. And, you know, at least the state of Minnesota has not yet combined dollars to that. We're in it to see if maybe there one day will be dollars tied to it back with the state. But I would say for us, you know, it's a lot of work to do all of that paperwork. And it's not yet tied to reimbursement. So hopefully we'll see those come together. I agree. And I think the reason why they did, you know, why we did it with all those physicians is, yeah, it is a cost. You know, there's an application cost and there's a whole process. So definitely you can't just jump into PCMH without, you know, going through the Meaningful User, the MIPS process, and make sure that, you know, you're reporting year after year and successful and have all your workflows in places. So it is a lot of work, and yes, I do agree. I hope there's some incentives that tie, you know, they get tied into PCMH recognition based on two different, you know, three different levels of recognition they have. I think for right now, you know, if practices are interested in it and can and have resources to do it, it just adds another value. But I think in the long run where everything is going, I think that it will play a role somewhere down the line, or at least I hope so, because it is a pretty, you know, it's a lot of work and it's hard work, and it's a good recognition level, you know, well, especially if you're level three recognized for that program, so. I think there was another question. Nancy, was that you that was gonna chime in? So who was that, who were you saying? I thought someone before we were continuing was unmuted that asked our question. Anyone else wanted to chime in? I know there's a couple of questions in the chat we'll bounce back to before we move on, Amanda, I thought you said. Okay. Okay, we'll chime in if you haven't. Dr. Hun, to answer your question about, are the metrics adjusted to the area you service? So the quality metrics are risk adjusted, not that, I mean, there are, you know, as far as the flat visit fees and geographic adjustments and things that go on in the quality bonus, but so I'm not sure if that's what you were getting at. Again, they look at your whole patient population. That's not, you know, necessarily patient specific, but all primary care first practices had to, you know, if you were three or four, you all were measured on advanced care plan days at home and the patient experience survey. So there was no exceptions to that based on region. So again, for, and I know Tony, this got into your question for the specs for advanced care planning, you had to drop either the advanced care planning billing code or the quality code for every patient, at least once a year to show that they had that conversation and they had that advanced care plan documented. The days at home is a claim based measure where Medicare just looked at healthy days at home, not in a hospital, not in a SNF or an institution in the light setting. And then that patient experience survey, again, that's something that the practice had to pay for a third party vendor to anonymously survey your patients. And then that's just a, again, very similar to patient satisfaction, but they call it patient experience and looking at those measures. But Amanda, anything else to add there? I was going to ask on a cost side, the ACL reach is tied to your county rate. So that is specific to your service area. If you're in a convened organization, I'll take the, you know, the average of that, the weighted average piece there too. So I wasn't a thousand percent sure where that question was, but. Can I chime in a little, if you don't mind? So when I was looking at primary care jobs in particular, and I looked at value-based organizations, they had quality metrics for say the suburbs compared to the inner city. And they would show me the stats and the suburbs, you meet those quality metrics a lot higher than the inner city. But in my opinion, the inner city is where a lot of it is needed and a lot of the healthcare can accumulate. And I just thought that if it was more kind of region specific, that would encourage more primary care providers to service those areas. Because especially for models like these, if you're joining one of these models and you're wanting to service the inner city, you're going to accumulate a lot of cost because of the compliance issue. I'm not aware of any of the models adjusting quality metrics to regions. Am I wrong about that? Well, not necessarily quality metrics, but one thing that they're doing with ACR reach, is they're trying to focus on rural areas. There is an opportunity for a potential bonus or adjustment if you can show that you care for a certain underserved population. So that's kind of the closest that I've seen it get into. Again, the core quality metrics don't have that geographic, based on location adjustment, at least for the models that we just talked about. But I know ACR reach is looking at a bonus adjustment if you serve a large percentage of an underserved population. That's probably the only other similar thing I've heard of. I also think that's the idea potentially around where some of the collection of data around social determinants of health. So we really only talk about that metric here in these two days, but we talked about it a little bit on the essential elements of, I think there could be, I could see a world where if you use the Z codes, that it would start waiting differently. Right now we have Medicare's completely based payment on acuity, but I could see social factors intersecting in that weighted model in the next couple of years, next five years, next 10 years. So I think potentially that again, I'm not sure then if like quality measures would adjust or you would just receive a higher payment structure, generally like the individual quality measures or HEDIS, the subset stars, and they're compared to the entire population that you're looking at, whether it's kind of a narrow network or kind of your Medicare population. Yeah, and I'm gonna start it over and Amanda, but I did, for those of you that didn't attend the central elements, they did just put a link in the chat on some information on those Z codes that we're talking about for social determinants of health. Again, those are ICD-10 diagnosis codes. Right now they're not necessarily tied to payment or HCCs, but they could be a good way to track kind of a QI project or evaluate, you know, what kind of social determinants of health needs your patients have and then how you might fill those gaps and drive intervention. I think, especially for those who haven't put together yet a robust HCC capture plan, and we'll talk about that day two tomorrow, this could go nicely with, if you're gonna roll something out of capturing data on individuals, that you could roll the social determinants of health right in that. And even though it might be a little bit harder for those who already have programs up and running to kind of start thinking about it, but for those that are brand new, you know, just kind of make it a one in there, you know, a two in one to, what is the saying? Kill like two birds with one stone. There's really bad. That's really bad saying really, but the same, I guess it works. Really bad saying. So should we talk about Medicare Shared Savings Program? So here's some basic definitions that we talked about. So Accountable Care is just a group of, and these can be found on Medicare, but it's a group of, you know, doctors, health providers, health systems that are taking responsibility for improving that quality of care, care coordination and the outcomes. And it's also ultimately reducing costs, improving quality. An ACO, so Accountable Care Organizations are groups of these that are doing this high quality coordinated health services and coordinated care and managing costs. And so ACOs can, you hear it used a lot. You hear it as REACH ACO. Jennifer, you've talked about NextGen ACO that was after Pioneer ACO. I'm going to talk about Medicare Shared Savings Plan next. And that's also considered an ACO. Private health insurance plans might have ACO networks. And so you might be a purchaser for your company for health insurance and your network might be an ACO. And again, it's this idea that we can group hospitals, doctors, health systems, we can group things together and put that then ACO at risk. So it acts in my mind, a little bit like a network, kind of like a HMO network idea, except everybody in the network is fundamentally responsible for the cost and quality of care given, unlike an HMO network. So, but it does create these groups of patients. So it gets used a lot. It's not an exact program so much as it's a concept, again, that people are using often to group cost and quality together. And that leads us to the final definition, which is value-based care. It's paying for health services that directly links cost and quality and the patient experience. And a lot of people have seen kind of cost, have kind of seen some sort of cost quality value kind of proposition over the years of what that looks like. I'm using, I tend to use value-based care in the very broadest sense as anything that's not just fee-for-service. But again, a true value-based care contract is linking the cost and quality together. And then in the patient experience, you see the patient experience get linked a lot more at the national federal level because they have some of those abilities versus being directly responsible at kind of an individual MAA plan level. Oops, I was advancing and my advancing doesn't work. Okay, so an MSSP overview. This is a voluntary program that encourages, again, these groups to care for Medicare beneficiaries. So it's Medicare Shared Savings Plan. They have accountability for the patient population. They coordinate the fee-for-service patients and they encourage investment in high-quality efficient services. And so just a really high note on MSSP. MSSP is actually created as part of the Affordable Care Act. So it's part of legislation. It's one of the reasons I like the program is because to fundamentally change the MSSP, one would have to have an act of Congress, which at this point is difficult. So I kind of like it because it becomes relatively immovable. It does create a couple of different tracks. The first track is the ability to kind of have no downside risk and to just try stuff. Eventually, I do think this will transform into being pushed into downside risk. If you do it after two years, sometimes three, depending on the type of population you have, you could get no downside risk for three, and then it would push you an upside downside with some ceilings and floors until you eventually go into an enhanced model. And again, this is aggregating your original Medicare fee-for-service patients. So part A, part B, anybody basically not in part C, and then because Medicare is not responsible for the part D programs, you get data about part D spend, and you certainly need to think about, in good practice, think about medications, but it's not part of the shared savings model. And the general concept is very similar to how Tom outlined at the beginning. The financial model around DCE is you get kind of a pot of money, and you're drawing against that for all the services consumed inside of that. If there's money at the end of the day, if it's kind of in a track one or track A model, you get upside. If you reach a threshold of over 4%, you start to get some dollars back in the shared savings pool. Anybody want to make a comment on MSSP? I do think that we'll continue to see conveners in this space as well, to try to see people grouped together. We do have, this has been more popular, certainly in primary care, certainly hospital systems. We're seeing the rise of a little bit of nursing facilities. I think we will potentially see the rise of home-based medicine in this space. There are different funding mechanisms between an MSSP and a REACH ACO. And so again, to kind of my point of, think really long and hard about what a platform is that you'll have to kind of beat. Medicare shared savings really sets it up that you're beating yourself and you set your benchmark for five years and you're beating yourself. REACH ACO generally sets up that you're beating the county, the county rate. And those are different components. And so I think, again, I think there's some interesting places here that home-based primary care will continue to grow in. But any MSSP utilizers, comments? Okay, slide. Okay, let me check. I have one slide on Medicare Advantage. So Medicare Advantage is part C. This came in as part of, let's see, the Balanced Budget Act of 97, and really wraps together part A, B, and part D into one product. So it's actually a replacement plan responsible for the Medicare benefits. So it's not MedSup, MedStup, it's not included in this. It's not filling the gaps of Medicare. It is Medicare passing on the risk and the cost and the quality to a partner. And this is really gonna be another health plan. And so premiums tied to overall risk score of the member population, and then you're held accountable for the HEDIS measures. And really those are kind of the five domains of effectiveness, access, experience, utilization, and kind of descriptive information. Typically we would see our types of practices be delegated providers. So we're not creating the Medicare Advantage plan, but we are working as a delegated provider inside of that. And then again, so you can contract directly with providers and services, and that would be us. Anybody have some Medicare Advantage experience that they'd like to share? So, and the other programs really exclude Medicare Advantage. So these are people, again, who aren't on original Medicare, aren't qualifying for some of the other programs. This is his own service. And we see a wide range of Medicare Advantage plans. Some of them are $0 premium, high deductible, you know, different deductible incentives or co-sharing, or excuse me, cost-sharing dollars to push someone into higher or lower utilization in something, right? Maybe the hospitalization stay is $5,000, but there's a waived copay on visiting primary care or having them visit you in the home, right? And so we see lots of different health plan design in Medicare Part C. So certainly interesting to talk about and to think about your networks of who has Medicare Advantage patients today. The way I always start with where should I focus is take all of your patients, pull the revenue report, and group them together, and just create a pie chart with numbers and percentages of everybody and see where your biggest bang for your buck is, right? So do you have Blue Cross Blue Shield, Medicare Advantage plan, and 25% of your patients are in that, and everybody else is a mix of original Medicare, other plans, duals. You know, do you have 40% in original Medicare just buying A, B, and Part D separately? Okay, well, maybe start with that program. So I think this is an interesting way to kind of cut the data, and certainly there are opportunities inside of Medicare Advantage plans. Slide. I was just gonna add, Amanda, on Medicare Advantage, I think some of the unique kind of opportunities, like small opportunities, where I've seen home-based primary care practices work with Medicare Advantage plans is, hey, I'll do in-home annual wellness visit for your patients, or I'll do in-home transitional care management for you, and then they kind of work out a way to get their foot in the door that way. So there's no right or wrong way to do it, but again, just kind of, Medicare Advantage is much more flexible than traditional Medicare with how they can work with people and kind of the supplemental benefits and things that they can kind of pre-program for, if you will. And there are two types- To your point, they can be very difficult as well. Oh, very difficult, very difficult. There are two types of patients. There are the patients where you can lower costs to where you make money, and there are the types of patients where you just are lowering the loss and you're lowering the spend. And one potential idea, again, within a tight network, is go to a Medicare Advantage plan and say, I'm interested in your top 5% of your utilizers. They know who that is. And you pull those patients out. And that, you don't take risk on. That, you get a straight medical fee management, and it's probably pretty high to go in the house and manage those patients. So again, everybody has a problem they're trying to solve. Everybody has a top 5%. Even if their top 5% is lower than someone else's top 5% of high utilizers, it's still an important metric, and they're still trying to lower it. And so understanding who those patients are, where their headaches are, and I think that potentially is another spot for Medicare Advantage to be in. Unless you had a very, very large saturation of Medicare Advantage patients, and you really felt like it was a spread risk, right? And I would put maybe some of your lower risk in some sort of managed congregate living setting. If you really had that, then you could talk about taking a risk. Otherwise, I think these are carve-outs inside of programs that exist today. Slide. Okay, so another part of Part C is the Special Needs Plans, often referred to as SNPs. And there are really three types of SNPs. There's institutional, those who are living in a nursing home. Sometimes you hear institutional-eligible SNP, so an IE SNP, and that would be someone who meets the clinical criteria to be living in a nursing home, but is living somewhere not in a nursing home. Those locations can vary. They can be the community, independent homes. They could be assisted living. They could be independent living. They could be group homes. And so IE SNPs historically have been nursing homes, but I think they are growing into kind of community. And again, community is a broad term. There are, I can't remember if it's 125 or so, but there's a lot of different types of SNPs out there. There, I can't remember if it's 125,000. I'm gonna get someone wrong on that. In IE SNP, beneficiaries in IE SNPs today, the largest provider of IE SNPs is Optum. The second largest is Caremore. Dual-eligible SNPs are beneficiaries for Medicare and Medicaid. And this is gonna vary by state because it runs through the state program. So it's actually your state having a contract with Medicare to offer dual-eligible SNPs. And sometimes the state will delegate the Medicaid work to another large provider. So they might say, United and Aetna, you are two kind of SNPs and you work on our behalf with Medicare on offering these. Sometimes it goes directly through the state and you really deal with all the state, you know, politics and details of the state. And there's spectrums inside of SNPs. There's the fully integrated, dual eligible special needs plan, a FIDI SNP. There's shared models, and then there's kind of fully unintegrated, disintegrated, never integrated Medicare, Medicaid benefits, but they still could, would be dual eligible, but they may not be inside a program that is actually part of the Part C program that's the official SNPs. Then the final one is a smaller group called chronic condition or the C-SNPs. These are for beneficiaries with one of 15 specific diagnoses. And you might have some of these, you're gonna see C-SNPs be really successful in places where there's large current concentration. And so they're large concentration, you know, New York, you know, Houston, Chicago, look for the health plans that have C-SNPs. And you would, again, you'd see something on their website too. If you have CHF, you can sign up for the special program. Again, I wanna highlight these because they work from a cost perspective, a very similar way to Medicare Advantage. Really the duals add in Medicaid and the Medicaid dollars, but really, again, they are designated contracts with health plans to take risk on these patients. They're just built for specific populations. And you may find that you have a high overlap of patients in these programs. And it might make sense for you to talk with the payer about these. Medicare Part C programs is Medicare pushing down risk on entities willing to take risk for populations. So it's not a direct provider necessarily, it's a payer, but there's still opportunity, you know, and I think we talked about it earlier this morning when you say, hey, what are people really signed up for? What are they trying to improve on? These are the kinds of things they're trying to improve on. These are the, especially if they have the dedication for an organization to create a special needs plan, then they are looking at higher risk patients. The only other caveat I'd add here is, again, these are health plans. We are seeing the rise of not really dual eligible plans, but ISNPs and, I haven't seen CSNPs yet, but ISNPs do partner with the backend TBA to start that for organizations. And so potentially that could also be the case, but it's generally, generally the health plan is gonna hold the H number with Medicare to run these programs. Why shouldn't they have special needs plans for me? Or Rhianna? Okay. Slide. So, okay, just, I mean, our key takeaways were just, there are a lot of different vehicles on Medicare contracting, and they're gonna all continue to grow. The SNPs are gonna continue to grow. They have a very strong lobbying effort. Medicare Advantage will continue to grow as people continue to change benefits as the cost plan sunset in 2019. And so I think that took out like 300,000, 400,000 cost plan members. And so, how do we really think about working with Medicare, working inside of Medicare contracting? Really research the detail. There's so many very specific details that we didn't go in depth on these, but there's gonna, there's start of a lot of webinars specifically targeting, not just, hey, get into value-based care because at this point we're past, it's time to convince you to do it. We're into the space of here specific details and find the detail that works best for your practice. And again, CMMI as kind of the wing of CMS or as the innovation brands, they're gonna keep creating new things. We have got to figure out the cost component. We also have to figure out the quality. I would say, unfortunately, I think cost is the major driver here. And if we can improve the quality, we're gonna see lower costs. So I'm gonna look at the chat. Any final? I was just gonna add, if you're looking for an easy way to kind of stay up to date, you can subscribe to the CMS or the CMMI listserv, just on their website so that you're notified of new payment models or they do, you can choose your preferences on what you wanna subscribe to so your email is not overloaded. I always recommend if you're a practice manager or you're someone kind of helping run the operations, those are things that you should be subscribing to for multiple reasons, not to just stay up to date, but also with policy changes and things like that. So just a super easy way to not have to go search for these things and to kind of be in the loop. CMMI actually has their own newsletter now on APMs that I think they do it quarterly. But if you just subscribe to the listserv, then you'll get those emails. And I would add one final thought. I see some discussion in the chat, which I think is really good around Medicare Advantage. I think if I was gonna kind of provide some sort of summary of my belief, as I look at, I run the payer list for all of our patients and I look at that pie chart and I say, well, how many are in each product and what does that look like? I'll tell you right now, if your patient has a Medicare anything, if they're in Medicare today, there is a value-based contract to be had. Someone, if you lower the cost of care, if you reduce the hospitalization, if you improve the polypharmacy so they have fewer bad outcomes, when you do that, someone is making money on that. And my point is it should be us making that money. Medicare Advantage, SNPs, primary care first, really there is no patient in Medicare again today that couldn't be in a value-based program that you could be involved with. And even if, again, even if they're not today, if you reduce the general original Medicare plan, thank you for us, right, as a taxpayer, thank you for reducing that hospitalization and you should be getting some of those dollars back. So maybe I should open with that, but everybody who, everybody who's over 65 on your patient roster has the ability to be in a plan in which you could somehow figure a way to contract for value. And Amanda, that's a really good transition to our next session, because we're gonna kind of start to move into this clinical block of sessions, starting with medications. And you've identified that managing costs of care is a huge part of your success in value-based care. Well, what does that look like when it comes to managing medications in polypharmacy? And so if there are no other questions at this time for Amanda, you know, she's not going anywhere, so we'll come back to her. Why don't we move into this session with Michael Kingin? Yeah, hi. So thanks, Melissa. Amanda and Brianna spent the morning talking about building the quality and financial impact of home-based primary care. And