Good morning, everybody. Welcome back. Hi, Samantha. Thanks for posting in the chat. Yes, the chat is our friend. And I'm going to turn it right over to Amanda. She's going to get us started. Hey, y'all. Welcome back. Typically, we hear that after the first day, your minds are just blown. And then you got a whole nother day. So we're excited to keep going. Ask questions throughout. Oh, here they go. We're pulling up the slides. And then pop anything in the chat kind of as you as you slide to get me to the first one. Pop any of the chat if you still have any questions you want to cover today or any burning thoughts. Hey, guys, I'm having an issue with my computer on my screen. What can what can you see right now? We can see the opening slide. Okay, I'm having a hard time advancing them. For some reason, it's not working. All right, I'll let me get set up. I can do it. Okay. Well, in the meantime, should we I can jump ahead, actually, and talk about we don't have this written down. But there were three questions that were in the chat that I wanted we want to address that we weren't planning to address today. So again, anything else? Any other questions? But first one does malpractice coverage need to be changed if a practice starts doing procedures? And here's my answer. And other people jump in. But we have not seen that if it's if it's a family medicine or internal medicine, and they're just doing minor procedures in the home. We've not seen that increase malpractice insurance. Huge caveat, you know, there's an application that you fill out when you sign up for malpractice and you review it annually. And just make sure you disclose everything and talk with your provider. We do see increases if they're people are picking up medical directorships or hospital hospitalists work or get outside work that you're covering under your malpractice. But I've not seen it for, again, kind of minor procedures in the home. But anybody else have thoughts or questions to help Alex with their question? Okay, question two for the homebound would appreciate hearing how folks are solving for lack of podiatry who make house calls. This is not something that we've been able to solve for at all at our practice would just throw in anybody want to jump in and say how you guys all solve for podiatry. Elena spoke yesterday about how they contracted with a local podiatrist. Any other ideas? It's Michael. We do have this problem as well. There is the American Podiatry Association, they have a resource you can look up a provider I just copied and pasted the web link for the directory in the chat. It's it is a little bit difficult to decipher if they do house calls or not. And then the other option is I do nail care in the home. And some of our other providers will do that too. And you can go for we do nail care, but we don't have a podiatrist. Right? Anybody else? Best practice sharing. I would just say look into your community resources. And you know, I know Illinois does have several larger, you know, like for care at home, Chicago for care at home, people, you know, companies that are being used for podiatry, but even your local senior services, area on aging, home health hospice, I would check with those, you know, types of organizations on and they may have some resources for home limited patients that you're not aware of. Brianna, and some reasons. Oh, Paul. Yeah, absolutely. It, you know, I talked about how relationships are so important. Talk to your home health nurse, talk to your hospice people, and just say, you know, I'm really struggling finding whatever. And they may say, Hey, you know, I ran into so and so and she's a podiatrist that's taking care of one of our patients. So network and share information, ask for help. Can't agree more about reaching out to others and share with them, you know, what you're looking for. You just may be surprised what kind of experience or resources others may be able to share with you. Great point. Yeah. There are also some resources in the chat people have been throwing in there. And the final question we got was best practices for billing frequency quality guidelines for different visit types for homebound patients. Do you want to take that one, Brianna? Yeah. So I know for those of you that may have access to it, we did cover billing much more extensively in essential elements. If you didn't have a chance to take essential elements, like I said, HCI is offering that later this year again. But as far as billing frequency, this is how I'm interpreting the question. And please jump in the chat if this is not what you meant. But the common question that I often get is how often can I see my patients? And that just comes down to clinical needs. So for especially for the Medicare program, you just have to support medical necessity. So as long as the patient you're individualizing, and it's a clinician judgment decision based on that patient's need. You know, and I'm gonna let Michael chime in on kind of some of the common practices in his practice, where you get in trouble, you just can't set a blanket statement for all of your patients without considering their individual needs or stratification based on their health status. Like, for example, if you were going to say, I'm going to see every patient on my panel every four weeks, that would be a Medicare audit red flag. But if you're saying this particular patient, because of these chronic conditions, because of this exacerbation, I need to see in four to six weeks, absolutely no problem, as long as you're not scheduling all of your patients on a set schedule, because you need to personalize visit frequency to the individual needs of the patient. And that should be a clinician judgment decision. And I just have a comment to make about