as we've already kind of touched on, now we're gonna apply those principles to the medications and polypharmacy. Next slide. Here are the objectives we're going to cover. Next slide. In the interest of time, I won't read them all. So what is polypharmacy? Although an elderly population comprises of less than 13% of the population in the U.S., they utilize over 33% of prescriptions annually. Approximately 50% of hospitalized or ambulatory care patients or nursing home residents receive one or more unnecessary drugs, and adverse drug events occur in at least 15% of older patient population, which contributes to poor health, poor outcomes, disability, admission to the hospital. Next slide. So here's where we look to the data regarding polypharmacy, and there are six studies listed here. And the first two are in the ambulatory setting, and Cueto found that one third of female and male patients greater than 75 years old were on five or more prescription medicines in the ambulatory setting, and almost 50% of those were over-the-counter and dietary supplements. Rossi in the ambulatory setting found that almost 60% of all patients were on one or more unnecessary prescription drug. In the hospital setting, Hajar found 384 patients in the United States, 37% of those hospitalized were on nine or more prescription medicines, with almost 80% of the sample on five or more, and almost 60% were on one or more unnecessary med. The NOBLE study was a study done in Italy, and what's notable in this study is on admission to the hospital, 52% of the patients were on five or more prescription meds. At discharge, 67% of the patients were on five or more medications, which is a 15% increase in percent of patients on five or more meds. If you think of extrapolating that over multiple admissions, that really can dramatically increase the amount of over-prescribed meds. In the nursing home setting, Dwyer looked at U.S. residents in the nursing home, 13,500 patients, and here they found 40% of them were on nine or more prescription meds. And Bronskill did a study in Canada of 64,000 patients, and 15.5% were on nine or more prescription meds. Canada marked a difference compared to the United States, where the United States residents had 40% on nine or more, and Canada has only 15%. So it does make me wonder, what's Canada doing different? Next slide. So thinking about polypharmacy, there's a number of factors that you should consider. The first is the physiological changes associated with age, and these are largely the change in composition of muscle, fat, and free fluid in the body, and overall change in organ function. Under-prescribing speaks to not treating patients with conditions that are preventable, such as anticoagulation therapy in AFib patients, or not achieving blood pressure goals, or not screening and treating osteoporosis. Over-prescribing is simply over-increased dose or increasing drug utilization that may not be necessary. Mis-prescribing speaks to prescribing an error. Prescribing cascade, I think we're all familiar with, is the addition of a drug to counteract a side effect of another drug. And recent hospital, thinking about the studies that we just talked about with the increase in drugs at discharge, when you're evaluating hospital follow-up patients, you should consider looking at their med list and what medicine did the hospital start that may not be indicated now that they're back in the home setting. And the same thing really goes to specialists. When my patients see a specialist, in the really rare instance that they go out to see a specialist, often additional medicines are added that may not contribute to improved quality of life outcomes or the patient's goals of care. So whenever they go out to see a specialist, I think about some medicines after that visit. Next slide. So thinking about polypharmacy medication management, we want to think about what evidence-based tools do we have available to providers to use. And there's two validated tools listed here. The BEERS criteria, most folks are probably familiar by now. It's published by AGS. I believe the last update was in 2020, and it focuses on over-prescribing. And with each update, they've really tried to simplify the tool to make it easier to use. It stratifies medication classes by the degree of risk. And then it sort of says, avoid or use with caution or limit use. And those with the greatest risk are usually listed as benzodiazepines, first-generation antihistamines, those types of things. And then the BEERS criteria, by the way, is usually, you can usually find it for free. And then the Start-Stop criteria is a European tool published by the European Agent Aging. And it helps, the Stop portion of the tool is a screening tool for older persons potentially inappropriate prescriptions. And then the Start portion of the tool is a screening tool to alert the provider to the right treatment, and it organizes risk by body system. Next slide. Next slide. So when you're doing your medication review with your patients, you always wanna remember to include over-the-counter supplements. And oftentimes they may bring out several bags of medications, some that they're taking, some of them that they're taking some of the time, and some of them that they're taking most of the time. Thinking about compliance, you can use the mnemonic WEBS, W-H-E-B-S-S, or adherence is probably a better word for this. And that speaks to what medicines are they taking? How are they taking them? This is the one that I think is most important, because you find out that they're supposed to be taking two 20 milligram tablets of furosemide, and they're only taking one, or they're supposed to be taking a medication multiple times a day, and they're only taking it one time of the day. So how are they taking it, or are they taking it with food without those types of considerations? And then does the medication work? And if they're not taking it, what is the barrier to taking the medication? Do they have any side effects? And then do they miss doses? They usually say something like, in a week, how many times do you miss a dose? Giving the caveat that it's expected that at some point, everyone's gonna probably miss a dose of their medicine. And then once you review the med rec, then think about applying either the beers or the start-stop to consider deprescribing. Next slide. So thinking about which drug to stop, you may think that there was no indication found for it. It's no longer indicated. You know, they're beyond PCI with stenting, and they no longer need their antiplatelet therapy. Those types of things are pretty easy to just stop. Is it part of the prescribing cascade, or was it a medicine that was used to counteract an adverse drug reaction? You may think about stopping one or both. A preventative drug that may no longer provide benefit, such as the recent recommendations regarding aspirin. Or is the medication too burdensome for the patient to adhere to use because of cost, because of multiple dosing, how many a day? And then think about what drug are you gonna prioritize to stop? And the first one is sort of the one, you should think about the ones with the greatest risk. And as the beers recommends, benzodiazepines are at the top of the list that are often the hardest to get patients off of, or maybe the over-the-counter drugs. If they're not taking the medicines, those are easiest, often easiest to stop. I do find you may need to build a trusting relationship with the patient and the family, so if it's your first visit, you may try to focus on only stopping medicines with the greatest risk. And then implement your plan, and then monitor the effects of stopping those drugs. Next slide. So here we're going to spend some time with Minerva, a case study in polypharmacy. I think you probably heard about her, and those of you that attended the foundations portion of the program. And we'll use the evidence-based principles and decision-making in her case study. Yep, Melissa's gonna put the case study up. And then while you're reviewing Minerva's case study, hopefully you can see her medication list most importantly, but think about what medicines would you continue, what medicines would you stop, what medicines would you change the dose on? And then we will go over the medicines as a group, thinking about what we would do with her medicines. So maybe I can try to summarize Minerva's case study. It'll be easier. All right, so Minerva is an 86-year-old female who was recently admitted to the hospital for recurrent leg swelling and cellulitis due to decompensated heart failure. She has a history of Alzheimer's with behavioral disturbances. Her dementia was diagnosed six years ago, but it's worsened over the last six to nine months. She's become more forgetful, asking the same questions repeatedly, asking to eat soon after having a meal. She occasionally gets agitated with personal care. She's having frequent verbal and sometimes physical aggression. This morning at breakfast, she got upset and threw her juice to the floor. She's had also recent admissions for UTI and altered mental status. You're seeing her for a follow-up hospital discharge two days ago for the admission for heart failure and cellulitis. She's got heart failure with a reduced ejection faction of 35%. Alzheimer's. Had a stroke five years ago with some mild dysphagia, CAD, hypertension, CKD3, macular degeneration, osteoarthritis, hypothyroid, GERD, a history of breast cancer, recurrent UTI. Let's see. On exam, she looks like she's got some hearing loss. She's got a sacral wound that has some drainage. Her leg swelling is still present. I think those are the highlights. The family is looking for advice on how to manage her heart failure, leg swelling, and avoid trips to the hospital. Does anybody need any additional information to help make and consider her medicines? I'm just trying to be mindful of time and not read the whole thing. I'll give you a few minutes to kind of think over the medication list. Okay, do folks need more time? So the case study is in your handouts, which includes the med list. And there's also a table that looks just like this that you may think about using when evaluating your patient's med panel. So the Dinepazil, what do we think about this? It's prescribed for Alzheimer's. And the beers and stop profile are kind of silent about this. But what do you think about keeping it or stopping it? So I hear some, a vote for keeping. So she's on Dinepazil as well as Mementine. Mementine is also prescribed for Alzheimer's. So just thinking about the risk profile that Dinepazil can contribute to GI upset and insomnia in greater than 10% of patients. And Mementine can contribute to dizziness in greater than 7% of patients. So you might think about stopping one or the other or both. Families often worry that their illness is going to worsen with stopping or reducing the dose. So I do it kind of cautiously and think about if they have a change in mentation, you can always go up on the dose. I'm looking at the chat. Debate keeping both since the risk might outweigh the benefit exactly. Family report that dementia is advanced, but these may no longer be giving benefits. So you might, from the long-term, may think about trying to stop them. And you might need to do so in a stepwise fashion with conversation with the patient and family. And how about the isosorbide? So on 60 milligrams daily, indication is coronary artery disease. She doesn't have any history of chest pains that we're aware of. Considering beers and for stopping, consider the indication. Is this indicated considering there's no active chest pain as her functional status declined to the point that she's really no longer having exertional chest pain and this drug may no longer be indicated. So you may think about trying a reduced dose and monitoring for any new symptoms, especially chest pain. And then how about the furosemide? So I know this is for her half-ref and she's had several admissions for decompensated heart failure. She's on 40 milligrams twice a day. Yeah, so we're gonna probably try to keep this. I'd like to consider what non-pharmacological interventions can we do to augment symptom management, such as compression, how much fluid is she taking in? What's her diet? Is she missing the afternoon dose? So maybe you give her a larger dose in the afternoon, excuse me, a larger dose in the morning. So think about maybe going once daily. Can you monitor, you can't really monitor her weights because she's bed bound. But it's something that we do need to keep. Also wonder if she's having a good diuretic response. If she's not, you may need to go up on a once-daily dosing or go to an alternative like torsemide. So yes, I'm just looking at the chat. We're saying we're gonna keep the diuretic and anything we can do to support the effect, the beneficial effects of the medicine. And the potassium, she's on 20 milliequivalents twice a day supplementation for her diuretic and potassium loss. Beers and stop criteria don't say much about this, but probably can't stop while she's on a loop diuretic. Not sure if she can tolerate a larger daily dose. So we probably would continue this medicine. Might think about checking her out, making sure her labs still indicate it, especially if we're changing the diuretic dose. And then the mag, magnesium chloride, 64 milligrams, two tablets twice a day. Her case review doesn't have any concern of hypomagnesia, so maybe this medicine can be stopped. And patients on diuretics with a PPI low mag may be reversed just by stopping the PPI. So the question is, is this prescribing cascade? We're not sure, but we could think about stopping this medicine. And she is on omeprazole when we get down the list. She's on metoprolol, 25 milligrams daily. She does have half ref and hypertension. On your exams, her blood pressure is 136 over 62, her heart rate's 65. And this may be contributing to increasing her cardiac contractility with the goal to reduce edema. And here, you'd think about is she on Tarotate versus Succinate, and ideally transition to a once-daily dose to avoid missed medicine. It's not effective, or if it's impacting her blood pressure, you may think about an alternative beta blocker like carbadolol. If you do have to switch to carbadolol, you remember that it's a twice-daily drug without a once-daily alternative. Next medicine is the hydrocodone or Norco with Tylenol. What do you think about this? Senator, I wanna give some thoughts about her. Does she have pain? So as patients with advancing dementia, I speak plainly with my patients and family in terms of they understand, and I always say, poop, pee, and pain, and then are they thirsty or hungry? Yeah, so here, Karen's asking, Nancy's asking, when was it prescribed and for what? Is she able to communicate pain? And that's what we're not sure of, but we do know that her dementia with symptoms is worsening. And the question is, is that related to pain or something else, or is it just disease progression? This opioid pain medicines can contribute to adverse drug reactions. So if we're continuing the medicine, we need to monitor side effects. Is Tylenol being used and perhaps maximizing the daily dose of Tylenol without the hydrocodone additive? Perhaps that would control her pain adequately without the risk of the opioid, because the next drug you see there, she's on Tylenol as well. So maybe we could try to get her off the hydrocodone. Nancy's mentioning topical agents, that's great. Topical agents are the first line of medicines for chronic pain in older adults. So I do agree. And the next medicine is the Tylenol. 325 as needed. And perhaps we said maximizing the Tylenol dose, we could limit the hydrocodone dose with the caveat that we want to avoid exceeding the total daily dose. And then the Levothyroxine. I'll give Melissa a second to catch up. She's multitasking with typing and listening and navigating the screen. So she does have a diagnosis of hypothyroidism. Yep, Karen, exactly. So what's her latest TSH? Do we need to draw a TSH? And then of course, is the medicine being given, administered appropriately before a meal with a sip of water? And then we check her labs. Yeah, avoiding co-admission with magnesium. And then miomeprazole, we kind of touched on. She has a remote history of GERD. This may have been prescribed as a prescribing cascade. Perhaps her GERD symptoms were related to another drug. She doesn't currently have any complaints and this medicine, considering the stock criteria, this medication may be contributing to her low magnesium. So we may check her mag, think about stopping the omeprazole. And then in my experience, doing a gradual dose reduction in H2 or PPIs is usually more effective to avoid rebound symptoms. So Nancy's saying, try to discontinue the medicine, likely started during the recent hospital for GI protection and wasn't stopped at discharge. Nadia says, stop the omeprazole. And if she has symptoms, try an H2 blocker. Both good points. So the OccuVite, she does have a diagnosis of macular degeneration. Ears and stop don't say anything specific about this medication, but this may be one that we try to stop. She's also on a multivitamin, which is at the bottom of the page. I think for those of us that have been doing home-based medicine for a while, you find all these supplements that patients are taking in the home that you may not know about in a clinic setting, and they can get very committed to their supplements and you may need to negotiate sort of a gradual de-escalation and, well, which one will you stop today if they wouldn't stop, you know, both magnesium and the multivitamin or OccuVite and the magnesium. So sort of, again, building that trust and deciding where you can de-prescribe. Does anybody have any additional questions about her medication profile? Or did we miss anything? Is there anything that's not being addressed? So the one thing that I have on my list that may not be addressed is her mood, her agitation, her behaviors, her sometimes verbally and physical aggression. That's something that we may need to do. Thinking about, is she depressed? Can we assess her mood or depression? Yeah, is her hearing impacting her mood? So maybe she has impacted ears. That's also another factor that's sort of hidden in her exam that you may kind of forget about. We're not really sure about her sleep habits. We're not really sure about her functional status. So as PTOT indicated, what's her function doing to contribute to her wound care? And yes, constipation is also not well addressed. And we would probably expect that she'll need a bowel protocol. Anything else? I think we've covered everything I had written down. Okay, next slide. So I'm thinking about the key takeaways. You want to think about those physiological changes in our older adults and how they contribute to polypharmacy or how polypharmacy contributes to those physiological changes. At minimum with every clinical change, change in care setting, following a specialist visit, you want to do a really thorough reconciliation of medications as we discussed today. Think about utilizing evidence-based tools to help you deescalate or discontinue medications such as the Beers Criteria or the Stop Start tool. And Wenda indicated develop an individualized deescalation plan for deprescribing. Next slide. So here, if there's any additional questions, I will just say that you do have guidelines for deploying a deprescribing algorithm. Going over the five steps that we just talked about a little bit in a little more detail to help you think about deprescribing. Next slide. Sometimes they say, follow the money. And in my work, I generally find myself saying, follow the medicines. So I hope this was helpful. We did it a little differently this time. So if you have any feedback, we appreciate that. Yeah, thanks so much, Michael. So yeah, we're kind of assessing the time as we go through here, because some things are taking shorter than we planned. So we're actually going to lunch a little bit early. This is a reminder that you have your HCCI learning plan. Please be filling that out. Michael does need to leave us for the rest of today, but he's going to be back tomorrow. So if you have any questions for him, go ahead and throw those in the chat and we'll make sure that he gets them and can address tomorrow. And Nancy, yeah, I like that idea too, of following the medicine. I think that's the first time I'd heard that, Michael. So that's very helpful. All right, we're going to go to lunch. Here's what's going to happen. I recommend you do not disconnect from the Zoom. I mean, if you do, we'll let you back in, of course, but just put yourself on mute, turn your camera off, go enjoy some lunch. And we will reconvene here at 12.50, that's five zero central time. Thank you all so much. All right, very good. Well, let's go ahead and get started. So I'm happy to turn it over at this time to Dr. Paul Chang, who's going to talk to us about managing dementia. Thank you. Well, Lisa, thank you very much and welcome back everybody. First, well, the next two sessions, I'm gonna talk, I'm gonna spend some time and talk about first dementia management of that and the other is heart failure. As I was reflecting on the overall course design and all the conversation that happened this morning, yes, this next two section is going to be clinical, right? Dementia and CHF. We're not gonna talk specifically about money and dollars per se, but when we thought about the course and thought about these topics, I hope you don't see this artificial divide here that good clinical care is so important in terms of, well, not only for clinical outcomes, but also for your bottom line, for revenue. We heard this morning about different payment models, right, CSNIP, MIPS measures, quality metrics such as readmission and so on. These next two are important topics for us to understand and master because patient care depend, of course, patient care depends on our abilities to do so, but also our revenue and our quality. So let me get started. First, we're gonna talk about dementia and I wanna thank Dr. Allison for sharing these slides with us. Next slide, please. Let me just minimize my screen here for a second, okay. All right, go ahead, next slide, please. The objectives for the dementia section, we're gonna talk about the optimal care, treatment goals, management strategies for homebound or home-limited patients with moderate to late stages of dementia. We're gonna try to identify some triggers for behavioral disturbances and assess appropriate preventative and interventional strategies, both non-pharmacological and pharmacological approaches to managing these patients at home. Now, in the many years I've been doing this, next slide, please. I think this is one of the most challenging part of management of chronic conditions. And I'm gonna talk about why in a little bit. I think just to contrast with my next talk that's on heart failure, heart failure has specific guidelines. These are the medicines they should be on when they have this, this, and this, whereas dementia, we don't have specific guidelines. We don't have FDA approved, majority of medications aren't FDA approved for management of their behavioral disturbance. And I think the final stress point is that it is distressing for the patient and the caregivers who are doing their best trying to take care of the patient and also stresses the providers. We want to help them, but sometimes medications are not always effective and we're gonna go over a couple of classes of medicines. So I think those are some of the challenging aspects. There's no clear guidelines, no FDA approved medications, and just the stress that's related on both sides, whether you're coming from the caregiver side or the clinician side. So what are some of the common behavioral changes that we see? We can see changes in mood, that can be anxiety, depression, changes in thinking, delusional, hallucinations. I just saw a patient yesterday and the family, the daughter, who's the primary caregiver, really distressed about mom hallucinating, seeing people having paranoia about imaginary people that she sees outside of her living room. And we can also see changes in activity, whether it's apathy or the more challenging part perhaps is just the agitation and aggression and combativeness, especially when we're trying to do personal care. And then there's the danger of wandering around. And then just in our office last week, we had talked about patients with inappropriate sexual behavior. Those are all challenges that we face, that you will all face as you engage with some of these patients with advanced dementia. Next slide, please. Why is this important? I think many of you already know a lot of these people, a lot of these patients with memory impairment disorder will have behavioral problems. They're associated with significant morbidity and functional decline. I already talked about there's no FDA-approved medication for this, and there's no... I love flow charts, right? Go A, like an anemia workup, right? Do this, do this. You go down a flow chart. There's not a clear roadmap for us to go as we handle some of the challenges that these patients present to us. Next slide, please. So what are some of the tools we have? We have assessment tools, we have non-pharmacologic approaches, and of course, we're gonna spend a bulk of our time today talking about medications that we can use to help manage these patients. Next slide, please. So what are some of the things that we need to ascertain as we engage with our patients? What are the assessments that we should be looking out for as we talk to patient and family? Well, it's similar to any other condition, right? It's about getting the history. You know, what causes the patient to act out? What have we tried in the past? What other conditions does the patient have? Are there other psychosocial needs that's not met? Michael talked about adverse drug effects. Is the patient's behavior potentially due to that or drug-drug interaction? And then what are some of the other medical conditions that we need to think about before we just say, well, you know, grandpa's acting out? Is there a pain that's unaddressed, a constipation issue, urine retention, sleep deprivation, right? Are there other recreational drugs that the patient might be using? We had a palliative care in-service at our office yesterday, and we spent a little bit of time talking about the hot medicine out there. It's THC or CBD. Could some of those, Michael talked about making sure that you also look at non-prescription medications. Are patients' symptoms potentially related to a non-prescription medication or intoxication, alcoholism, and so on? And the final piece, I think, in all of this, and I think you'll see why in a moment here, who is the legal guardian for this patient? Who is the power of attorney? Because we're gonna need to talk to the person in charge and we need to institute or implement medications that are off-label use, that may have a black box warning related to its use. So we need to have that discussion with the legal representative for the patient. Next slide, please. When we talk with a patient that has dementia or is disoriented, take the time, identify yourself, tell them who you are, maintain good eye contact. I know that is so hard to do. I have a tendency, and I confess, with my patients, I look down because I gotta look at the computer, I gotta do data entry, and that might not be a good strategy for these patients. Why are you talking to the machine or are you talking to me? I'll speak slowly, not necessarily yelling. Give them simple yes, no questions to handle. One question at a time, don't give them two or three questions that they have to work with. Nonverbal communication can help, especially now many of us are wearing masks, all of us probably wearing masks as we talk with these patients and care for them. So we may have to use hand gestures to help to communicate better with our patients. Be careful of joking because I'm not a comedian by any means that sometimes when I try to joke, it lands pretty flat. Don't argue with a patient. Don't argue, I have a 103-year-old who often sees there's a train, there's a ghost next to me when I visit her. Their train in her backyard, I mean, they aren't there. Don't necessarily argue or try to convince them that there's no ghost next to Dr. Chang. That really doesn't accomplish a whole lot. Trying to get the person's perspective and then embrace their reality. What do you miss about if they're hallucinating seeing their husband who passed? Maybe just talk about what does she miss about her husband? What was the one thing that really stood out in their marriage and so on? Next slide, please. This is from Dr. Helen Kales. She's a geriatric psychiatrist, I believe. I think right now she's at Ann Arbor, Michigan. She developed this DICE approach in terms of assessing the behavioral disturbances in our patients. And the DICE stands for Describe, Investigate, Create, and Evaluate. I'm sure there are other pathways out there for you to consider, but this is one that has been used that I've seen quite frequently. Next slide, please. There's some other non-pharmacologic aids, caregiver training and supporting them. I can't emphasize that enough. It is really, really difficult work. Again, going back to the visit that I had with a daughter yesterday, the patient's over 90. Many of her siblings live to be 102, three. She's the primary caregiver, the only caregiver for the most part for her mother. And I often take the time just to close the laptop at the end of the visit and just talk to the caregivers, you know, how are you doing? And often that's the time when they start to cry, to tear up, because many of us don't take the time. We focus so much on the patient, and yet the patient depends so much on our caregiver. So make sure we support and provide resources for our caregivers. Yes, she needs me time, and I encourage her to take that, getting social services involved to help support her as well. Environmental adaptation. That could be something like putting door locks on the inside that the patient cannot unlock, putting a lock on a refrigerator for patients who have disinhibition regarding food intake. Give them activity program, such as folding clothes, as an example. Music therapy, aromatherapy. I saw the message down there about lavender being helpful. Robot, whether I have this patient who plays with, it's a pretty cute and somewhat lifelike cat that can help calm the patient and so on. There's pet therapy. I know some hospices do bring in music therapists, pet therapists to help patients with their behavior. And then the simulated presence, for example, in a previous recording or using a smart device, your iPad and whatnot, and trying to engage with a patient. But we're not quite sure if that really makes a huge impact at this moment. And as many of you can imagine, sometimes it's hard for our patients to understand who's that person in the screen that's talking to me. Sometime when we try to do a FaceTime with a patient, they take the phone and they actually put it up to their ear. So there's some limitations to what our patients can do with a simulated presence. Next slide, please. So let's get into some medications. I'm not gonna read them all for the sake of time. And you just, I have trouble hearing myself talk for the next, what, two hours or so. So I will spare you of that. I think I'll just bring some highlights here. When there's psychosis and agitation and aggression, one of the medication commonly used is haloperidol. It is not necessarily safer or better than the typicals. Extrapyramidal effects, tardive dyskinesia, anacholinergic effects, and hypotension can all happen when we use haloperidol. And be careful when using haloperidol in patients with Lewy body dementia can actually make their symptoms worse. Next slide, please. What about atypical antipsychotics? You can see the medication listed there from aripiprazole, quetiapine, olanzapine. I don't have as much experience with brexiprazole or clozapine. I don't have a lot of experience with those, more so with the top four medications. Again, the evidence is modest or questionable at best. There are practice variations between regions. These are slides from Dr. Ellison. And towards the end, I'm gonna talk about what we do here in our office as part of Northwestern Medicine in terms of our approach with patients with dementia and behavioral disturbances. Next slide, please. So what harm can they do? They can make patients fatigued, sleepy, orthostatic hypotension, trouble walking, tardive dyskinesia with long-term use, be careful patients with Lewy body dementia. The ADA warns of risk of diabetes with all atypical antipsychotics. And there's that black box warning. Remember early on, we talked about having a conversation with the power of attorney about the use of these medications. Adverse cerebral vascular events, increased mortality. So one thing I would encourage you is to have talking points, be comfortable talking with the caregivers, family members, power of attorney about the use of atypical antipsychotics and a black box warning. You don't want them to find out the information on the internet and then come back and say, well, how come you never told me about this? That's not good medicine on multiple fronts. So get that elevator speech ready and be comfortable having that conversation with the responsible individual. Next slide, please. Again, for the sake of time, this is just some summarization of studies that looked at the uses of antipsychotics and the causes of death related to them. Many of the issues that we ran into based on this study were heart-related problems and then also pneumonia infections. Next slide, please. So these are the new guidelines from 2016 from the American Psychiatric Association. It is really important for us to try non-pharmacologic interventions first. There's the Alzheimer's Association website. You can go and download some information about how to manage behavior without just reflexively going to medications. Antipsychotics when agitation or psychosis is severe, dangerous, and causing significant distress to the patient. Heloperidol, although we use that often, is not the first choice. Best evidence, although, again, modest evidence, Risperidol for psychosis and agitation, olanzapine, eripiprazole for agitation. Again, monitor for treatment responses with neuropsych... There's one psychiatric monitor toolkit, if you want to call it that, is the neuropsychiatric inventory. There are many others. All that is to say, don't just prescribe and forget. Do an assessment. See if patient is responding. Always try a taper after several months. Otherwise, you're gonna get... We all probably all got those nasty letters from either your insurance company or the pharmacist telling us that we're bad doctors or bad providers because we have patients on antipsychotics. So take the initiative after a couple months to... Michael talked about in the deprescribing about PPIs and so on. Have the same mindset. After a GI bleed, maybe we should taper and stop. And a PPI, the same can be said for antipsychotics. Next slide, please. Document. it's really important. Behavioral, environmental, you know, what did you try? Did you try anything? Or did you just went straight to medications? Maybe you needed to describe the patient's symptoms and the condition and the severity. Did you document education and consent again about that black box warning? Now, coordinate your care with other involved clinicians. Often, our patients are on cardiac drugs or other medication, for example, that can prolong, say, the QT interval. And you really need to use one of the previously listed medications, getting input from, say, a cardiologist. I think it's recommended. It's good care for our patient. Have a timeframe to assess for the result. Again, don't just prescribe and forget, as we do with antipsychotics or antidepressants. Reassess, monitor for adverse drug reaction. Similarly, we can say the same for, as we talked about yesterday in our meeting here, for opioids. Is it benefiting? Are you experiencing opioid-related constipation, for example? Reassess and document. Lowest dose necessary, shortest possible time. You guys have all heard that before. There is no magic bullet. Risperidol is not better than haloperidol. And there is not one drug that stands out as heads and shoulders above everyone else. Next slide, please. What about anxiolytics? You see them listed there. Sometimes it's used for an acute agitation. In our practice, we do use it for situational anxiety or agitation. For example, say the patient needs her weekly shower. And that period of time when she's getting personal care, it's really agitated or combative. That could be a situation where alprazolam or lorazepam can be used right before this anxiety-provoking event. Next slide, please. What harm can they do? You all know them. Sedation, habituation, falls, disinhibition. Yeah, we've all got the phone call like, oh, you gave mom lorazepam. That mom is now even worse than ever. They already got cognition problem and we're giving them more benzodiazepines. And sometimes it can make things worse. Dependence, tolerance, withdrawal. And again, there's no good data that says benzodiazepines are, you know, they're just top, the best drug to use. Buspirone, sometimes they can increase agitation. Again, that it can be tried. It might be used for a patient who say got anxiety, but you're hesitant on using a benzodiazepine. Again, not one magic bullet here, but certainly keep that medication in the back of your mind as a potential medication to try. Next slide, please. Antidepressants, are they safer for agitation? Citalopram, escitalopram, sertraline, fluoxetine, paroxetine. Can we go back, please? Thank you. Again, Dr. Ellison's slide here says the best support is citalopram. In our practice here, we use more escitalopram as recommended from our memory impairment clinic. Lexapro may have a faster onset than citalopram for agitation and behavioral disturbances. Next slide, please. What harm can they do? They can prolong QT. That's really a challenge for us. As I stated before, we have patients on other QT prolonging drugs, and sometimes it really handcuffs us in terms of what we can use. Agitation, insomnia, nightmare, hyponatremia, don't forget that. Bruising, bleeding through antiplatelet effects that SSRIs can have. And depending on which medication you use, it can either increase or reduce your appetite. Next slide, please. What about seizure medications? Anticonvulsants, carbamazepine, valproic acid, lamotrigine, gabapentin, and so on. Again, the data is either poor or lacking or modest at best. You can see some of the dosages there and the ranges. Next slide, please. What harm can they do? Carbamazepine, Stevens-Johnson syndrome. Keep that in mind. That's just a rare but a serious condition. Valproic acid, people can get tired, fatigued. Rarely, they can cause liver toxicity and thrombocytopenia. And one patient I'm waiting for an ammonia level to be back today, and that's a rare side effect related to valproic acid use. So just to keep that in mind. Gabapentin, again, sedation, agitation, constipation, weight gain, leg swelling. The point about gabapentin, it's renally dosed. Keep that in mind. Creatinine clearance, not your EGFR. Don't look at the lab. Pull out your favorite app. Do a creatinine clearance calculation and find out the maximum dose of the gabapentin that you can use. Next slide, please. What about quinidine dextromethorphan? The indication is for pseudobulbar effect. And there's a soft indication, or not an official indication for agitation in patients with Alzheimer's disease. It's been tested in patients with ALS and MS, mainly for PDA. One randomized control study showing that this medication may help with agitation and aggression. Again, it is not the magic bullet, and it can have a barrier, the added barrier of coverage and cost. Next slide, please. What harm can they do? Diarrhea, vomiting, dizziness, cough, weakness, can cause abnormal liver function test. Again, that QT prolongation. Next slide, please. Cannabinoids, I alluded to that earlier. Again, the data is not huge. Many are anecdotal. Maybe some positive evidence to support in terms of reducing agitation or aggression or resistance to cure. You can see some of the recommended dosage for these medications. Again, medical marijuana, that's the purity, the concentration, all of that is really unregulated, and it can be very difficult for us to recommend one particular medication in that category of class medicine. That is, next slide, please. What harm can they do? Drowsiness, dizziness, low blood pressure, hallucinations. Yes, it can make their hallucinations worse. Dysphoria, headache, palpitation. Next slide, please. What about stimulants? When they're apathetic, when they're depressed, and you're trying SSRIs and they're not working, certainly you can try a medication such as methamphetamide. It could be some modest benefit with apathy, and you can see the dosing there. Stimulating antidepressants such as bupropion can also be tried in patients with apathy. Be careful, I think that's in the next slide. Next slide, please. What are some of the side effects of stimulants? Agitation, anorexia, elevated heart rate and blood pressure. What about bupropion? The main one is I teach the residents here when they come through from Northwestern is seizures and loss of appetite. Again, it's more of a stimulating medication than compared to say a mirtazapine or sertraline. Next slide, please. There are other medications. I won't go through all of them. You can read them when you have some extra time. But again, none of these are FDA approved. And again, the evidence is small or marginal at best. Next slide, please. Again, some of the side effects, you can see that with each class of these medication, whether it's prazosin, dronabinol, cyproterinone. Next slide, please. Next slide, please. What about hypnotics? Many of our patients with their family members, they call us and say, and she's, or the patient's up at night, not sleeping, what can we use? We're all very hesitant about using benzodiazepine because of multiple risks. So there are some medications for us to consider from trazodone to zopanem to mirtazapine, depending on the situation. For example, if you've got insomnia with agitation, maybe trazodone, and you've got depression with insomnia, maybe anorexia, maybe you should try mirtazapine to combat the symptoms. As Michael said in his talk, there's the Bayer's criteria. Remember to avoid diphenhydramine. And that's your Tylenol PM, your ibuprofen PM, your Unisom, that's over the counter. Many of our patients or caregivers, they're just desperate. They're just wanting to try something and they go to their local drugstore. So we need to advise them against using first-generation antihistamine. Melatonin has been used to treat and prevent delirium. We do use it in our practice here. Try any medication to help them with their sleep disturbance. Next slide, please. Trazodone side effects, sedation, hypotension, rarely priapism, zopedem. We all know about the sedation falls and the sleep driving, the complex behavior that some of our patients do when they go on zopedem or Ambien. Next slide, please. I personally have not had a lot of experience with Pimibasterine, which has the indication for treatment of hallucinations and delusions associated with Parkinson's disease really associated with psychosis, all right? You can see the dosage there. They are, of course, using this medication in patients with Alzheimer's disease as well, perhaps showing some benefits, not only in AD patients, but possibly in patients with Lewy body dementia. Next slide, please. What harm could it do? It can cause drowsiness, swelling, increased BUN, dizziness, falls, and we're all terribly afraid of making our prone patient fall even more, and hypotension, and one of the routine things that we do in our practice is orthostatic blood pressure checks to make sure that the medication that we're giving our patients hopefully not potentially causing another problem such as orthostatic hypotension. QT prolongation, that's almost ongoing conversation here as you go through these slides and look through some of the medications that we are trying to use to help with our patients' behavior. Next slide, please. There are situations we simply have very little success and medications are not likely to help with such as repetitive questions or statements such as poor attention, such as shadowing you or wandering out of the home or rejection of care. So we need to have that degree of humility and say, well, we will try, but we're gonna do our best, whether it's pharmacologic or non-pharmacologic, but there are situations where we simply can run into a very challenging scenario. And this is where I think partnering with a caregiver, taking care of the caregiver is so important because we need them to provide the ongoing care that is so important to keep these patients out of the emergency room, out of the hospital and delay nursing home placement, as Dr. Cuomo said in the video, as long as we possibly can. Next slide, please. Before I go into the key takeaways, for our practice here at Northwestern Home Care Physicians, when we have a call in terms of patient's behavior, one of the things we assess is the urgency of this call and the urgency of the behavior, I should say. If it's not urgent, we try, actually we try to use acetylcholinesterase inhibitors first, such as rivastigmine, galantamine, epazote. We do use memantine if there's agitation. Again, if the situation is not very urgent. If it's slightly more urgent, we go to SSRIs. Again, escitalopram or Lexapro, according to the expert here, has the fastest onset in terms of helping with behavior. If there are even more urgent behavioral issues, we use valproic acid, Depakote or gabapentin. And if there's really an emergency, a crisis where the behavior is really getting out of hand, then it's Risperidol or Seroquel. Again, we use benzodiazepine for situational anxiety. Takeaways, use assessment tools, try non-pharmacologic treatment, whatever's possible. Have working knowledge of the full range of medications that we talked about today. Choose medication based on symptoms, side effects, drug interactions and other patient factors and educate the providers, the caregivers, I should say. Monitor responses and adverse reactions. Lowest possible dose, shortest possible time. Comply with regulatory guidelines, especially if you have patients, say in a nursing home or a assisted living facility. And don't just prescribe and forget, but prescribe and reassess and deescalate whenever you have the opportunity. And I will stop there and questions. Hey Paul, there was a question that Nancy Zaner put in the chat. I see Haloperidol prescribed frequently. Do we think this is because they are trying to address the acute episodes? Yeah, certainly that's my, reading that question, I would say probably that's what they're trying to do. And also there's a lot of prescribing, how can I say, there are prescribing habits, right? We all have them. Dr. Allison, you see his take on how he would manage his challenging patients. And I share with you here, how we would do it from our practice. So I would, again, get used to your local practice style, if you will, in terms of which medication to use, whether it's Haloperidol or Risperidol or Kutaiapine. Wow. So there's no easy fix for this. Broxism, that is. You can try, we've tried different things to muscle relaxants, anxiolytics, antipsychotics. I don't have a magic answer. Again, just like many of the other things. There's one resource I want to point you to, and that's an app called Fast Facts. Fast Facts is published by a medical college in Wisconsin, I think. And they will give you some additional insights into managing really a terminal, it's about palliative care and hospice care, terminal advanced symptoms and broxism or hiccup, intractable hiccups. They have some resources there as well. Again, I don't have, we tried different things. We have not found the magic bullet. Any suggestion on how to help these people, these are families. I'm not sure if you're referring to families or the patient. Again, I tell my patients and families, you know, I'm just a doctor. I don't know all the resources that are available for you. That's why I need a social worker, or you can go on the Alzheimer's Society to help, or area agency on aging to get some additional resources to help them. So yeah, again, it's really one of the more challenging scenarios that we face. Other questions? Dr. Cheng, I think I put the right URL in there for Fast Facts. Fast Facts, yep. All right, in the chat. All right. So we're going to move on to, um, to talking about another common condition that causes a lot of, um, um, utilizes a lot of healthcare, healthcare resources, uh, whether it's provider visits or healthcare dollars, uh, readmission to the hospital and so on again, you know, we're talking about, uh, one of the learners, uh, talked about, uh, MIPS, uh, about quality measures about, uh, patient center, medical homes and so on. One of the MIPS measure is about using ACEs and ARBs and, or Arnie agent, which I'm going to get into in a little bit, uh, in managing heart failure. So again, um, good medical care really again, you know, good medical care should, uh, ideally have, um, well again, good clinical outcomes, but also it should reduce costs. Um, it should keep patients out in emergency room, out in the hospital and, uh, we should be comfortable. Um, uh, and I'll get to that in a little bit, uh, towards the end of the presentation here we're talking about, um, um, and the life care, uh, uh, advanced care, uh, planning discussions, uh, getting patient appropriately, uh, onto palliative or hospice care and those patients with, with advanced heart failure. Uh, so good care is good. Good heart failure care is good. Medical care is benefiting to our patients is benefiting in terms of cost reduction, right? Uh, and it's a good heart failure care is good hospice and it's good palliative care. Um, so, uh, even though our, our lectures are kind of, uh, divided into sections, if you will, like, you know, we talked about the, the money thing this morning, um, but I