that. No, but for practice, as I look at, you know, what were the changes that we're going through? What is the saying, I got two feet, one in each canoe, right? It's kind of hard to row, I'm rowing in fee for service. And now I'm also rowing in value based care. I think one of the biggest difference, as you know, the question is talking about the visit frequency, the mindset is a little bit different. And the essential elements we talked about, for example, a Naylor's model for post hospital follow up, you can look up on that, I don't know if we're able to share a link on the Naylor model. And one of the things we're implementing here, especially if you're thinking and going into value based care, and we'll talk about metrics in just a couple minutes here about readmissions and so on. So one of the things we're trying to institute here is post hospitals, particularly for conditions like COPD, CHF, weekly visit for four weeks, and then go on to a monthly visit and then expanding from there on. And you can certainly document in your chart, high risk of readmission or frequent readmission to the hospital visit necessary to keep you know, patients stable and so on. So that is, I think a change in a mindset regarding how frequently you want to visit your patient both from a clinical stability standpoint, and also if you're going into value based care, and trying to meet your metric. One other comment, and we'll talk about it in our session on ACC, is it's about risk stratification, if there's software for you, as you look at your patient risk. And for example, if you have ACC score between this range and that range, is there a way to see, you know, when was the last time these patients were touched? And if they have not been seen, if they have a high ACC score, for example, greater than two, and they've not been seen for four weeks, is your software capable of alerting you that this patient is out of range and needs a visit? So that's something we're also working here in our practice is risk stratifying and alerting us that patients have been missed, perhaps, and needs a visit. Great. Throw any other burning questions you have in the chat, and we'll try to address them throughout the day and find places for them. So thanks for putting those in. Again, I know your brains were all swirling over the evening, and maybe you were more like, give me a glass of wine, I'm going to block it out and start again the next day. Or maybe you again, you were dreaming and taking notes at 2 a.m. saying, I should really ask about this. So we still have time, we have a whole day. Okay, at the end of the day, we ask a couple of questions. And so what's really cool is the HCCI team goes back and puts it in a word cloud. So could you go to the first one? And those who are not familiar with word clouds is the larger the type, the more often something was mentioned. And so what did you hope to get out of this workshop? And if it's a little bit smaller, it was mentioned fewer times than if it was bigger here. And so I think you see a lot of commonality. And what I really love about doing these two questions is again, you see, oh, yeah, that was what I said, or we all said that. That's really cool that we were saying that. So, you know, tips, efficiency, workflow, tools, we're all in that boat, how we think about value-based care, considering that's a lot of our discussion, that's great that it's popping out. Where do you get referrals? How do we think about the patient population? How do we think about safety? A couple of the smaller kind of details, community health workers, ACL reach program, staffing ratios, you know, those might, they're still important, they're just maybe weren't as mentioned as often. So I think that there's a lot that people were hoping to get out of the workshop. And then as we transition to the next question, we really ask everybody, what were you really glad you learned yesterday? And pop out Michael's, you know, follow the medicine, certainly de-prescribing is always really fun, hot topic. RPM, boy, really the was it really the surprise one here for me, but I think good opportunity and certainly good feedback that we can continue to add some of our discussions in there. High-needs DCE, a lot of people, I think we'll continue to explore it. And we talked about the value of exploring some of the direct to Medicare programming. So the high-needs DCE now through the kind of reach program. And then I think there's kind of this collection of four that were in the similar vein around recruiting and celebrating and networking and empathy inside of the work. You know, we put those softer skill things towards the end to provide a little bit less, a little bit less of, you have to pay really close attention, but maybe it cuts in and hits a little bit of your heartstrings as you start to think about, again, putting the whole practice together of how you manage forward. So I really had a great day yesterday. I went home, told my wife, had a wonderful day, looking forward to today too. I think we have a lot of fun things to talk about. So back to you, Melissa. Well, yeah, that's a great cue up for our agenda for today. And so you can see that we're going to start out with Amanda and now, is it Amanda and Brianna that are going to talk about demonstrating the value of home-based primary care. So how you do that with, you know, payers and partners and what quality metrics to be highlighting. And then Amanda and Brianna are talking about evaluating productivity and staffing in the house call program. We have a big chunk of time after our break where we're going to be really diving into that HCC coding and risk adjustment and home-based care. And then a new session for us on optimizing value-based care and just all of