hope you can see that, you know, what we do here, what we do at home, uh, will definitely impact on the money part that Brianna and Amanda, uh, talked about this morning. So for the next 15, 20 minutes or so, I'm going to go over some of the guideline recommendations for medical therapy and patients with heart failure, um, uh, talk about heart failure medications, uh, drug reactions, dosing strategies, and talk about potential barriers in, um, um, uh, optimizing heart failure management and how to potentially overcome some of these barriers. Next slide, please. Let's start with the case, um, to get our, our thoughts going. Uh, I know you've been hearing me talk, uh, for a little bit here. You want to, um, uh, since we're on zoom, you can, uh, if you want to do some pushups or do some burpees just to get your mind, uh, alert again, feel free, um, uh, no judgment, uh, uh, from the center. So 79 year old patient that we're seeing at home post heart failure, uh, some, uh, uh, hospitals, hospital for heart failure, leg swelling, and shortness of breath. And the patient has had recurrent hospitalization for CHF, uh, CHF exacerbations, uh, this year past medical history, you can see his, he's got half ref with an EF of 35%. He's got other comorbid conditions. Yes. These are the kinds of patients that we take care of at home. It's not just that, you know, I have heart failure and period is I have heart failure plus, you know, 10 other conditions, which all we'll play in here in a little bit as we talk about the drugs. And also, uh, as the capes, uh, develops medications, uh, you can see he's on a PIXA band, metoprolol subsonate, uh, bumetanide, uh, is, or got his compression stockings. Uh, he's on L-agliptin, uh, metformin, uh, and he's on scuturofelsartan, which is a brand name in Tresto, uh, post-hospital, uh, and he's also on tamselosin, um, uh, vitals, uh, you see there, um, uh, um, and he's got some leg edema, but he's got no gallop is, uh, O2 saturation is very good. And the laboratory, um, uh, studies you see there, he's got, uh, you see his EGFR potassium and his glucose. And as you, um, as you consider the guidelines for, um, uh, heart failure medications, uh, management, uh, with different medications, what are your management considerations for this patient with multi-complexity, with this current medication that he's taking, with the laboratory studies that you face, uh, that you see here, what can you consider changing, adding to keep this patient out of the hospital, right? All right, next slide, please. Heart failure, very common, uh, a lot of hospitalizations, uh, huge costs related to, uh, to heart failure care, one-year mortality and a five-year mortality you see there, um, listed on the slide. Next slide, please. There are a couple of, uh, heart failures. I think many of us know about HF-REF and HF-PEF, um, two new, uh, categories, you know, why are these important? Um, uh, because we talked about, uh, in the guidelines that came out, I think this past April from American, uh, Heart Association and the American College of Cardiology. So there's the, uh, uh, the mid-range, uh, the HF-MREF and the HF-INPEF. So there's the mid-range ejection fraction, and then there's the improved ejection fraction where the patient was less than 40% and with therapy intervention and whatnot has improved to more than 40%. So again, um, and I'll get to why this is important in a little bit as we talk about overcoming some of the barriers and so forth. Next slide, please. I think it's important for all of us to, to be, uh, to, to think about heart failure and to recognize our, our, uh, uh, our patients with heart failure. We can't treat anything we don't think about or we don't diagnose. I mean, that's obvious, right? So we know about leg swelling, shortness of breath, don't forget orthopnea. And then it gets into some of the more, um, nonspecific, uh, symptoms such as, you know, I'm just so tired. Uh, the patient's not eating, the patient's nauseated, um, uh, and sometimes they, you know, it may not have a lot of leg swelling, but the water is accumulating, uh, in the abdomen. All right. So always in the back of your mind, uh, think about, you know, are, are, are, are the patient's symptoms possibly due to an exacerbation of, of CHF? Next slide, please. Diagnosis physical exam is really important. Uh, I'm still practicing on my JVD. Uh, sometimes it could be, uh, difficult to, uh, assess, uh, whether it's lighting, whether it's obesity, uh, or, or whatnot. Uh, but, uh, uh, that's one, uh, and of course, heart lung exam, uh, very important in terms of helping you, uh, get the diagnosis chest x-ray, um, echocardiogram, uh, in our practice. And I don't know, uh, in your particular region, uh, we have mobile companies that can help us with x-rays and mobile companies that can do, uh, echocardiogram, uh, for us, uh, POCUS or point of care, ultrasound as becoming more and more of a popular item, um, uh, especially for us, uh, in terms of getting the information that we need at the point of care, right. Um, uh, in terms of, well, you know, um, do I hear rails or not? You can take out your, uh, your POCUS and can see if you can find any curly B's or curly C's, uh, on the long exam. And you can take a quick look, uh, at the, uh, uh, using your POCUS at the left ventricular function, um, uh, using that new kind of, uh, uh, technology that's available to us. Laboratory studies, uh, uh, what, whether we're talking about, uh, electrolyzed BUN creatinine, and also, uh, about, uh, BNP level, which I'll, uh, I'll mention, uh, in a little bit. Uh, and then implantable devices, uh, again, technologies helping us, uh, manage our patients at home. So, uh, implantable device, I think there's one that's called a CardioMem. Um, it's an implanted device, um, for New York heart class three or greater. Uh, it basically measures the, uh, pulmonary artery, uh, pressure, um, and it transmits, uh, to, uh, a receiving device, uh, that can help, uh, manage our patients, uh, better. Next slide, please. So, um, so the four categories of medications, uh, that I want my, um, my residents and, and hopefully, uh, for my, uh, for my nurse practitioners and for myself, management of patients with chronic heart failure, uh, with reduced ejection fraction, they're basically four categories. Uh, you got your ARNI class, um, uh, your ACE inhibitors, uh, ARBs, you got your, uh, heart failure indicated beta blockers. That would be bisoperolol, metoprolol, succinate, not tartrate, and carbadolol, either the immediate release or the CR. MRAs, that's, uh, your, uh, uh, spironolactone or your eplironone. And then the new category of medication, uh, uh, on the block for treatment of HEF-REF are SGLT2 inhibitors, uh, particular, I believe it's the pagloflozin and the pagloflozin. Uh, they have the indication, uh, for HEF-REF, uh, for African-Americans, hydralazine, isosorbide dinitrate can be considered for them. I put diuretics in parentheses, um, um, you know, we all have patients on, on your loop diuretics and whatnot. Um, that's, um, certainly it has its places for management of acute symptoms and so on. But once you, uh, decompressed your lungs, uh, and, and get the volume control, um, don't forget to tinker or think about the four upper categories of, of medications, uh, that, uh, our patients should, uh, uh, should be on, or at least you have considered it. Next slide, please. Um, medications for, uh, HEF-MREF, uh, again, is similar, um, ACEs, ARBs, A-blockers, MRAs, SGLT2s, or, uh, or diuretics. Next slide, please. For M, uh, MPEF, uh, the medication really is mainly, um, MRAs. Uh, spironolactone, uh, has probably the most data. There's some data on SGLT2 inhibitors. Uh, the patients are hypertensive. You can use ARNI, uh, uh, uh, uh, agent or a, uh, or ARB. So this is probably the, well, it's, it's new words, not really new anymore. Uh, sacubitril, balsartan, uh, or intresto for heart failure. Um, sacubitril, it's a neprilicin inhibitor, causes vasodilatation, um, and, uh, naturesis, and inhibits fibrosis. And balsartan antagonizes angiotensin II, uh, causing vasodilatation and reduction in, uh, in aldosterone. And it's indicated for EF less than, based on the studies, less than 57%, uh, percent. Next slide, please. Um, uh, what are some of the, uh, effects that we need to, um, uh, to, uh, be on the lookout for, uh, worsening renal sufficiency? Uh, typically, uh, from our practice here, uh, it's about 30%, uh, from baseline. Uh, that's when we consider it's, uh, it's, it's, uh, maybe a dose reduction or medication change is necessary. Renal, um, um, uh, one of my providers asked, you know, is renal insufficiency a contraindication to a safe ACES or ARBs and so on? And when we have the cardiology, uh, just here giving us the, um, uh, a short in service, um, renal insufficiency per se is not, but it's more hyperkalemia, which you see there, uh, uh, and that applies for ACES and ARBs and, and so forth. Uh, again, uh, symptomatic hypotension, renal artery stenosis, you cannot be on an ACE inhibitor for 36 hours. You need that washout period, uh, before, uh, starting on, uh, an ARNI agent, uh, uh, severe liver disease. Um, and then there's a potential cough, uh, related to, uh, to this. Next slide, please. What about SGLT2s? Uh, do patients have to have diabetes, uh, to go on this medication? The answer is no. Um, this medication blocks glucose absorption in the proximal tubules, it causes natriuresis, uh, actually decompresses, uh, de, uh, reduces the pressure within the glomeruli, uh, glomeruli. Uh, it reduces ventricular preload, it can lower your blood pressure, uh, uh, your blood pressure, your body weight, uric acid, and it has indication for both HF-REF and HF-PEF. Next slide, please. What are some of the side effects related to, uh, SGLT2, uh, use, uh, uh, DKAs, uh, because it's spilling out sugar. Uh, some patients get recurrent, uh, genital fungal infections. It can worsen kidney function, and you got, uh, cutoffs for your EGFR, for dipagliflozin, and then pagliflozin, um, uh, in terms of, uh, whether, uh, it can be, uh, used in category of our patients with, uh, with CKD. It should not be used in patients with type 1 diabetes or patients are, who are on either chemo or peritoneal, uh, dialysis. Next slide, please. What are some of the other considerations, uh, for HF-REF, and you all know this, uh, salt and fluid restriction, and it's really important we get our patients, if they're able to be, uh, uh, to stand up and, and weigh themselves, you know, um, we, we tell them if you gain three pounds a day, five pounds a week, you, you have to call us. Um, when, uh, one of the advantage of, of being at the home, uh, is that, uh, you don't have to go to the doctor, you don't have to go to the doctor, you don't have to go to what I think a really deep dive into medication compliance. Uh, you get them pull out all their pills, you go through all their bags and their, uh, boxes and so on, make sure that they are taking medication as prescribed. Deprescribe when it's not needed. For example, uh, maybe lowering the dose of your diuretics, uh, once, uh, your patient has, uh, overcome the acute heart failure symptoms. And then maybe perhaps you can increase some of the, uh, the dosage of say a, uh, uh, a ACE inhibitor, uh, and, and so forth, uh, because you're concerned that, oh, I'm not going to drop the pressure and so on. So, um, uh, and, and the other comment I want to make is, you know, look at the bottles. When was it filled? You know, how many pills are left? Um, you know, in our mind or in a computer, it can say, well, I think he's taking his metoprolol. Uh, but if the metoprolol was filled, you know, a month ago and it still has 29 pills left, uh, then maybe, uh, the patient is not taking the medication as you suspected. So use the house call is a huge advantage, uh, in terms of, uh, monitoring compliance and talk to them, you know, why, why are you, why are you not taking your pills? Uh, anything that we can do to help, uh, is it a cost issue? Is it a, um, uh, uh, a fear, uh, issue like, you know, side effects and so on, or maybe they just don't understand, like, I feel okay. Why do I need this? And have patients report increased weight, like swelling, cough, shortness of breath, appetite changes, and the, the, uh, you know, I can't sleep flat, uh, uh, symptoms elevate your legs whenever possible use compression stockings, um, uh, to help with leg swelling, rather than just, you know, giving them more and more, uh, water pill, which as we all know, uh, it's not always effective. It can cap and it can also have adverse effect on your electrolytes and your kidney function. Next slide, please. So here's a summary. You can read them, um, in terms of, uh, uh, medications for, uh, uh, with half ref or patients with EF less than 57%. Um, uh, those, uh, those medications there and then beta blockers, you can use it for, um, mildly reduce or reduce ejection fraction, uh, MRAs you can use, uh, for, uh, nearly all, all of the indications, uh, and similarly for, uh, the new class of SGLT2, uh, medications. Next slide, please. So for our patient, what we decided to do, we continue his metoprolol. We continue his sucrobutyl, balsartan, uh, allopliptin. Um, it really has not been good, uh, study in terms of a cardiac outcome, um, uh, using a DPP4 class medication for, uh, diabetes. Um, so instead we started at the pepliflozin instead at 10 milligrams daily. We asked the patient to, uh, monitor weight at home, uh, his blood pressure, as you can see there, follow up blood test, uh, um, uh, do creatinine stable, potassium stable, glucose a little bit better compared to before, um, uh, follow up that the leg swelling's a little bit improved, uh, and he's still having some dyspnea upon exertion. So again, remember his EF was 35%. So at this point with his creatinine, uh, being stable, potassium being stable, we started, uh, uh, spironolactone, uh, 25 milligrams, uh, once a day, follow up blood tests in seven days, other people say three to four days. Um, all that is to say, keep an eye on the kidney function and, and potassium. Next slide, please. So what are some of the barriers to treatment? Number one is probably cost, whether we're talking about, uh, CHF or COPD with all of his different inhalers, um, your, your, your llamas, your llama, lava class, your lava, your X combination. Um, uh, so cost can be a barrier, uh, to our patients, uh, medical complexity. Um, we're adding a lot of drugs, you know, this poor gentleman is on multiple drugs for multiple conditions. Now, are there things that we can do to help them, uh, minimize the dosing or help them, um, uh, maybe, uh, put a calendar up, uh, or a chart up with a different medication that's taped down there perhaps. And then write down, uh, you know, what each medication, uh, uh, is for. So, uh, this person can, uh, and say, well, let me look at this. Uh, if there's any question, of course they should have the ability. Hey, they should be able to call you and get advice, but then maybe have to go to the chart on the wall and say, well, uh, Dr. Chang wrote down, this is for, for my heart. It could be side effects, uh, or some intolerance, uh, lack of clear instructions, literacy issues. You know, why am I taking this? Um, what's it for? I feel fine. Um, there's the additional barrier. Whenever we change medication, change their dose. Uh, if we say we're going to start your, uh, spironolactone at 25 and we're going to go to the go-directed, uh, uh, uh, medication therapy dose of, um, uh, 50 milligrams and you need it, why do I need another blood test? Uh, so some education, um, may be necessary. It's so important, uh, to have that trust, trusting relationship, um, build that trust early, use advantage when you get to the home. Um, you know, I talked about, uh, uh, building the rapport when you get to the house, look around, um, uh, find points where you can connect with your patients and loved one, whether we're talking about heart failure, we're talking about, uh, using a black box warning medication for dementia, having that trust. It is so important in, in helping our patients be compliant, keep them out of the hospital and so on. There could be unaddressed depression that we need to, uh, tackle, uh, simultaneously. Uh, if they are feeling down and depressed, they may not want to take their medication. So don't forget that part. And then Amanda and I will talk about cure transitions tomorrow. You know, our patients do go to the hospital. They do go to different settings and they do get different instructions. They do get different medications when they come home. They can be very confused. The other is inertia. You know, I struggle with that. I'm so used to just doing this, this, this, you know, don't introduce another whatever for me to think about. I'm just going to keep on doing this. So overcoming inertia can be, can be difficult. And then again, again, preference, you know, I like to do the things this way. And maybe the patient has a certain preference of how things want to be done. And then there's the food, there's the transportation insecurity. For example, if they can't go to the drug store, they picked up the medication, you know, the social determinants of health that Amanda talked about earlier today that could significantly impact the life and the health of our patient. That's going to become more and more of an issue as value-based care come across our country here. Next slide, please. Here are just some heart failure prognostication tools. I gave you two of those. There's the magic and then there's the Seattle heart failure model. You can Google them, be comfortable using them, be comfortable talking with families about them. Because a lot of our patients, I'm seeing a patient on Monday with an EF of 10. Okay. I need to be comfortable having that conversation with the patient and the family about, you know, if we do aggressive care, do you want this, this, and this, or we're going to do more palliative care, which may involve this. And this is the predictive model based on your age and so on. And be comfortable with these models or whatever tools that you like to use and having that conversation when their heart failure is really towards the latter or end stages. Next slide, please. What are some key to success? Go back. You can Google the latest guidelines for treatment of heart failure, frequent visits, frequent contacts with patients from your nurse, from yourself, through electronic health patient portal, such as a MyChart. Give them clear, understandable instructions. And as a clinician, do keep in mind the cost and the complexity, especially when we're talking about 10, 13, 14 different medications. For those of you maybe starting early in this journey in home-based care, develop that relationship with a local cardiologist. I still run into a lot of difficult and challenging situations, and I send a message to my favorite cardiologist and say, you know, help me out here. What do you think I should do as an additional support for you? Also, if you're able to, under your different payment model, or if your clinic has the services of a social worker or pharmacist, get them involved as well, whether it's a prior authorization, whether it's patient education, whether it's getting transportation needs met for our patients, getting additional team members on your team, I think could be a huge benefit for supporting our patients with complex issues and needs. Next slide, please. Key takeaways. It's a common condition that we encounter in home-based care. We talked about therapies for HF-REF. We talked about medications for HF-PEF, and really involve your team, social worker, pharmacists, nurses, and so on, to help improve patient's condition and medication adherence to better patient outcome. And there's one more thing I do want to bring up, and I'll give a thanks to Michael. There's an app. I know it's available in the Apple's store. I'm not sure if it's available for Android. There's an app called Treat HF. Treat HF is put out by the American College of Cardiology. You can download that app. It has wonderful resources. It has a lot of pull-down menus. You can put things in, and it will give you some guidelines regarding therapy for the app. It's mainly for HF-REF. Even has cool things like how to overcome insurance barriers or prior authorization. That's why I said it's really important to repeat. Let me see if I can just pull it up for you here. It's called Treat HF. Oh, whoops. It went away. It's Treat HF. Treat HF. Yep. That's it. Thanks, Sarah. I will stop there. I think that's the last slide. Yeah, it is. Thanks so much, Paul. Are there any other questions for Dr. Cheng? All right. Well, if you think about any over the break, just come back because Paul's going to be doing the next session on working with specialists. When to treat, when to consult, when to refer. We're going to take 10 minutes. Please come back at, let's see, 2-11. We'll just be really precise. Thank you. Thanks. Sorry, I might have clicked over, Sarah. Anyway, trying to get this going again. Hi, everybody. Welcome back. Oh, Alina is asking a question about the training schedule tomorrow. We're a little bit shorter tomorrow. Let me tell you exactly what that is. We still start at 9 o'clock Central, but we'll be done by 3.30 Central. We finished up an hour earlier. Yes. All right. Let's go ahead and get started. Paul, do you want to, or Margaret, we'll get back to the start of the session and take it away. Well, thank you. Before I get to working with a specialist, there are just a couple of comments I want to make about the heart failure intervention. Many of us take care of patients with heart failure and they also have chronic kidney disease. As we give them more and more diuretics, we see their creatinine start to rise and we get a little concerned. People have asked how much is too much in terms of the rise in creatinine. For our practice, it's an increase about 20-30% that we consider that reasonable. When you get beyond 30%, you may want to consider other interventions, backing down their water pills or changing their ACE inhibitor or whatnot. The other question that comes, so 20-30% rise in creatinine. The other question that comes up from time to time is the patients on high dose of furosemide. For our practice, about 120 milligrams a day. If you look at the Treat HF app, I think they said it's 160 milligrams a day. The patient's not responding, what should I do? There are a couple of options. You can add a thiazide diuretic at that point. The common one we use occasionally is metolazone in addition to your loop diuretic. Some people rotate to a different loop diuretic instead because of bioavailability improvements such as torsemide or bimethanide. Those are just some considerations as we are trying to decompress, decongest our patients when they're volume overloaded in terms of diuretic use and keeping an eye on their kidney function. Also, for patients who are just resistant to diuresis, what are some of the options available to us? Working with providers, doing primary care at home is challenging on multiple fronts. One of the main stressors for me still is that I'm home alone. I don't have the full support of a cardiologist, a pulmonologist, endocrinologist, and so on right next to me at the home. There's that unique pressure that's there. I'm going to talk about some of the logistics related to care coordination with specialists. I'm going to talk about two cases and get you thinking in terms of taking care of these medically complex patients. When to treat, when to refer, what's your gut comfort level. There's that fine line, as I said in the past, there's a fine line between confident and cavalier. I think the line is different maybe for all of us here individually, but there's that fine line in terms of, I feel good, I can take care of this, whether we're talking about heart failure or agitated dementia patient, or I'm really getting out of my league and I need to have a specialist input. Again, I can't define that line for you. That line will probably fluctuate depending on our own personal experience and comfort level with a particular disease condition. Let's move on to the next slide. Let's start with case one, 85-year-old patient, moderate to advanced dementia, living in a group home. Past history, multiple problems, high blood pressure, AFib, CAD, CKD, eosinophilic colitis, medication you see there, Imodapine, Torvastatin, Losartan, Apixaban, and so on. Next slide, please. When I saw her at the group home first visit, she's comfortable. She's alert. She's talkative, but she's confused. Vital signs are great. On exam, she's in AFib. Degenerative changes in the hands, crepitus within the knees, the tug time was a little prolonged, and a MINI-COG of zero. So I thought things were great. Made no changes with the care plan. A week later, the group home nurse calls and says, you know, she's got lots of diarrhea. It's not bloody. There's no other symptoms. Next slide, please. So labs, I ordered labs. I gave her some Imodium. The diarrhea continued. We did stool studies, and they came back normal. The lab showed a little hypokalemia, probably from the diarrhea. The rest of her lights were okay, and so I discontinued Imodium. I tried Imodil instead, but the diarrhea continued. Up to 8 p.m. today, the caregivers were getting a little frustrated and concerned. I added some fiber. That didn't work. X-ray was ordered. Maybe she was impacted. She was not. Given her history of eosinophilic colitis, the diarrhea worsened, and she's up to 11 BMs a day. The family's calling says, you know, frustrated. You know, nothing has been done. You know, it's been a week. What are you going to do? Again, think about what you're comfortable with in your area in terms of geographically, who can you reach out to to get some assistance with a patient, or are you there and say, well, she just has to go to the emergency room. I've done all I can. Get your thoughts going in terms of how you would manage a patient like this. Next slide, please. Second case, 92, COPD, respiratory failure, HOMO-2, PEF-PEF, and a litany of other medical conditions. You can see there, okay, living with a paid caregiver, post-hospital, CHF, medications. You can read the medications there. Relevant exam, patient's alert, confused, not oriented. She thinks she's still in the hospital. You see the weight, heart rate, oxygen level. Her mini-COG, she actually did okay. You can see the relevant laboratory studies there. Next slide, please. Remember, her weight was 135, so the caregiver calls a couple days later. The weight is up. She's more tired. Remember, I talked about recognition of heart failure. It's not always shortness of breath. It could be something else, you know, swollen abdomen, I'm really tired, I'm nauseated, and so forth. So the furosemide dose was increased. I asked the caregiver to call me back a couple of days later. So the caregiver calls me back. The leg's still swollen, right? The weight is up more. Still tired, but no shortness of breath. The furosemide dose was increased even more. Now you see the laboratory studies as such, you know, we're replacing her magnesium, replacing her potassium, and then the furosemide was increased again. Next slide, please. On a follow-up exam, you know, I got to go see her, you know, what's going on with the patient. The vitals are there. O2 sat a little bit lower. Her weight was 135. Now it's 142. She's got some rails, some pitting edema. She went over the medication with the caregiver. She's taking all of her meds, and the patient is on a low-salt diet, and this flu restricting her, the caregiver that is, the labs are there. Family's calling about the weight and the worsening renal function. You know what to do. What are your next steps? Again, thinking about what we just talked about. What are you comfortable with? Who's around you? Who can support you? So that you don't feel that distress in managing complex patients like this, and yet at the same time providing great care for these patients who really need our help. Next slide, please. So what are the unique challenges? You know, we're the sole clinicians who step through the door of our patients' homes, and our patients don't have just one condition. They have multiple conditions, and we have competing priorities. We talked about, is it the kidney? Is it the heart? Or is it both? Is it the sodium? Is it a potassium? So on. There are travel limitations. So we'll just go follow up with your cardiologist, and sometimes they can't, or it's very difficult for them if they're on, they got mobility issues, or they got oxygen, and so on. And then there's the goals of care. The patient may not want to see another clinician or provider. They may not want to undergo a procedure test, such as, I don't know, a TAVR for their aortic stenosis or whatnot. So these are some of the challenges that we face when we go into a patient's home. Next slide, please. So I talked about that line between confidence and cavalier, you know, when to treat. It depends on your knowledge base, your experience, and your confidence with a particular condition or conditions. And it also depends on how certain are you with the diagnosis. And to treat at home can also depend on what the patient prefers. Do they want you to do what you can at home for them, or do they want to turn over more stones and find out what else is going on? Is the shortness of breath mainly heart failure or only heart failure? Or are you worried about maybe there's a PE that patient will need more advanced imaging? Okay. So those are some considerations regarding, you know, to treat at home, your knowledge, experience. You're pretty certain on the diagnosis, and the patient wants to be here. Next slide, please. When to refer or at least maybe consult with a specialist. When you're not knowledgeable, you don't think you're knowledgeable enough in the area, or you don't have enough experience in this. And certainly, we all have different dispositions. Some of us are more maybe I shouldn't take more likely to do things at home. Others might be more cautious and want to do things in a hospital. That depends on our personalities. When we're not sure of the diagnosis, I'm just not quite sure what's going on with you. Maybe that's time to refer or consult. If you're really trying, trying, trying, and a patient is not responding to what you're doing at home, like the heart failure patient, you know, the creatinine keeps going up, right? And you're doubling on the water pill and things are just not responding. Patient might prefer, I want to know. I want to know what's going on. I want to go to the hospital and get more testing and get specialist input, knowledge, or having some procedure done for a patient. You may want to have a follow-up note or visit with a specialist, especially if the specialist saw the patients in the hospital. They may want to know, you know, did their intervention help? What's going on? What's going on with the patient? Again, patient's goals of care will probably drive that particular visit, or maybe the patient just say, forget it, Chang, you can just take care of me at home. And then the final is the availability of specialists to us when we face challenges, whether it's by phone, whether it's a curbside, or a message, or even a formal consult. And I see that comment there, it's hard to find specialists and come out and see patients. So it's hard to handle these scenarios. So if it's possible to have that relationship, somebody mentioned earlier about marketing, I think, you know, getting referrals for your patients. I think it's an option for your practice to go out and talk with maybe a cardiology group and identify some of their high-need, high-cost patients, and say, you know, I can come along and help you with it. So introduce yourself, what you're able to do for their patients, for their COPD, or their heart failure, or for their cancer, or whatnot, as you visit the hematologist, the pulmonologist, or the cardiologist. Again, not only to market your services to get possibly more referrals, but also to develop that relationship. Now, there are some specialists, they love to help us. They have no problems getting back to me in my electronic health record here. I just had a message regarding a particular COVID treatment for a patient who cannot swallow pills, right? So the oral options are gone and the patient has transportation issues, you know, what are, what IV monoclonal antibodies. So it's available for you. So there are specialists who would love to help us because they know what we do and they believe in us. But then there are other specialists. And again, it's going to be case by case, even individual by an individual. There, there is one specialist that, you know, that told patient, I don't want Chang to touch any of my medicines. Do not let him touch anything. Okay. So, so there will be a potential, I think, great collaboration, but then there could be potential, you know, bumps in the road that you have to, to overcome again, building that relationship, talk about your practice, talk about what you can do for these patients, not only to, to get perhaps additional referrals, like I said, but also to get you some help when you need it. Next slide, please. So when you're referring to a specialist, tell them the patient, you know, why, why are you doing this? You know what? I hate the hospital. Why do you want me to go there? You can tell them why, the reason. And I think it's really important to call a specialist up, especially if it's somewhat urgent and tell them, you know, Hey, I'm sending, can you see Mrs. Smith this week? Because I'm concerned about X, Y, and Z. Again, it's about having a rapport, building that relationship, having that warm handoff. That's really important. You know, we're, you know, Brianna, Amanda talked about, you know, value-based care, the total cost, right? You know, what can we do to reduce the cost of our patients while providing great care for them? And I think relationship is, is, is an additional or important part or aspect of that. Work out your logistics when it comes to referrals, whether it's an internal work queue, or do you call or do you fax? Make sure the family know who they're seeing, where they're going to go and, you know, the phone number and so on and send to the specialist. If you share the same records, that's great because it just makes things easier. If you don't share the same electronic health records forward, what records you have so that everybody knows why Mrs. Smith is coming to see Dr. Bob and so on. Next slide, please. Again, fostering that relationship is so important. Can't emphasize that enough. See if a telemedicine option is available for your patient. It may or may not be with your, with your systems, with a particular group. They may be very open to a telemed option, or they may say, hey, you know, I just can't do this over the phone. And if there are transportation assistance you can provide for the patient, especially like a non-emergency transport for them, give that to the patient, give that to the caregiver so that you will help with some of the distress in leaving the home. Next slide, please. I do need to take a minute here and talk about working with home health providers, home health nurses, home health therapists, and so on. They're just, as I think about my experiences with them, some I trust completely, some are more, I am more concerned about their knowledge base. Okay. So there's, there's, so not, not even, yeah, so not, not only the, so I can't, what I'm trying to say, I can't, be careful labeling one company as bad when there's such variability within the providers of that company. Some providers are excellent within that company and some are not. So be careful of just grouping everybody in and say, well, I'm never going to use XYZ Home Health because they're, I had a bad experience. Just understand that some are not less knowledgeable than others, just like us. And some of that lack of knowledge might be due to lack of information from the hospital or the skilled nursing home. Often they go in without the necessary information. Again, care transition is the next talk. We are going to talk about, what makes a smooth care transition. One of it is discharge summary and medication list and so on. The other is make sure we provide them with clear orders, working with home health agencies, especially when it comes to wounds or medication change and so on. Be specific if you can, rather than just being that, just kind of, you know, wrap legs and call me if it's worse. Be specific. What kind of wrappings do you want? How often do you want it changed? At what point do you want addressing change? 30% strike through, 70% strike through. So be specific about that. Be careful how you interact with the home health providers. Build up their confidence. Try not to talk down to them. We are a team. We need each other to take care of our patients. Think about your own office call center barriers, called phone tree, the buttons you press. The protocols may help me be more efficient, but actually it can be a hindrance to the care of the patient. For example, the phone tree might have nine different choices, right? You can say, well, I'll take a message for Dr. Chang and he'll get back to you. But if there's an urgent problem, what is the avenue that your triage nurse can get an urgent message to you? Because by the time I get to that message, it might be five o'clock in the afternoon and a home health nurse is long gone. And you're finally getting to the message and it's already too late. So think about that. And what are some of the solutions? Improved information exchange with home health agencies, such as faxing your entire visit note, perhaps, rather than just the after-visit summary to get more complete information and a plan of care and a management document, okay, regarding orders for this, orders for wound care. What do you want them to monitor when it comes to heart and lung and so on? Call them or fax them. Discuss patient's conditions and what are your concerns with the clinician in a professional manner, not in a demeaning way. Think about modifying your triage protocol so that the home health nurse can get the messages to you in a timely way. And that's pretty much the last point there as well. Next slide, please. So the takeaways, understand the unique challenges that we face in terms of getting additional specialist input to help take care of our sick and complex patients. There are clinical logistical factors to consider in terms of effective care coordination with specialists and give clear documentation instruction to home health agency and providers that can improve a patient's experience and definitely their outcome. Next slide, please. Questions? Paul, there was a question earlier. I know you talked about, you know, helping to coordinate transportation, non-emergency transportation for a patient to see a specialist. But what if a patient truly can't leave the home? And she, you know, Alina says, we find it difficult to get specialists that would come out and see a patient and the patient's not able to get to the specialist's office. How do you handle the scenarios where a patient needs to be seen by a specialist but can't find one to see the patient? Yeah. So again, building that relationship, see if you can call and talk to the specialist, see if the specialist is open to a video visit to help you take care of a patient who's truly, truly homebound and cannot leave the house. And then having that goals of care conversation. Do you want the ambulance to come and take you to the hospital and get treatment? Or do you think that we should, you want me to do my best here? I'm not the emergency room. I'm not the hospital. I'm not a hematologist. I don't know why your political account is 1.2 million. But if your goal is, you know, having me do my best and with that understanding, you might just have to do your best and live with what I call the unknown. So having that relationship, see if telemedicine is available and having the goals of care conversation. All right. Thanks. Any other questions? I'm working with specialists or any, any of the clinical topics we've been talking about. All right. Well, thanks very much. Why don't we move on into our next session? And if we advance that slide, so it's managing care transitions in a value-based world. I think Paul, you're starting, starting this off and then Amanda will pick up, right? Yes. And thankfully there are only, I'm only responsible for a couple of slides. You guys get to see the happy face of Amanda and hear a different voice instead of Paul Chang coming at you for the last good grief, almost three hours. So thank you for your patience. You're almost done listening to me today. There's never too much of Dr. Chang. All right. Next slide, please. We're going to talk about the key risk factors related to managing transition for complex patients that we see. We are going to discuss some strategies for an effective clinical care model and talk about the differences and flexibility to approach care coordination in a value-based world. Next slide, please. You know, it's actually not funny. This prompt notification of discharge, I just got a note here in my electronic records that the patient has been home for almost two, two and a half weeks from the nursing home. I'm not, nobody told me there's no, so your notifications can come a couple of ways, right? It can come from a phone call or EHR or health information exchange or some other vendors that tracks the patients where they are or having, you know, depending on the relationship with your patients to say, Hey, when you get home from the hospital, you got to call me. So there are different ways to that can, that you can perhaps overcome the scenario that I just faced, not knowing the patient has been home for almost two weeks. Timeliness of follow-up. There's a slide. Next slide would, I will give you a kind of a peek into the importance of getting to our patients sooner than later, getting that phone call out there in 24 hours and see how they're doing. Do they have any needs and so on and getting a clinician to the house in three days and three days, preferably and definitely by seven days. If you can prioritize, prioritize your concerns. You know, what's, what's important here. What are the pressure points that they need as they transit from A to B? Is it, they don't have their, they don't have their medications or they're confused about the medication or they're, they need, they need DME. Prioritize what you need to do when you go and make that visit. You know, I think we talked about the importance of medication management so much today. Our patients do take a lot of pills and they do go from facility to facility with different formularies. So they may come back with completely different pills than the one they left their house, their home with. They may not be able to access their pills because they can't leave the house and the prescriptions at the pharmacy. How do you overcome those challenges and what additional supports at home do we need to consider that can impact care transition? The patient's home and there's nobody to take care of them. Their condition might get worse. That vet store might get worse. So these are all important factors for us to consider. How am I going to be notified? How quickly should I get there? When I get there, what should I pay my attention to? Exquisite medication management. And don't forget, you know, our patients are complex. What other support do they need at home? Next slide, please. And this is what I was referring to. This is an article that was published looking at CHF readmission. Look at that. 13 percent, they went back to the hospital in three calendar days. And roughly a third went back in seven days. Two thirds in 15 days. So this patient is two weeks out and I have not been notified. OK. And the risk for pneumonia is even greater. Next slide, please. So it's really important, as Amanda talked about, you know, not only it's not only about quality, it's about metrics and so readmission and so forth. But it is it impacts your bottom line. If the patient goes back three days later for heart failure, you could have stepped in and prevented that. You know, think about how your practice is going to potentially overcome some of the barriers that was on the on the second slide. And don't forget the importance of having that advanced care planning conversation. Remember, I said I'm going to see a patient on Monday with an EF of 10. OK, this is going to be part of the conversation. Be comfortable talking about advanced care planning. There are the five D's for the timing to have that conversation. Every decade, new diagnosis, deterioration, discharge, divorce. And I will add another D when when the patients or family demand not demand it, when they've asked for it. I think those are those are time when you can really step in, take a minute, take a deep breath and say, you know, where are we going with with this? You know, you have a EF of 10 percent. What are we looking at? Next slide. Amanda, thanks, Paul. Yeah, you know, before we kind of get into care coordination, you know, I just want to talk a little bit about the importance of this and how this differs from kind of fee for service. So we deal with care coordination and transitions in a fee for service world. We just aren't getting necessarily paid for that work or we're getting small amounts of payment for that work. I think there's a huge opportunity to think about, OK, if you are really responsible for the longitudinal care of someone, how do you get paid appropriately for that? And then if you are paid for that, this is a major area to consider. I tell my my folks all the time I say, you know, nobody's just sitting on their couch in their house thinking today's the day I go to the hospital. Today's the day I move into assisted living because I can no longer live here. Right. They all have some transition. Something happens. And that's where break, you know, care breakdown happens. Right. It's it's something has occurred. Now the medication isn't working. Something has occurred. And now we need something else. And trying to and I think Paul did a great job talking about this, but trying to translate the goals of care across everybody that could touch your patient is really, really challenging, even sometimes within your own organizations. And maybe I would say sometimes helped by sometimes helps by technology and sometimes really not helped by technology, really, really hindered by technology. So let's talk about about a little bit about care management, care coordination. A lot of the things we're talking about, it is kind of a framework for how to put together kind of care management, care coordination. And it can be expensive to to do these things. This is why, again, this is a critical piece as you think about value based care. So I typically think about care management, care coordination is kind of interchangeable words. I think of them as some of the most gray words in health care. People use them all the time of something's being care managed. What does that even mean? If you say you have a care manager, you have a care coordinator, it doesn't designate what credentials they have or what work they're doing. If you say a physician or nurse practitioner, you usually know what credentials they have, and you have a pretty good general 80 percent idea of what they're doing. So I think there's still, again, some opportunity and framework that we're going to talk about and not necessarily here's how you have to do it. So really, when we think about care management, care coordination, they're actually kind of separate. Care management is more an episodic caring for, like a CHF, and care coordination is really long term, the longitudinal representation and managing of medical psychosocial support systems than all your aspects of care. And so there's going to be a lot of content on some of these slides, but I think it's really worth going back over time as you start to build a care management, care coordination structure and say, how are we going to kind of combine these ideas? You know, how do we hire the right person for this field? Slide. So kind of broken into five different sections, and we'll do a slide on each of them, but really around engagement. The team may need to do several home visits to establish a relationship before making changes. Right. And you all know that you don't go in and you change everything all at the same time. And having a proactive strategy. I think I've called it before, but we call them kind of frequent flyers. You know, people who are using the ED as primary care, people who are going back to the hospital, people who are calling on Friday afternoons because they know they're going into the weekend and they might not have anybody else to talk to for the entire weekend. Right. How do we think about all those things as proactive strategies to think about who needs what? Team-based approach. A lot of these, again, these are care coordination and management strategies inside of work that we do. It doesn't necessarily mean that a certain person with a certain degree has to do it. We think about team-based approach, you know, making sure that we have clear communication channels. Everyone's on the same page inside your organization. And if you need to communicate outside of your organization, that you're passing along that critical information. Education. You know, how do we, and sometimes we talk about tools inside of that, right? Like the teach back method, but how do we really, at its core, empower patients to feel like they are in control of their own health care and that they have, they are in charge of their own change. And finally, best practices. You know, who are you serving? What your practice, what is your practice doing to stay up to date on evidence-based strategies for your population? And so again, we're going to kind of talk about each one and kind of put this all together. Slide. Jump in. I know someone's monitoring the chat for me. Oh, no, not yet for me. Yeah. Okay. Engagement. This is really the foundation of all of the care management work we do, right? It's just, what does the patient want? What do they need in their words? And we're eliciting that in our work to gain kind of their goals of care, but really suspending