the, bringing kind of together all of the six components we've been covering in these two days to talk about, you know, tactically really how we're doing that. We have our 30 minute lunch and then after lunch, it's very clinically focused. So again, just, you know, if that's not something that's going to help you just know that kind of after lunch, you know, that's pretty much the end of the operations time, but this is still real valuable content. Michael's going to cover in great detail, you know, the wound care and how you do that in the home to make sure that you're providing the highest quality care for your patients, avoiding pressure injuries and others and other care. And then in the managing costs of care procedures, we're talking about trach changes, G-tube changes, knee joint aspiration and injection. And Tony Perry asked yesterday, who is, you know, who is Tom Cornwell going to be at, which, whose joint is he going to be aspirating? Well, no, we have simulators and videos. We produced a couple, several high quality videos on this where they're demonstrating with with the simulators. And then I know Tom will be on video live with the knee model and we'll answer any questions as will all our faculty about the specific procedures. So we do have a Q&A and wrap up at the very end of the day. This is a reminder to get those learning plans. If you wanted to start a fresh plan for day two, go ahead and do that. I know we received a few learning plans at the end of yesterday. So thank you for sharing those, but make sure that at the end of today, you do send us your learning plans. All right. And so now I'm going to turn it over. Oh, I'm sorry. It was Paul and Amanda and not for this first one. I'm so sorry. So I'll turn it back over to Amanda. Thank you, everybody. And good morning. The object, our objectives this morning, we're going to talk about key quality metrics that demonstrate value of home-based medical care and talk about the approaches, how to implement these quality improvement efforts and using this data for potential partnership and engagement with payers, as we talked about yesterday. Next slide, please. You know, as we think about quality improvement in HBPC, you know, there's so many, there's so many metrics out there. I think one of the challenge for us and for all of you is to, to find a meaningful metric that not only it's impactful, meaningful for our patients, but something you can track in your EHR and also maintaining a culture of continue, continuous improvement rather than just, you know, having a dashboard and you just sits on a side and you look at it maybe once a year, that might not be helpful to you. Again, there's that interface between data and what you are trying to do with clinical care and especially under value-based contracting and a foster buy-in support and accountability. It is so important for your team to understand, you know, why you're doing this. And, and it is so important for each one of the, the staff members on your team to be aware of, you know, the, the, the role that they play in, in all of this. For example, you know, we talk about the importance of revenue cycle management and the front office has to know about, you know, when they check in a patient and so on, get their insurance, their particular plan that you don't want to get a denial later. Or see a patient who's part of an HMO and you didn't get a prior authorization and that whole time that just went wasted. Again, just to have your team understand why you're doing this. Just quickly here, I'm looking at my dashboard. I wish I could show you, but obviously there's too much patient information. In terms of our quality metrics, as I'm looking at my metrics, it has a dashboard. It's really colorful and pretty. It talks about my annual wellness visits, what percentage I'm at, my A1Cs. It also has a box here that talks about my, actually plots out a graph of my RAF score. Again, that's going to be important. We'll talk about that later today. And also on the ACC, we'll talk more about that. The risk adjustment factor, and I can see the trend of where I'm hitting, which is good and it's better than the year before. And then there are some ambulatory quality measures. And again, and I'll get to that in the next slide. There's the A1C, dilated eye exam, colorectal screening, breast cancer screening, immunizations, depression screening, fall risk, annual wellness visit, pain contract agreement. And then I think I already said vaccination status and controlling blood pressure. Now, as you listen to some of those measures, and I think you and I have the same feelings, like, well, some of those really don't, they don't apply to us. Especially for example, say, breast cancer screening and colorectal cancer screening. A lot of our patients are older. And that really doesn't apply. And that's where this national home-based primary care learning network comes into play here. And this was started in 2012 by Dr. Christine Ritchie. She's out of MassGen now. And Dr. Bruce Leff, he is at Hopkins. And they wanted advanced standardization of meaningful quality metrics for home based providers like us. And to drive applied research to support best practice evidence that's evidence-based. They also periodically had the opportunity for practices to apply to be part of the learning network collaborative. And where the practices are coached and let through QI projects and have opportunities to network with their peers to share learning and best practices. And if you can visit their website for more information, if you're interested. Next slide, please. Now, the reason that they are promoting HPPC reporting on cognitive assessment and functional assessment, because they, through their work, these are two quality metrics