judgment and calling for active listening and understanding their life journey and history, and then following through and being really consistent. Do what you say you're going to do, honor what their wishes are, and then provide that consistent voice. If you say, you know, your nurse is going to be the person on the other end of the line, or you can call me for things, you know, be that. That starts to build that engagement for someone to build trust. And we talked about it already, but kind of this idea where you may have multiple visits before you tackle really complicated things. And we've given a couple examples, but as we, especially in essential elements, there were a number of really detailed examples where there's a lot going on. You don't have to be homebound or home limited, but typically the patients we're caring for have enough happening where you're not, you're not sitting down and tackling everything in a 25 minute conversation. And so I know I'm preaching to the choir on that one, but that's part of the foundation for how we think of all other care management work. And then finally talk about boundaries. What are the boundaries for you, the practice and the patient? And what are the things that you can really work on together to create strong boundaries so everybody feels respected in their relationship? This is probably one of the things that gets the most attention is how do we proactively think about something before it's going to happen? And technology is telling you that every technology, right, is we can tell you before someone falls off the cliff. We could tell you an expensive person. We can tell you someone has poor quality outcomes. Sometimes yes, and sometimes no. And I think it's good to use the data you have to create clinical pathways and to really stratify who are your patients who need you most. I like to say in my group that I think the person who wins healthcare first uses resources really successfully. How do you figure out who needs you today versus your entire panel of patients who will need you one day, but maybe won't need you all today? Talk about, you know, maintain your communication, keep an open line again, especially as something could be happening and create care plans that are meaningful to the patient in their own words that they would understand. And sometimes it's for the patient and sometimes it's for the caregiver, but a lot of this can come with prognostication of here's what's about to happen. And we can talk through some of those scenarios. So when those things occur, those events occur, we all know what to do. And it's good to know what to do at two in the morning and the end of the, you would do the same thing at two in the morning that you would do at two in the afternoon and then formalize those things and a pulse, a mals, other advanced care planning and make sure everybody is, it's known there. And if there is a way to file that with your, you know, with your state or your health system, do that as well. The third one is to really take a team-based approach. And I think there's a, there's a lot of value from different disciplines. Now we're all different sizes. Some people it's just one provider or, you know, you're starting their, your team and some people you have a really strong gap or you have a really strong bench. And some of that's because of separate funding as being part of a big care system. So maybe you're, you know, your care system can lose a little bit of money. Some of you already might be in value-based care, but how do you really kind of provide the holistic wraparound and some, some things and jump in. If I miss people, patient, provider, registered nurse, social work, social worker, a medical assistant, LPN, a pharmacy consultant, a mental health practitioner, specialist. I don't use community health workers. I know someone else talked about that. If anybody wants to jump in with their experience with a community health worker, I think this is a great time to do that. You know, let's talk about they're all really valuable and they bring different pieces of perspective and different opportunities for a partnership to the table. And finally, the patient benefits only when everybody is really supporting the patient goals and the caregiver. So I'll stop for a minute there and say, who else did I miss that are important parts of your care team? Are there specialties that I missed? You know, who's, who's the person on your care team? That's kind of maybe not the traditional person that we would think of. That's your go-to person to kind of keep everybody organized on top of things or see the world in a different way. Again, that I haven't mentioned. Hey, Amanda, I want to make sure you see that Alina put something in the chat. She says her EMR offers CNN's care coordination module and reporting that goes along with that module. Super helpful. Maybe see if your EMR has that feature can can be game changing on the managing of patient populations based on diagnoses and comorbid conditions. Yeah, great. Alina, would you tell us what EHR you're on? So we are using the clinical works. And I mean, the reason why we want in the first place with them is because I that's what we use. I use in my previous life. So it just made sense. But they have the care coordination module. So yes, it is a little bit extra month per provider. But the modules that incorporated within an EMR to where you're working with your existing patients, you're not using a different tool. I find it to be very helpful. So, you know, it takes a lot of work, I think, to create those care plans. I think the first stop that I'm trying to encourage our providers is to enter, you know, as an MA, that's kind of part of my job to to document the patient's entire care team. We get a lot of consult notes, a lot of different hands, right with the patient, even home health and hospice and, you know, who's seeing patient one, getting that team kind of documented first, you have a big picture, and then creating those care plans does take a long time, because you have to figure out how you want to structure them, do you want to do it by diagnosis or by comorbid conditions, you know, look at your patient population. But what I found useful by using the module with an EMR is because you can also report out. So, you can see how many, at least in our EMR clinical works, we can see at what stage, you know, how many care plans patient had and what stage of the care management they are. And you can like admit to the, put patients into the care management, certain care management, and then remove patients. So, if your EMR has that, I would explore it. You know, I looked into other different, you know, care coordination management systems and tools you can use, there's a lot of them out there. And the same thing is for a remote patient monitoring program. But if your EMR has it, even though it's a little bit more cost, it's integrated. So, I found it very helpful to use the tools that, you know, within the system, I should say. Yeah, no, I appreciate that feedback. Thanks. You're one of the only people I've ever heard that said our EHR solved our pop health problem. So, which is great. And I would say, and this again can be my, this is why we, this is the fun part of the dialogue that continues, right? I would say, I have repurposed EHRs in my mind to really just call them clinical data repositories, that they're just where you put information to store it because you legally have to, and it's helpful to sometimes look back on that information. But in terms of population health, it can be incredibly challenging for understanding RAF score and the full care team, and sometimes even identification. We'll talk more about identification tomorrow. So, I think that's really great. I also think that, you know, there's other technology. There's also, you know, for smaller practice, there's also, you know, Excel spreadsheets. And so, for us, you know, and I'm going to talk about this coming up in rare stratification, but for some of our smaller programs, we just keep a list on Excel and update as we go through. So, I think when we think really about kind of our team-based approach, you know, it's really everybody looking at this information, you know, who's coordinating, and who's collaborate, or who's pulling that information together, and then who's presenting that is really the team lead and who owns that piece. I think we have a huge opportunity to continue to get better at both that kind of proactive strategy and kind of our team approach. Yeah, and I think, you know, spreadsheets, yeah, for smaller practices, I agree. I just, I think the most important thing that I've learned throughout the years and, you know, managing small practices to big practices is that putting workflow in place, that process in place, and identifying, like you said, that key person who's going to own it. And if you have a good system, whether you're doing it in Word document, Excel, Google Sheets, whatever tools that you use that you're comfortable with and working for you, you can, when you grow, you can, I feel like you can always transition that to any tool, any EMR, any electronic version of that, but the key is to have that process and to keep person in place, because without it, like, that's not going to work in any tool that you use. So, I agree. Yeah, I completely agree. You know, I think the fourth piece is when we really think about education is, you know, how do we empower the right, the patients with the tools and resources to really feel in control? How do we think about resources that they can access? It might be a community resource. It might be things like, you know, monitor these specific clinical things. And how do you, you know, sometimes we talk about this. We certainly can talk about this, about bringing in interpreters, but how do we also provide materials in the patient's primary care language? And how do we think about the patient's literacy level? I think it is a lot of patient materials that have actually been created for literacy levels are written at something like the second grade reading level. So, how do we continue to teach back so everyone's understanding? I have, you know, we've all maybe had stories of these, but certainly there are examples. And again, you know, jump in if you had an example, but of the patients nodding, nodding, nodding, and then it takes a little while to figure out that the patient actually can't read, or they can't read to the level in which you've provided the written instructions. So, it's sometimes it's the, you know, see, do, teach method. It's the teach back method. Sometimes it's just handing someone something and having reading them back. But I think there's so, so many ways as we think about a whole care coordination program is how do you actually provide the education that is going to be proactive and helpful today and in the future and going to be used? Like how many times have you said, here's what I'd like you to do. Here's what we talked. Here's what I'd like you to do based on your goals. And it doesn't go anywhere. Right? And I think there's a core piece there that again, it doesn't have to be a care manager person, but with a mindset of how do we get to that education piece is a top of mind thinking. Slide. And finally, really review best practices. Make sure you know your population and your changing population. Make sure you know the new patients that are coming into your practice. Think about your evidence-based practice and how do you stay up to date on strategies for the population being served? How do you stay up to date on the DEI principles for the population being served? And configure new ways if there are new things to be thinking about for your practice. And so, sometimes we think about things as foundational when in reality, they're not foundational. They're all tools that we're really applying. The idea of best practice becomes a kind of foundation for us. The tools might be, here's the way we practice. And those might need to be changed over the years. And so, I've been with my current company 10 years and we've had to change things because the world's changed and our population has changed. And we have to stay up to date with the changing environment around us. Slide. Okay. So, a couple of things around, you know, Elena, to kind of your point around how do you think about some of this data and what do you do with it? So, you know, really identifying gaps in care. Sometimes you can get health plan data, you can get Medicare data. This can come from claims data. If you're waiting on claims data, it's coming later. And that's unfortunate if it's coming after the fact. You can collect your own data. That might be examples. That might be tools you build inside of your EHR, tools you build inside of your pop health. You know, think about kind of all of your transitions. You know, how did that happen? We do talk about in a different course, kind of thinking deep on a root cause analysis. And so, a lot of times some of the NCQA materials when you sign up for these programs will say, hey, make sure you do a transitions root cause analysis to really understand what happened here. And readmissions, hospitalizations, EDs, you know, fill in your own blanks on what information is important to you. But again, these transitions are really costly. And often they're very expensive, or excuse me, they're poor quality of care. So, if you said, Amanda, every time I have a patient go to the hospital, I get the best quality of care. The patient comes out better than they went in. I just love it. I'd say, well, then it's worth the cost. But it's not always. So, again, how are you tracking that piece? Number of meds, comorbidities. One thing that I'm very interested in to ask the whole group is if anybody's tracking reduction in meds. This has been an area I think has been a huge opportunity. And my practice is interested in that is, let's say that you can track from the beginning they've joined with 15. Are you tracking on a regular basis by 90 days within one year, their medications have been reduced by 20%? Is anybody tracking that from a volume standpoint? Brianna, do you want to? Okay. And that's where I think that would be really interesting. I think that would be really, really interesting and a really good statistic. I'm not seeing people do it today, but I think that's on my radar as a future one. And then use risk stratification at every visit. And so, this is a piece of care coordination. If you're just having providers do this, it could also be your just end of meeting or end of visit plan of care. When am I going to see you next? Think about how you interact in the primary care community. You have an ear infection, I won't be seeing you again. You have this chronic thing, I'm going to see you every two weeks until we get X medication worked out. Slide. So, here's an example of at the end of the visit, say, how are you doing? And have the care coordinator, have the provider, have the person who's doing care management say, what's your risk level? Are you in an acute change of condition? Are you in exacerbation of a chronic condition? Did you, am I visiting you because of a hospitalization? And that can then transition to how often I see you and what our strategies are going to be until we can move you down to maybe a more moderate level. Or maybe you've, we've stabilized, we have a good chronic condition management plan with slow decline. We have maybe chronic pain. And the final one would be a functional cognitive baseline, stable chronic condition. This is not set in stone. You don't have to use this exactly. These are ideas to set up. Here's when someone needs us most. And at the end of every visit, we're setting eyes to say, here's when I'm going to see you next. And here's the care management things I'm going to do to make sure that we stay in touch on this plan. Right. And so I've seen some of these kind of come up. I see them in kind of pop health world where people are trying to be risk stratified, or there's a frailty component or something. Find out what are the clinical things under that. And then I think the huge opportunity is again, take this and translate that to visit frequency. This and Brianna can stop me if I'm wrong, but this is a very legal way to say this, this person is had a review and needs to see someone this often. And then in the future, when they don't have that anymore, we can downgrade them to a lower risk level. And so if they're in that risk level, you can set more of your schedule. And so I really like that. I think that becomes a really great way to start thinking about your entire population. And then can you pull your entire population or by provider, how many patients are high, moderate or low risk. So just a way to think about risk stratification. So you then know, here's where I'm putting my resources. Here's where I'm putting my time. Slide. So we did talk about the different types of roles here. These are again, examples. This is potentially an interdisciplinary team in home-based primary care. And these might be the regular players on the team. Maybe the provider is leading the care team. The RN is kind of the eyes and ears. Maybe they're doing acute visits. They're collecting CCM. They're collecting any follow-up assessments. They're collecting all of the work maybe after a high a high risk visit in the risk stratification. An LPN MA could be in the office, could be remote, but may not be on site, could be on site, could be gathering, fulfilling paperwork, gathering information, getting someone ready, and then could be providing proactive calls to a frequent flyer. And I really like this idea. I just, there are so many patients that are lonely, especially after COVID. And it's really important to understand who's using the ED for some form of social connection. And then finally, really a social worker. And we see generally social workers in play in home-based primary care when people have the dollars, you know, dedicated, like funding dedicated just to that position, or they're large enough for this. But huge opportunity to do episodic care and potentially longitudinal care for those who have complex psychosocial needs, those who are homeless, those who need a lot of caregiver support. How often are you sitting there saying, wait, am I treating the patient or the caregiver in this moment, right? That's where a social worker can really help to transition the care to focus on the patient. Anybody, would anybody add anything on different roles that they see in home-based primary care and the connections? Let's see if I miss anything. Okay. Slide. So interventions that care management can do, right? Comprehensive assessment, functional, cognitive, psychosocial, home and safety. Certainly getting those eyes and ears that primary care in the clinic did not get. How do you think about interdisciplinary team rounds? And so this might be a very quick once a day. We've heard practices who do like a 15 minutes to start every day. We've heard practices do kind of a weekly call and they kind of go through high risk, unstable and transition. If someone's in the hospital, does someone need a new resource? How do we think about those rounds together? So you're connecting on those patients and someone's really reporting out what's happening right now. There's also kind of transition management. And so this is based on Eric Coleman's and I think funded by the Johnny Hartford Foundation around have four pillars of care coordination and understanding medication, self-management, the personal health record, timely, you know, primary care, specialty care, follow-up knowledge of red flags that indicate a worsening condition. And so that piece is really, really key to again, understand those pieces. And you can gather that information again, in the tools that you have already, or in, again, even Excel or free note to start putting that together. The one thing I will say about any sort of free note is there's just no way to mine that data to see those patients. And so we are always working with our EHR to see if we can get more specific data on some of these important care coordination interventions. So proactive communication, you know, someone who's wanting that weekly call, which I talked about, so you don't beat that one. But, you know, that one is really, really validating. We did certainly have an LPN who was calling people just to sometimes connect on that and, you know, create a reliable communication channel. How does the family and the patient want to be communicated with? And then doing that, right? And touching base before something's really wrong, making sure that you, they know you're their person and you'll be there if you really need them. And then we don't have to talk in depth about the kind of specialty providers, since Paul went over a lot of this, but, you know, specialists and service providers, how are they communicating with your team? How are you efficiently working through paperwork? What does your team want to know? What does their team want to know? How have you figured out how to work together? And if you can spend some time fixing those processes that may be broken, because a lot of care gets lost in the paperwork shuffle. And so is there a better way for specific specialties or interventions or transit transitions to the ED to communicate? Any ideas people have there on how they really broke down a system barrier and communicated really well with ex-external specialist or partner? Cool, cool, cool. Strap in the chat. Sounds good. Sounds good. Thank you. Slide. Okay. Let's see. Education. So just a couple things. Chronic condition education, right? If it's not an acute thing, now we need to think in a very different way. How do we do education today in the current state? And proactive thinking and monitoring. And this is where I think potentially remote patient monitoring might be helpful. You know, how do we think about some of these CHF diabetes and hypertension? Can we get some of that separate data and do something with it? I got to tell you, I'm a real mixed bag on remote patient monitoring. So I would love for someone to say, come step in and say, this has saved our practice. But I just think it potentially could collect a lot of information without the ability to easily condense it into really meaningful information and really actionable information. So I love the concept of collecting data electronically. It's just, do we really have the staff? And we really know what we're looking for. And it really is working really well. Someone challenge me on that. I always love to be wrong. I'm not going to challenge you, but I can pretend play devil's advocate because I have heard some success stories from RPM. I think it's so new, right? Like we're waiting for like the true evidence base to come out. I think if you're going to do it, you really have to have, number one, you need a vendor or technology that lets you customize readings, right? So you don't just have to live with whatever the standard in range is. You have a patient where their vitals may be abnormal normally. A lot of the solutions let you customize that and that'll minimize alerts. And second, usually the practices that I've seen this have a dedicated nurse or a dedicated person that that's their job to receive and filter that data within protocols, within their scope of practice, and then filter as needed to the provider. And they're the first communication. So I did hear a really cool story. It was a patient that had a fall at home during just the RPM check-in. A nurse, the husband had shared there was some alcohol abuse going on in the home. She had fall. She really severely injured her back, but really refused to go to the hospital. They got an x-ray and there was a minor fracture actually, but it wasn't within her goals of care to go to the hospital. So they were actually able to arrange same day x-ray and evaluation and a back brace at home. And so all of that got arranged through the RPM check-in. So that's one cool story that I've heard. Not my story. I can't take credit for it. Just often providers like you all that share these things with me. I think it's early on, but I think where I've seen RPM be effective is if you can afford to have a dedicated person that's really responsible for kind of triaging that need so that, what does Dr. Ting call it, alert fatigue, or that you're not putting that burden on your providers. Yeah, I think that's really great. I would still, I still conceptually challenge it, right? Only because, again, I think that it possibly could. And again, I'm just providing ways to think about it, not don't do it, because I do think it's just going to get better. And I think it'll get significantly better when we have AI really sorting through that, right? Like how often are we, you know, alerted that someone, you know, has an A1C over under where they need to be. And I'm not clinical, so I'm not, I'm talking a little bit out of turn here, but some of that might be within their normal range of what happens, right? How often is the urine, UAUC come back, and you're like, oh, I need to act here. And so sometimes I think in geriatrics, sometimes more data can be sometimes distracting, and it could be distracting towards the goals. So I think it's just, you know, how do we as humans filter through what's meaningful data and what's actionable data, and how do we keep working on that? So I think it's a super interesting area. I wish there was a lot of external funding, you know, what if Medicare was starting to pay to try some of these things to collect really cool data, not just like sponsored testing, right? And let's just see what's out there and what could work. And again, my gut is, and I don't know a lot about artificial intelligence, but my gut is as that gets smarter and can weed out some of natural, each individual's variation versus population variation, we might even get more actionable data. But I agree with, you really need a person to kind of look at and talk about that. So, you know, again, and I think there's some comments in there, chronic condition education, as someone has something that could lead, you know, to a transition, you know, a MedA stay, hospitalization, an ED visit, an OB stay, whatever these things are, you know, and that's not their wish. It's, you know, their wish is to have something really well managed, then how do we get access to information on the, on the front side? Let me. Oh, something I want to add, if you don't mind. I attended an RPM webinar. And something interesting that I heard that might be coming to other states is one of the physicians spoke up, and he said that in California, through Blue Cross Blue Shield, he, the Blue Cross Blue Shield, I think it's like a special, like just a sub plan of Blue Cross Blue Shield. So basically, patients can get a free device from Blue Cross Blue Shield for physicians who are participating in California in the RPM program. And I think that's very smart from the insurance standpoint, because they know that eventually, they will, it will decrease, let's say, ER visits for blood pressure, hypertension, right? Because those readings are going to be coming in. And they train patients on how to use those devices and everything. So I thought it was a really cool program. There's nothing like that in Illinois. But I, what I foresee in upcoming years, it probably might take a while, right, for the data to collect and insurance companies to report out on that. But I think we will see that there will be some shift in the RPM and some shift in payers that they say, okay, you know what, maybe we should provide a certain patient population with these certain devices for certain conditions, you know, and it will drive that value to where it will decrease overall dollars for the readmissions, admissions, and the, you know, ER visits. So that was kind of a cool webinar. Yeah, I think that's super cool. Thanks for sharing. You know, Grace pointed out something too here around, you know, the barriers getting patients to understand how to use the technology too. And how much is it, what is it called? Was it sample size bias? Is that what it's called? Where, you know, like think about your insurance company offering you $20 off if you check into your gym 12 times a month. The people who sustain that are healthier. Because they generally are the people who go to the gym more often, right? The people who can use these things really well and maintain them to where you're not getting all these dings and you really can like focus in on it, generally are healthy enough to use some of these things. And so there's a little bit of bias there. And it's actually having that whole conversation earlier this week with a different practice around, you know, what is it, sample size bias? It's something like that, right? So I think it's, again, I think it's super interesting. I think there's a huge opportunity. It covers a lot of this page on education. You know, how are you going to track this stuff? Who's going to use it? How do you train it? You know, I'm, I talked to a practice in, I think it was Kentucky, that they didn't, they're a big portion of their patients didn't have running water or floors, they had dirt floors. You really have to ask how am I getting any data out of that system, right? We don't have the infrastructure to get that information out yet. So I think, I think we have a long ways to go there. But, you know, I just thought it would be kind of a really fun, deep dive to go to talk about RPM. Sorry, Brianna. Brianna posted something about being reimbursed for RPM. So within the same, within like within the same webinar, they talked about, you know, you have to have 16 days of consecutive reporting in order to bill for an RPM, because you have to follow up with patients. So it is you, you know, if you really do implement RPM, you can get reimbursement on it. And it can help patients. But I think the biggest barrier that we see is, from what I read, and I'm not sure if it's correct or not, but you have to get patients consent to participate in RPM program. And a lot of our patients have like a POA, or is their daughter son just taking care of them, and trying to have that conversation of them, you know, they already have so many specialists, they have home health, some of them, you know, are in hospice care. And it's like having that conversation with them, and under making them understand, what are the benefits of RPM, I find it to be most difficult, because in my mind, and in the long run, I see what those, those benefits are, and for patient what those benefits are. But I think it's very hard to educate and make the caregivers understand the benefits of RPM program, because they just think it's another thing you want to sign up, you know, sign them up for. So. Great, thanks. Harp on RPM, my last point before we move on to, but I just felt like it followed Grace's point, and your point really well, too, is like, if you're going to start RPM, I feel like a lot of the pitfalls that I've seen is that you just try and do it for everyone. Like, you need to screen patients almost like you would when you're screening them on intake, to your point, like, is it, you know, obviously, you want to find technology that is geriatric friendly as possible. But, you know, are they going to be able to use the device? You know, would they need someone there? And what diseases even like, I've seen this work well, if it's really a small target, targeted population, where, okay, we're only focusing on our hypertension and heart failure patients, and we screen them to make sure that it's actually feasible for them. So, you also have to keep that in mind, if you were going to be doing RPM, it's generally a very small percentage of your total patient population that would really benefit that. So, that just needs to be a workflow consideration. And Elena, the tip sheet that HHCI has going over the billing in great detail, I've done a lot of research and taught on RPM a lot. To your point, just to clarify, the 16 days, so it has to be 16 days worth of data within a 30-day calendar period. It doesn't necessarily have to be consecutive days, as long as it's within the same month. But yes, to your point, it can be very cumbersome. Again, is it worth it for your payment model, whatever that looks like for your practice, because there are a lot of requirements. Yeah, absolutely. All right, thanks. A couple more tools. Let's see, slide. So, one, I want to talk about transition logs. So, again, keeping this as part of your EHR, your PubHealth, or even in Excel, you know, make sure you have a way to measure your transitions. How many people went to the ED? How many people went to the hospital? How many people were readmitted to the hospital of that number, right? And use that and then measure your interventions and see if you can bring those numbers down. And this is incredibly helpful to look at this information. We look at it monthly. You may want a date. You may want more specific data. But then, really, once you can identify what happened, do a root cause analysis. Were the proactive measures put in place? If yes, were we wrong? And I think that's really, really, really key is understanding that piece. One of our contracts in a one-year period, I believe, had a small population. Let's say they had 10 hospitalizations. I think that number's wrong. Let's say they had 10. Half of them were because nobody notified us. We found out much later that they went to the hospital. And so that means that we haven't done all of the right things we need to do to say, hey, contact us before they go to the hospital. If they're in the hospital, let us know right away. We're finding out after the fact. The opportunity to intervene before that happens is because we've built great, we have best practices, and we've built great communication, and we have the proactive measures in place. So hopefully, we're reducing the chance that it even happens. But if there's exacerbation that happens where you need hospital and ED, we go back and we say, what went wrong? Slide. And then when you have that, create diagnostic, excuse me, diagnoses, specific pathways and protocols. Understand what you want to do. Create the checklist. It could be even standing orders. It could be standing materials that you need on site. If they're in an assisted living, here's what the assisted living team's going to do. Here's what the loved one's going to do. Here's where the patient is. If you have an exacerbation of COPD, do you have the materials you need on site, or are you always going to have to send out? And make sure that you educate the team and the providers about an exacerbated COPD event. Here's what we're going to do. We have a, and again, I'm not going to be perfect on the cloud side, but maybe we have a nebulizer on site. And we've been able to quickly utilize that. And then, you know, continue to use tools to empower the patients and families. And again, this can be logs. This can be remote patient monitoring. It might just be things that you're keeping track of. Someone's keeping track of on a notepad and making sure that someone's, you know, checking in on them. You really want someone, you know, to be eyeing that patient. Sometimes we say that, you know, like in the hospital or in a facility that sometimes the person that might be changing out the trash might notice the most about the patient versus the clinical person. They notice when some of these things have changed, when someone stopped doing acts. And those are important things to try to arm caregivers and family members with. If you see them, you know, they're always up at 7 a.m. and all of a sudden they start to wake up at 10 a.m. instead. You call me. You know, you see them not eat dinner the way they usually eat dinner. You call me. Those are the types of things to give tools in really layman's terms. Slide. So, some key takeaways, you know, prompt attention and care interventions for patients. Key to preventing utilization. Higher utilization is higher cost. And again, I'm willing to spend the money, you know, if it makes sense. And we all should be willing, if it makes sense. And if it, if it doesn't, if it's the thing that the patient, excuse me, the patient, you know, the patient doesn't want, the care, the family doesn't want, you know, make sure we're finding other ways to dig into deep of how we can fix that in the future. And there are certainly lots and lots of ways based on your clinical model to build that interdisciplinary approach to care coordination. Again, I'm not saying you have to hire a bunch of people. These are frameworks of how to think through caring for a patient beyond just the clinical diagnosis and prognostication. And then leverage flexible payment models, hopefully to add to it. So, I think Brianna put the RPM payment information in there. Certainly that's a resource. Certainly CCM and TCM are resources for, for this. And then any other type of value-based contract. If you get in a value-based contract, or you're attempting to make some additional dollars on kind of the fee for service plus, your care, you care about transitions and you care about keeping the transitions to only the necessary ones and avoiding the unnecessary ones, right? That's the, the W in the fraud, waste, and abuse that Medicare's talking about. Any final questions for me on transitions or Paul or Brianna or any of our other faculty here? Well, Amanda, I think we're right back on time here to move into our last session of the day. Great. Paul, Paul, were you going to say something? Oh, no. Oh, okay. Okay. Well, pop in the chat, anyone. Okay. Well, I have just kind of the last final and short session around hiring the right and hiring right and supporting the house call team. Slide. So, hopefully, you know, a couple of slides on creating sound hiring practices, thinking about retention, recognizing common stressors facing our practitioners, identifying coping strategies, and then how do we think of administrative and operational strategies and ideas to continue to avoid burnout and career dissatisfaction. So this hopefully will be really fun to end your day. I know you've been sitting a long time. There's a lot of content coming at you. And if you're not wholly in value-based care today, you're like, wow, there's a lot to think about if we get in value-based care. And don't you worry, HCCI's got you. But let's talk about the people a little bit. Slide. So one thing that we think about in home-based primary care, which I just think is so awesome, is let's keep positioning it when you're posting something as the answer to traditional primary care or hospitalist medicine. I actually think this is a perfect time to fill your coffers with the right people because people are burnout in traditional medicine. And it's coming up after COVID. And I think this is a way to create meaningful and targeted job postings and make them very, very clear. And depending on the market, you could work with a few staffing agencies to try out staff at a lower cost model. Anybody who's ever done kind of hourly staff, typically it's a period of time, or into perpetuity, you owe a portion of their first year salary back to the staffing agency. I've done it where if you ever hire them, you owe 23% back, or if you hire them within the first six months, you owe 25% back. But it is a way to try out different things. And then adjust your hiring methods if hiring is difficult. So I love, after this, I'm gonna open this up to the floor around hiring challenges that people are having right now and see if we can kind of brainstorm a few ideas. And then review all internal policies for equity and simplicity. So I just really wanna throw that out there. This is the time to review your processes, review what you are doing. Think about benefits for inclusivity, right? Employees are looking for more expansive coverage, not less coverage. Remove antiquated things that you don't wanna track anyway. Counting tardies for hourly staff. Thinking about bereavement. Someone dies, do you really care if it's their neighbor they were close to versus their uncle? Like, why are we tying certain day, number of days to people's relatives? Boggles my mind. But that little stuff really matters to staff. And I'm gonna tell you right now, I think Gen Z will push us to think about employees in new ways. And I think they're getting a little bit of a bad rap being the only reason we need to think about employee and hiring in new ways. I think it is all of us after COVID. Every single, all four generations are thinking about how does my work fit into my life and not the other way around? And so, you know, creating policies that really are clear, they're simple to administrate, they're equitable, they account for the type of person you're looking for. Right? If you don't offer any sort of leave options if you're pregnant or if you severely limit those, you're gonna have a tough time getting potentially women between the ages of, I don't know, 25 and 38. I'm making that number up, right? That you just have to think about who's my audience and am I really posting and am I putting that meaningful targeted job post in the right spot and saying, these are all the things we really offer and then deliver on those things. Who's having trouble hiring? Any big problems that they're having trouble with on hiring and you wanna give us a 20 second example so we can see if we can all brainstorm with you? Hmm. Okay, well, this is good. Everybody's fully staffed up with the team that they need. So it's quick. We'll go quick. I know that's not the case. Maybe it's the end of the day. Maybe that's what it is. It's just the end of the day. But you know, this sounds like, I know it sounds kind of too easy. You say, Amanda, how could you put one slide together on hiring? I think the value proposition for the workers in our business is there. I think the employees are looking for mission connected work. And again, that value prep exists in our work. I think it's about getting in front of the right people and getting those right benefits set up. So people say, yes, I want to work X. That's my thought. Well, Amanda, I can't agree with you more. Regarding the burnout, this is a perfect place for somebody who's really mission oriented. We've said before that house call providers, we tend to be mission folks. So get them connected, get them to feel the importance of our work and the mission that we're on. Get them enthusiastic about the changes that are happening. We are having a hiring problem. We have had a position listed here for, well, for several months. And it's a challenge to get people in here. All this stuff that you mentioned, that we're trying to be flexible with what are allowed and wages and so on. So, yeah, it's been a difficult problem for us. And on the flip side is the staff retention. And I can't afford to lose anymore because we had such difficulty in getting people to come. So what are ways that I can do to engage my staff to make them feel appreciated? Again, to get them connected to the mission thing that you were talking about. I can comment on hiring too. I don't know how that's gonna sound to the group, but I feel like, I think that after COVID, everybody got a little spoiled in a way. I don't know if it sounds kind of direct or not, but a lot of people were on leave. A lot of people were getting incentives from the government to stay home. And I feel like every posting that I do for, whether it's an MA, a nurse, even for hospice and home health, or for our home visiting physicians, like an MA, I feel like the cost went up a lot. I feel like the bracket a little bit different, where before, just a general, right, I might not be right, but like, let's say for a MA posting, you would do like 18 to 20 or 17 to $20 an hour, right? Now you kind of, when you're looking at other people's posting, you have to up your ante. So now you have to be like, okay, well, maybe it needs to be between 18 and 24, 19 or 24. So I feel like it's, I feel like clinical people know that there's a need for them, right? And it's good because yes, we do have a need for them, but from the business perspective, the cost for hiring somebody went up tremendously since COVID. That's at least my interpretation. Yeah, I make two comments on it. I think that first comment around kind of people got kind of spoiled. I think I generally disagree with the comment, but would say actually regardless of where you fall on the comment, I actually think everybody came back and is redefining how they wanna work. And so the ability to add flexibility around FTE, start time, stop times, leaves, stuff like that, people are gonna want to maintain that. It was an incredibly difficult time and it then kind of, I think correlates to, again, this flip of, I don't work for my employer. I show up and they pay me and I really get to choose where I go now. And I think that's a totally different mindset. And again, I think Gen Z is getting a little bit more to blame here, but as the generations kind of continue, I think they're all doing that, but Gen Z certainly will push that agenda around how do you fit inside of the life that I'd like to create or that I have created. Okay, Joy said here, more work-life balance is what I hear all the time. I actually would, okay, so Joy, here's my thought. I think it was work-life balance and then it went to kind of work-life integration and now it's almost work, it's life, it's life, work, something, right? It's totally, totally, totally next. Do you wanna, Karen, do you wanna comment on that piece? And then I'm gonna come back to the dollar amount increase. Not just work-life balance. I didn't get off mute in time when you originally posed the question. So the challenge that we're having is for, as hiring and hiring to better parcel out the person who's really, really strong and working independently, this can be a really, really lonely post. And to your comment about being mission-driven, our nurse practitioner, we're primarily a nurse practitioner. We certainly have our physician partners, but we're primarily a nurse practitioner team. And, pardon me with that. The folks that have stayed have stayed, we have really strong retention, but we've recently had the case of folks who really fought hard in their interview process for their role. And then you bring them on and then six months later, they're really dissatisfied, high level of dissatisfaction in their role in making those leaps from either hospital or clinic to working from your home and being out seeing folks, number one. And number two, the difficulty with retention, the uncontrollables that come along with home-based care, whether that be fighting traffic to get there, whether that be Texas of late, temperatures of a hundred plus in excess, the entire month of June and July and probably August. It's very, very difficult, right? Doing that care, that uncontrollable then of being in the community. Yeah. I agree with that. That's so funny too. I was just down in Dallas for work and my coworker described it as a convection oven. That pretty much gets it, that captures it. I thought that was a really good sentiment. I think that's probably true. I think the thing that we're seeing is the people who have options, everyone has options today. The people who are utilizing those options recognize that they have other options if they're not fully happy and they're moving along. And I think there's a retention piece that we need to readjust our expectation around retention. And I think if you look at every generation that has ever existed, we've had to relook at our retention, right? Nobody works at a company, their entire career gets the watch and the pension at the end, right? Now it's, and then Gen Z came up and they said, well, we're gonna jump for the promotion, right? We may only, we worked for five, but we're gonna jump for the promotion. And then you have the millennials that are like, I'm gonna jump because of interest, right? I just have changed my mind. And now you have the Gen Z that's like lifestyle jumps. And that is hard to predict for, but I think if we adjust our expectation that people are gonna do that. I think my other suggestion on the hiring piece is around a root cause analysis. And I've done this, I actually have a position, a director of finance position that I'm really attempting to do a root cause analysis on because the last two people I've hired have not been the right people. And what did I do wrong in the interview process? And I think some of that is some of the base personality is getting to those really open-ended behavioral-based questions and make sure I get the right ones. Typically, if someone is really good at adjusting in X, even if it's in their personal life, they can translate that to work. If they can handle the blows, how do I really ask those questions in a meaningful way? And I think that's another piece of advice is dig deep on, I got that hire wrong, let's just not post the same thing again. Let's really think, what did we get wrong? Because at the interview time, you thought they were the right person and you've hired them. So you were, and it's okay, but we were wrong. And now we gotta figure out what we did wrong. Brianna, were you gonna say something? Oh, sorry. Melissa, you came off mute first, go ahead. Yeah, just real quick. This is a suggestion for those programs where this will work. HCCI has a house called Practicum and it's a two-day shadowing opportunity to go through. For someone who's never been exposed to house calls and maybe is considering that as a career. And I'm not saying that they have to go through our program, but what if a program made that kind of ride along or shadowing experience part of the interview process? I think it would be really important for someone who's never done this before to actually do a day of seeing it. And that may help them evaluate, is this right for me? And you may even seek glimpses, is this right for that person? Are they right for us? So I just put that forward as a suggestion. It's funny, Melissa, that's exactly what I was gonna say. I mean, especially for providers because they're so expensive to credential. Karen, I hear you on the nurse practitioner end. Sending them out for a ride along should always be part of the interview process if they've truly never done home-based care. And still you can only gain so much in house call or