endorsed by the National Quality Forum as MIPS eligible. And they feel like these are two that are very relevant to HPPC. And they are. But they need practices to continue to reporting these data to CMS and MIPS to keep them active as quality measures. Next slide, please. Brianna, do I turn this over to you or I can take it? Sorry, I was trying to unmute. You can take it. I'm happy to. Yeah, no problem. So again, as I talked about looking at my dashboard here, some apply, some don't apply. Some of the metrics for us to consider number, I think Dr. Cornwell talked about this in the video yesterday, death is home versus in a hospital or SNFs, incoming referrals per month and who are your sources for these referrals, number of visits per day and by provider and total number of death on hospice, hospitalization rate, ICU stays 30 days before death, hospitalization stays 90 days before death. Those are important because we know through studies that 30 days and 90 days, they are high cost periods for the kind of patients that we take care of. Yearly census, time to the first visit, time to TCM visit. Again, if one of our metrics is re, Amanda and I talked about a cure transition and one of the slides, it talks about, you know, 13% of heart failure patient goes back within the first three days. Your TCM visit can't be two weeks, it might be too late. So these are just some metrics for you to consider as you plan out not only staffing, but also like, you know, what can I capture in my dashboard to demonstrate my value? Next slide, please. Brianna. I think some of the metrics that Dr. Ching didn't talk about so far yet is, you know, we touched on a little bit yesterday, but getting patient satisfaction too. I mean, we talked about how in the value-based care models, that's gonna be a requirement from the patient experience of care surveys. But certainly even if you're not, you know, doing your own, you know, what areas can you really improve on? Do you have a way for not only the patient, but patient and caregiver feedback on how they feel, you know, their goals are being managed and that provider trust and, you know, the resources that they need. So again, we gave you a lot of metrics just to kind of brainstorm ideas. Pick one to three. What is gonna tell your story the best? So these are all just to give you kind of some food for thought. We certainly know the value of house calls often comes from reducing high costs, maybe unnecessary, you know, hospitalizations or skilled nursing facilities or things like that. So hone in on what you know your practice is really good at and focus on that. And HCCI does have a sample patient satisfaction form on our website. It's the form that it's referencing on the screen. And I can put a link in the chat to the tool and tip sheet page that has that. Dr. Chang, you wanna talk about patient stories and kind of this powerful story? Yep, absolutely. You know, patient stories are so important. And I was thinking this morning, you know, yesterday we talked about, if you wanna call it, you know, hard things, they're not necessarily, well, data, hard things, metrics, data, you know, contracting and payers and so forth. When you're talking to people, whether it's an elevator speech or talking with payers and so on, you know, data is very important, but also supported with story. You know, Tom yesterday in the video talked about Amanda and Elsa. I think it's Elsa, that's her name. They're just so powerful. And then as you go through your career, as you go through your practice, write them down and use them to support the data, the story that you're trying to share with others. You know, 65 year old patient, lots of medical problems, 16 medications. We did a study from our practice. You know, Michael talked about de-prescribing, you know, from our study, the average number of medications that our patients, in my practice, it's 17, 17 pills. That is, when I saw that, you know, I felt so bad. You know, we gotta do something about that. And Amanda talked about it yesterday. It would be great to have maybe a metrics or data that looks at, hey, you know, 17 pills, on January 1st, how many pills at December 31st? Have you made maybe even 25% reduction in that? Okay. So, you know, all of this kind of tied together, but I'm digressing. She's never married. He's got two uninvolved adult children, frozen meals, delivered meals. Next slide, please. So, as Paul transitions the really great story to more boring data stuff, but thanks, Paul, for doing that. Did you have any other thoughts on wrapping up your story? Oh, no. I mean, and you know, the story goes on, basically, you know, the patient had multiple, it's one of those frequent flyers. And I think, I think it's 11 hospitalizations, or 10 hospital stay within a 12 month period of time. Basically, she was in hospital every month. You know, after we started seeing her, her hospital stay went down to two hospital stays in the following 12 months. And again, it's not only our services, but getting additional resources, home health, Meals on Wheels, social services, getting a pharmacy to help, getting medications delivered, deprescribing, all of that, all that, you know, bringing in not only clinical stuff, but additional support to help the patient stay out of the hospital. So again, remember these patient stories and the meaningful impact that you've had in not only dollars and cents, but also on the soft side, how we care for them. And then the patient was very glad that she's home. She's sick and tired of the hospital, and the hospital is a little frustrated with her as well. So remember those story, and Amanda is going to talk about, you know, more hard stuff, you want to call it that, but also remember the soft stuff that is, you