one day of house calls and things. But I think that comes down to also being really transparent and honest about what to expect, especially for those not used to this kind of work. And so I would just encourage you all to be really transparent. This work is not for everyone. It's just not. And Dr. Chang, I know you might wanna chime in here too. So how are you really setting expectations and truly deciding is it the right fit for both people? Because it's hard work. Yeah, we've had our share of long hires and short hires. The shortest one, I think it was a day. After going out with us for one day, just said that this is not for me. So I completely agree with the comments that ride along is key, letting them really experience what house calls are like. This is unlike any other MA job, nursing job, whatever, a provider job, because it is, how do we describe it? You have to come and experience. It's an immersion process, as I've called it. I can describe it to you, but you really have to just come and experience for yourself, whether it's the heat or the smell or whatever. It is so important to get them to understand what they're getting themselves into. That's great. I have one more comment about the cost of people. I mean, we're certainly in an inflated market, right? What is it? Eight to 9% inflation. Historically, the way pricing for jobs would go is you'd wait till last year's market survey came out, you'd price the job, and then everybody incrementally works their way up every year, right? And so I see that there were a little increase. I work myself up. I gave 3%, but the whole market went up 3.5%. Next year, I might work my way up a little bit more. It's not working like that. To the point earlier around, I'm seeing, you go online and you see the posts. We're seeing nurse practitioners in our area starting at 140,000. That's a very different number than we've ever seen. And again, we have to make the decision. We can't afford that. So we're trying to supplement with other benefits and other flexibilities. But I think that will go on for some time. I think people have the ability to shop, especially for that kind of sweet spot of around, I don't know, 15, 18 to $20 an hour. If you can get that same job at Walmart or Amazon, you're gonna look for what are the other benefits that I could get. If you could get your college paid for by Amazon, so get $20 an hour. So we're no longer competing for, especially lay people, hourly staff, in introductory or intro jobs. We're not just competing against healthcare. We're really competing against everyone right now. I will say one final, final thing about it though, is there's a chance that we go into a recession or a mini recession. That's gonna be a different setup, right? That's gonna be a really different setup for how it's gonna switch. So I still think people are gonna be looking for certain things, but the price point might come down. Slide. Paul set me up really well to talk about retention. So here were just some ideas about retention. But, you know, create incentives and difficult job markets, including more time off, bonuses when goals are met, figure out how employees like to be recognized and delivered. I know Paul gave an example at the essential elements about recognizing staff, but really recognize how your staff like to be recognized individuals and deliver on that. I have some of my staff who really would like me to stand on top of the roof and say they're the best person who's ever lived. And I have some who would be mortified and would prefer a nice handwritten note. And you can do those things and you can meet people where they are. It's still even through all this, the number one reason people leave is still their manager. And so how do you think through, again, how do we recognize individuals and use existing network to attract high quality talent, which we're all doing? I'm going to give a big caveat here that, you know, within equitable hiring practices, we rely a little bit too much on this existing network and it can create a homogeneous practice without new ideas or representation. Right. So I know so-and-so and so-and-so is really great. So-and-so knows so-and-so-and-so. Right. You're like, this is great. But now we start to look very similar and we're missing our opportunity to to diversify our ideas and our creativity and our innovation. Be transparent and share a clear vision when available about how the employees directly fit into the goal, how is what they've done and how is what they're going to do directly the thing that meets the mission. I think that the new world, regardless of how salary plays out, I think flexibility will be a part of it. But I think people are looking for that mission driven work and people may work at Amazon for a year or two, but they're going to say, now I got this under my belt. Now I know what to do. I need to do I need to do something else. I need to do something else. I need to do something that's filling that bucket. And I understand the stressors and grief in this work and continue to reduce and provide coping strategies. So we're going to talk about these. So a lot of these, you know, but top stressors are mediating family conflict. Remember I said earlier, how many times are you treating the actual the family member and not the and not the patient as much? How is the electronic health record compiled in all the paperwork complexity we get? Now we have a mixed practice, but we get something like 60,000 faxes a month, right? That's a lot of paperwork to process. And nobody really enjoys it that much, oddly. You know, how do we think about our financial pressure? And we talk about that a lot here, but patient adherence, which they don't do what they say they're going to do, or they don't do what's really recommended. You know, is there a point in which you no longer support the patient and you're going to terminate the relationship, the scheduling, the logistics, and the provider's feeling unsupported? I think Karen gave a good example of really going out into the field and feeling like, oh, I'm all alone to manage these super complex issues. So we know the stressors exist. Slide. And then these things can cause burnout. And so stress is this physical body reaction. And burnout is really this long-term stress that marks us really with emotional exhaustion. And we start to depersonalize. And so I would say this, you know, maybe not all of you because you've opted into this, but we certainly know and work with individuals that are truly burnt out. Stress, we can reduce the paperwork and solve the problem. Burnout is a much, much bigger individual issue. And coming after COVID, we're all looking at this saying, who's really burnt out? Who really has depersonalized their work significantly? I'll take another slide. Because these outcomes aren't just individual. You'll see the depression, the exhaustion, that kind of curmudgeony, I'll never get better, the dissatisfaction. I'm not part of the change anymore. Those also can be higher rates of addiction. I don't know if you all felt like this, but in our practice, I had the most kind of mental health requests for short-term leave than I've ever had in 10 years during COVID. And it could be for mental health or addiction. This is a failure, job or career change, you know, suicide rates. I think it's still, you know, one in every five physicians have attempted or have thought about or have made no comment on they've attempted suicide. So again, these individual outcomes, which are the things you'd recognize first, right, as a colleague. And then you have patient outcomes, right? If the individual feels like that, there's lower satisfaction, lower quality of care, higher risk of malpractice claims, higher risk of litigation. And then the system never gets better. And that's the part that I think is, it's not the worst, but I think, you know, we do have to take that burnout and we have to kind of enlarge it to say, innovation's stalled. Our students aren't ready and we aren't preparing people for what they're really seeing. And that's really unfortunate, right? The other thing that comes with that is just the grief and loss of working in healthcare and certainly being such an intimate part of their family, right? You're going into their home. You have this power and privilege to walk into their space, to deal with their loved ones. Paul gives numerous examples of, you know, a daughter or a son who hug them and say, thank you. That is a different level of connection than many people get to their healthcare provider. And so you start to put all of this work into an individual, and then something happens, a transition, a death. And can you really recognize these stages within yourself? And then how do you move through these stages? Slide. So conceptually, right, if we all experience things differently, then do we all find a meaning differently, right? If some people like to be recognized by taking an ad out in the newspaper, and some people would like to be recognized by a nice handwritten note or a small gift card, right? Do we find meaning differently? And there's been actually a lot of research on this, that generally it's on your own timeline and it's very personal, but there are these universal supports that hold all individuals up. The way to express gratitude, I'm so thankful for, I'm so thankful for the life they led, I'm so thankful for the ability to be part of their lives. The lean into community that can be a faith or family or friends and to really have a support system in place. Sometimes feel this create action, right? How many people read legislation or something that comes out in the news and they say, I'm going to go do X, I'm in a march, I'm going to call people, I'm going to phone bank for my favorite candidate, right? That's the way that we say, I'm not okay with X. And then finally display love and acceptance, right? Is that I can continue to put out this love and acceptance of this space. And so we as employers, I would say over decades have started to lean into these things more, right? We recognize that if we don't address these, and it's not necessarily from a hiring, but from a retention standpoint, that our system could ultimately hurt and our individuals inside are really the ones, the ones, you know, our colleagues we know and love could really, really hurt too. Slide. So there's one of my favorite sayings called Ho'oponopono. And it's a four-step and you've maybe seen it, my favorite is when it's like cross-stitched on a bag, right? It's just this, how do you regain personal strength using self-love? And they're kind of four major ways to do this. And again, you've probably seen these, but say, I'm sorry, please forgive me. Thank you. And I love you. And so this is a way that combines love, forgiveness, repentance, and gratitude. And it really translates into English as a correction. And so as we think about, and again, it's a little touchy feely for the end of the day, but as we think about people working through grief and loss, we also think about how do we help get through that for them? And sometimes it's about meeting them where they're at. And then individually, people start to pull these components inside of themselves and say, how do I, how do I recognize this and pull this forward? This can be used and you, an example would be like, if you maybe lost a parent that you had trouble seeing eye to eye on, and you were like, gosh, I lost so many years because we didn't see eye to eye on it, right? You make that example, very individual to say, I'm sorry, forgive me. Thank you. And I love you to maybe part and start to work through the kind of forgiveness piece and love piece. But, you know, you can really apply this in other ways as well. You can really think about it as you need to move forward in any, you know, any relationship, any correction of what someone's doing and working through. I'll stop there for a second. Any questions about anything around grief, burnout, how to think about an individual system to challenge those things? Okay. Just a couple more slides, y'all. Let's see. Oh, home-based medicine is solution. You heard Paul say this too. Really, this is, I really believe that this is the best position, healthcare field that we have today, because it's really vocationally rewarding. You know, nobody went to med school to process paperwork. Nobody went to go be an NP to, you know, to see 50 patients a day. They went because they thought they could add a lot of value and it was meaningful work. And so, this work is really challenging cases and it really tests you. And if you have the personality, it can really be pushed and shaped and moved around. It's very vocationally rewarding. And it requires complex teamwork and partnerships. We're not in a solo vacuum, even if you feel like you sometimes are. And I think that's the opportunity of the employer to continue to bring us back to you're not alone. You're driving alone maybe, but it doesn't mean you're alone. You got your, you have our support. You have back office support. You have management support. You have other colleagues support. The reimbursement is lagging, but we talked about it today. There's so many opportunities today and going forward. And I think there will continue to grow reimbursement in this field as the baby boomers continue to age. And just remember, you know, if we think about the baby boomer generation, I'm gonna do some quick math in my head. You know, the last, the leading, the lagging edge, right, of the baby boomer population is going to be 65 in 2030. That still means that the leading edge is only 80 or let's say 85. So, you know, we have so many decades to get through. I mean, you're going to not see 60, healthy 65-year-old golfers for 10 years after that period. And so, there certainly were the growth of this work is coming and we'll have to figure out as a, as a, as the country had to pay for that. The entire team feels value added work as being part of a system that we can actually see the change and we allow for personal flexibility. You know, I worked in the clinic setting for a few years and you had, you know, it was a start and stop and you saw this many patients a day and nobody got any flexibility and you didn't just go get to see your, you know, your child's kindergarten graduation or run to the dentist without really interrupting patient care. This does allow for some personal flexibility that, again, I think providers and staff are looking for. And so, finally, some, a couple of things that we could maybe continue doing, right, joint visits to manage tensions, have separate meetings with family members, documentation, recognizing all the time that involved in the paperwork and scheduling time for that, both between work hours, you know, making sure you have holes in your schedule. I like the financial model. There's lower overhead, so it allows for flexibility in the numbers to be seen. You're not trying to push to create, to cover the administrative burden. The team approach to educate patients and families to reinforce the care plan, especially for those who are non-adherent to the work that you're agreeing on, and then administrative support to manage scheduling and routing. And really, as we think about all of our operational work, how do we, how do we manage and work to top of licensure? And so, I think that's a huge operational strategy to continue to reinvent that. I think, I mean, some of us on the call, some of the team that we're all on have very, very large home-based practices. We're still in the space where we have small practices. Let's be nimble. Let's try new things. If it doesn't work, let's just fix that then. Slide. So, here are some resources on burnout and depression and stuff, and I think it's not bad to keep looking at this and just openly talk with your providers. I know this is where you could be. Come talk to me if you're at this spot. I really want to make sure we find something that's really interesting and makes you happy and you feel like you're part of the change. Slide. So, I think some key takeaways is really understand the hiring market in your area and create meaningful practices to hire and to retain people. Recognize stressors as other professions, but this environment is not as traditional as an office setting, and it can create increased number of stressors that maybe other people don't have in medicine. And so, figure out how you can address coping strategies and how you can build operational administrative strategies that support the team and the individuals instead of kind of push to continue stressors. Questions for me or any of us? Slide. I just want to jump in and say that we've done so many of these workshops and other kind of events with HCCI. One of the things we always hear is how valuable it is to find a community of other providers who are doing this. And so, I just want to kind of encourage you that these are your people. This is your tribe, however you want to describe it. And so, just always feel like you can come and check in with this group, with us at HCCI, do another kind of a workshop. But I think that's important to your career satisfaction as well. Oh, absolutely. Especially for those who are, you know, leading practices or starting practices, you know, your employees are your employees. They're not your friends. You can't rely on them. And so, the ability to map best practices, but also just to have a colleague to run really hard problems off of, this is an incredible group. I love doing them virtually because I think you can create your own day and you don't have to travel. And I love them in person because then you get to shake hands with the person and you say, you're my new best friend. And so, you know, really, as you think about this evening and you go into tomorrow, like figure out how you're going to continue to be new best friends with each other because we don't share contact lists. So, you know, keep in touch, remember each other's names. When someone makes a comment, you want to know them more. That chat function is super slick. Yeah, you guys can make your own connections that way. It's the networking chat. Okay. Yes, we're wrapping up, which is great. So, one of my very favorite things is as we wrap up our day is to ask a couple questions. So, either unmute yourself or pop it in the chat. But what's one thing you're especially glad you learned today and any burning questions that we for sure got to cover tomorrow. Cannot leave without it. Sorry, I thought I unmuted myself. I'm going to say even if you speak up and share your answers to this verbally, at least the first question, what one thing are you especially glad you learned today? Also put it in the chat because we're going to do a little something to share with you tomorrow and it's easier if it's in writing for us. I think I appreciated all of the links. That was really helpful and I was actually copying those to make sure that I wouldn't miss them and I could go back and look at those later. So, I definitely appreciate the additional resources. Awesome. And by the way, I don't think I mentioned this at the beginning, but the slides from today's session will be put into your resources in the HCCI Learning Hub. And then at the end of tomorrow, we put the day two slides. So, just know that if you're interested in having a copy of the slides that those will be available. Great. Thank you. All right, seeing a lot of good things. Yeah, RPM, high needs DCE, special programs and additional resources, the PCF primary care first diagram. Oh, Michael's not here, but shout out for follow the medicine. I love that too. I'm always trying to remember to celebrate and show my team that they are appreciated. Absolutely. Care, care management, care coordination, need prescribing algorithm. Yeah, keep them coming. This is helpful. I think the funniest part is these RPMs. I was like, I don't really like them that much. And people are like, I want to know more. Hot topic. Always two sides of the coin. I'm not trying to say I'm super pro RPM either. I've just worked with enough practices that do it. If you have access to the essential elements course, unless I am totally losing my mind, I'm pretty sure I presented our billing for RPM in the essential elements virtual course. So if you have access to that, you can go back and listen to it. If you don't, I know that HCI is doing another essential elements course later this year, that's going to be in person. And there's again, that free tip sheet on our website too. But for those of you looking at starting RPM, just wanted to highlight, you may already have some additional information on that. That's awesome. The other, so everybody's putting in, what are you especially glad for? The other thing was any burning questions. So I thought I'd do a day two teaser on what we're covering. Paul and I are going to cover key quality metrics and value-based care. Brianna and I are covering evaluating productivity and staffing in the program. Paul and Brianna are covering HCC coding and risk adjustment and home-based care, which is usually a fan favorite. We're covering, all three of us are going to do a panel on optimizing value-based care for home-based patients using those six key things for value-based care that we kicked off the day with. And then we're going into the clinical stuff. And that part is always really exciting. And I always encourage anybody who's not clinical to stick around and learn because, again, I always say I'm not clinical, but the ability for me to at least be able to talk it a little bit and talk about that value is so key. And so wound care, the G-tube, the trach, and the joint aspiration injection are the three things. And then HCCI founder, Tom, will be joining us to do one of those. So those are usually just super fun and great. So questions going into tomorrow that people are like, I want to know more about those, throw them in the chat, talk about them. And anything that I listed that we didn't cover in either two days, it's actually Paul's. I also really appreciate Karen's comment in the chat that she, in addition to learning some new things, she confirmed some of the things they're already doing. And as an educator, I know how important that is. It's not always just about learning something new. It's about having that validation that you're doing something that is considered best practice or that your peers are doing in the same kind of way. And that's so, so important. So if that's even some, I think calling that out as something that was valuable for you is important. All right. Well, have we reached the time or we're just done done? Let's go to the next slide because I think we just have, yeah. Yeah. I just really want to say one thing. I know you actually end us, Melissa, but I just cannot reiterate enough that doing that learning plan is so key. It helps us and it helps you. And there's a way to revisit ideas and think about how much stuff wasn't on a slide that we're talking about. It's just a place where you're jotting your notes. If you're going to jot your notes anyway, jot them on those learning plans so you can revisit them. And then that gives us information to how we continue to make these better and improve them. And there's other content HTCI puts out. So it's not just these courses. You may say, I'm never going to attend an advanced course again. So I don't need to know if that's better. That's OK. There's all sorts of cool, cool, cool educational resources that will be put out. And your information and your feedback goes to fund ideas for all of those things. I just I cannot say enough filling out that learning plan. And now it's all yours again. Oh, yeah. I see people are putting those burning questions in there for tomorrow. We will our faculty meet a half an hour before the workshop starts. And we will we'll review those questions and make sure that we address them tomorrow. So thank you for doing that. Can we go to the next slide? All right. Here's your reminders. If you've completed a learning plan for today and you want to start fresh tomorrow, go ahead and send that in to us. There's instructions for where to do that, but you send it to the education at HCC Institute that email. And then day two will start at the same time as we did today, which was 9 a.m. Central Time. You use the same Zoom link that you used to get into this one. So hope I wasn't aware anybody had any problems. So that's that's good news. If you did have problems, remember, Sarah is here to help you. And we will finish. We're scheduled to finish at 330 Central Time. We're a little bit early tonight, which means you get to go enjoy the heat outside wherever you are. I think that's is that the last slide? I think it might be. All right. Well, listen, thank you all so much. Any anything else from the faculty? Or can we end it? All right. Thank you all so much. We will see you tomorrow at 9 a.m. Central. And have a great evening. Thank you. Bye.

video

sessions

value-based contracts

home-based primary care

high-utilizers of healthcare

comprehensive care

coordinated care

key metrics

Primary Care First

payment model

advanced primary care practices

quality bonuses

HCC risk adjustment

behavioral health services

integration