know, it's tear jerk, tear jerking. And it can tug on the emotional side as you engage with those that you're talking with. Thanks, Amanda. Yeah, thanks, Paul. Yeah, it is hard to transition a little bit from kind of the soft side and the big picture of why we're doing this to a little bit of the detail, but we just want to spend a few minutes to kind of talk about quality measures and what you're a measure to, and whether you're a delegated provider or you're holding the actual contract, these are important things for Medicare. And so Medicare quality metrics are really heatest, which you've heard a lot of. STAR measures, they're actually a, it's a five-star quality system, but it's actually a combo of some of the measures from HEDIS, CAHPS, HOAS, of course the PDP and the CMS administrative data. And so you may have, hey, you need to hit these 20 quality measures, or you may have, these are five really important STAR measures that we're following. And again, those could be a mixture. Typically you'd get like a HEDIS and a CAHPS as a delegated provider that you'd be responsible for. And then process and outcome data created with partners or within a practice. And I'm gonna talk a little bit about the difference between a process-based measure and an outcome-based measure but really how are you getting data from claims, utilization, HCC reports, are you getting it from Medicare, are you getting it from a delegated provider, and how are you putting all those measures together to be actionable? I think that's one of the key things that we've talked a lot about when you get into value is there are a lot of different things to look at, but how do you focus on what's actionable and meaningful for you? Slide. So the first step really, as you think about quality is make sure in your existing contract, and you might have created the contract so you know exactly what's in there, or again, you might be applying for REACH ACO or an MSSP, and there are certain things that are prescribed inside of that program. So what's required from a quality understanding or quality reporting? And then understand if your tech has the capability of doing that, or if you need new tech. And understanding that early is really critical. We just, our EHR just went through a large sale. And so I would say they definitely had the ability a couple of years ago to be more nimble and help us collect some stuff. And just because of their timing, they don't have that ability right now because they're doing other things. And so that's really key is if you need a new technology to understand that, if you need a new pop health support function, if your EHR is not supporting what you need to be able to collect and support back. And again, a lot of the Medicare measures are through HEDIS. But again, you need to know, am I getting close before you get claims-based data? If your data is created by a partner, and this is kind of what I mean, especially if you're like a delegated provider, make sure that you use that data in a meaningful way because they can cut the data a lot of different ways, but again, is it actionable? And if you're getting that information from Medicare, is it actionable? Did you put it in a format you can use? Evaluate what data you're collecting today, do your full landscape. And then research every detail of every measure. This is really critical. Go to the cited source from Medicare to make sure you understand what population is included, excluded, and if certain job requirements are needed to meet this requirement. And I'll give one example. You know, at kind of first blush, we have a HEDIS measure that said, you know, a follow-up visit within, you know, a follow-up care coordination visit within, you know, I think it was like 72 hours. And we were like, okay. And so we had some of our care coordinators make those visits. And we, you know, like do telephonic visits. And then, and we were going along and then it got put on my desk and I said, well, how can Medicare, why would Medicare put this measure? Like, it's not, you can't actually measure that. And they, and my team was like, oh yeah, no. It, you know, it's, and I said, no, like Medicare is this data, this specific HEDIS data can only capture claims-based data and care coordinators can't bill. And boy howdy, we learned a valuable lesson. So that's why I added this bullet point in, is I just, we tore apart that measure. And of course you need a pro-fee bill. You need something to come in. So the measure didn't just prescribe who had to do the visit, but it had to be a billing provider because it actually had to be recorded by Medicare. And having a care coordinator do it because we weren't billing CCM wasn't meeting the letter of the law. Had we been billing CCM, that would have met the requirement. And so we had, you know, again, truly understanding what is actually required, how the information gets collected, and then using your technology to kind of source back and say, yes, I did this in Q1 and I saw my, you know, I saw that by the time I get claims in Q2, I saw that measure worked and it measurably went up because I put this in place. So just a cautionary tale I'm happy to pass along. I think there's a question here about any EHR recommendations. You know, I don't have, I generally fall into the camp of, again, an EHR is a clinical data repository and I've gotten out of EHRs can do everything. You know, they're not built to do everything really well. They don't do practice management system really well. They don't do pop health really well. They don't do care coordination or risk stratification or data analytics really well. I think they do generally their lane really well. And sometimes what groups will do is they'll, like tech companies will buy other companies and they'll just plaster their face on the front side. So the user experience side, but the things aren't actually integrating and that's really frustrating. And so it's important to understand when you meet with a new tech vendor and say, you know, is your system homegrown and you built it all or is your method to acquire and integrate? And if it's inquire and integrate, it's gonna, it can be really clunky. And so sometimes you're like, well, why does my practice management system not talk to my EHR? Because that entity bought another company, they rebranded it and they just put the face of it to look like their face and they connected some of the dots, but not all the dots. So I don't typically recommend one EHR over the others. You know, everything, again, to my best, my gut cynical feeling is it's just for collecting data. How you interpret it, you probably need to pull it off into another system. Anybody else love their system? I know Elena likes eClinicalWorks for doing that. I haven't heard that anybody's really good at true pop health management and data analytics at this level. Okay. Just throw it in the chat if you really like yours and you're super happy with it. Slide. So I mentioned we talk about process versus outcome measure. So a lot of the work that you're gonna do directly with Medicare is gonna be outcome measure, but you may need a process measure to get there. And so think about the new things that you're doing. You know, a process measure is really just the activity was accomplished, right? We delivered six educational sessions. We create a new policy for tracking. We're rolling out a DEI strategy and that for us is we do one DEI event for the company every quarter. That's a process measure. That doesn't say we've met the actual goal. We've accomplished the actual goal and there's this impact because that's really an outcome measure, right? We've been able to lower hospital readmission rates from 18 to 16%. That is an outcome measure. That's something, again, you might see as a reported measure, but you may need a number of process measures to get to lower hospital readmission rates. Our process measure is that we're gonna have a care coordinator, some form of care coordination every two days after a hospital admission. And so to reduce readmissions, right? So that's how you can connect the process to the outcome. Yeah, so anyway, I think it's worth thinking about when we talked about quality, I just wanted to put in a slide because again, you may have dashboards that today because you're starting new practices are a mix of process and outcome. And I think that's perfectly okay. Eventually we'll all get to the outcome, but we need to make process procedural changes to get to those outcomes. And it's important to distinguish if we're connecting those dots successfully. And again, you're gonna have executive, board, management, provider, dashboards, and distinguish again between these two ideas and how you're connecting the dots between them. Slide. And when I create any measure, whether it's process or outcome-based, really think about smart measures. So I won't beat anybody over the head on this one, but I just think this is really great. There's so many fantastic tools on the World Wide Web to think about smart measures of how do you make it really, really specific. I put an example here, a HEDIS measure, right? Of completing a mammogram for individuals. And I can't remember the exact age ranges, right? So increased practice mammogram screening from 78% practice-wide to 82% practice-wide in the next 12 months. That is kind of, that's your outcome. That's where we're gonna try to get to. That's our goal. And we might have process measures inside that of how we're gonna try to reach that goal. Slide. And then utilizing measures. So again, we have these measures we have to nationally report. We have these measures that even though we have to nationally report to Paul's point, aren't the best examples of us sometimes. And that's why we have the great National Coloring Collaborative working in our field to get better measures. But sometimes you, again, need to kind of single out all the data to make sure it's actionable quality measures inside of your group. And so some things about disseminating quality measures is creating a dashboard, a dashboard for providers, teams, regional teams, technology built into the EHR, pop health system, regular meetings for discussing performance, goals for next steps. We have a scorecard. We call it an OKR scorecard. I did a lot of work around like a balance scorecard. I think I looked at like five different types of big practice ideas. And so we went with the OKR objective key results. So OKR scorecard, and it's pretty nimble. And we review it every week at the beginning of our executive meeting. We sit down and we say, how are we doing in these areas? Let's go deep dive in one or other. So again, that's one for the practice but the providers don't need to see that on a day-to-day basis, right? They have some tech, they have some built into the EHR around more of their panel size pieces. And so I think there are ways to kind of disseminate that but if you're focusing on a measure, again, whether it's a process or outcome measure and all of these are key pieces to get to those larger Medicare requirements that you're trying to do, make sure that you put it in a way that is clear to all the staff working in the space trying to get to that deliverable. And then this is the dashboard that Paul was talking about. So as he was kind of talking through it, this is obviously a blank dashboard but this is just built inside of his EHR that talks about, you know, how many people have had the wellness visits and then these quality measures on the side. And so it's an easier way to just kind of look at everything and start there. And typically if something is, you know, yellow or red, it just draws your eye into it. You know, we're a little bit of a smaller practice than Paul's practice. So for us, we do a lot of our work in Excel. And it's just, again, about trying to figure out how do you create that data that pops out at you that's really meaningful because there's a lot to look at. So my kind of, one of my final thoughts here is creating the internal processes is sometimes if you're trying to get to a measure, I'm trying to use the mammography as kind of a solid example through this, is it can require heavy resource allocation. And so you have to maybe think about a new process or resource, you know, and that means people, to manage a specific data. And, you know, do the ROI on meeting your goals and under saying if the downside penalty isn't worth us. We have one quality measure inside of a significant risk-bearing contract that is roughly worth $250,000. And for us, that's worth the person I have individually calling people to get a mammogram. But it's worth, again, looking at and saying, you know, what is really my downside? And so sometimes, I don't wanna say any of you guys do it, but certainly I've been guilty of, oh, we need to get to a goal, so we're gonna do it no matter what. Again, what is that worth for your allocation? And what I think, one of my final thoughts here is what I think on, I think one of the reasons that home-based medicine continues to be so nimble is very valuable is because we're really nimble. We have the ability to continue to reevaluate what we're doing. And what we see really big health systems do is build giant fixed infrastructure that they're never willing to change again. And that fixed infrastructure might be this giant care management department or might be this giant tech department or something, and then we'd never revisit it. And so those are really just built fixed expenses that we're not talking about. And so I think we have the ability to kind of say, I need to get, my goal is to get to X, what's it gonna cost me to get there? So I think that's, I always like to put, maybe it's just some of my finance hat that I wear, but I always like to put something in there about make sure that's worth it. And then review all these processes annually for any measurement changes. And Medicare will make changes. And if you have any processes that you need to adjust inside your organization. Slide. So I hope between Paul and Brianna and I, you kind of have some of these key takeaways, how you can use this to negotiate with payers and partners. We've continued to kind of tie this together around pulling actionable data and work those through. Utilize three to five meaningful measures and how they directly link to cost. Find a mixture of process and outcome-based measures if you have a system that's cumbersome and utilize these reports and find heatest measures where you can excel if you're working with a payer. So especially if you're a delegated provider, definitely, definitely, definitely try to find ones where you can be successful. Any final questions on quality for us? Paul, thoughts? Yeah, I know we're a little short on time. I think my thought is this. Find out what quality metrics you're interested and then perhaps ask what your EHR is able to do in terms of extracting data rather than building this gigantic all-encompassing I think you mentioned this massive enterprise data warehouse and then trying to get information out of it. I think that might be a little bit cumbersome and overwhelming. I think think about what you want and then see what can be built through the electronic health record to get the information that you can rather than sinking a lot of money to build this massive structure and then like, well, gee, I have all this data. I don't know what to do with. Yeah, Paul, I can't agree more. What I would say, too, is I'm seeing tech go in a really interesting way. I feel like all these tech companies are attempting to kind of build a whole product, a whole suite solution, and so they're less likely to partner with other groups. And so for us, we are attempting to, again, continue to look at quality measures, continue to look at dashboards so we can break up red tape and break up stuff that we don't need to keep following or that's not meaningful or a process measure that's not truly getting us the outcome as we keep looking at that so we don't waste resources. And from a tech standpoint, REHR doesn't do all of the things we need it to do. It can capture some of these quality metrics, but it can't capture some of the important metrics you and Brianna are going to talk about, like HCCs and RAF scores in real time. And so we do need to come up with another solution. And paying thousands upon thousands upon tens of thousands to get two companies to talk that will never really talk really well, we think we're going to just use physical people resources that can help mine the data to create some autopilot stuff. I'm not sure there's a right or wrong way, but it feels like every day, someone new is entering the tech field to solve our problem, and it's just keeping an eye on it. Anyway, yeah. So should we talk about evaluating productivity and staffing, friend? Let's do it. Why not? So I wanted to just kind of level set before Amanda and I dive in. So we're going to talk about, for this workshop, with the focus of kind of transforming your practice towards value-based care, how productivity and staffing is different in a value-based world versus fee-for-service. However, a couple of resources for you all, because based on some of the comments and the questions yesterday, I felt like there was still, I know we have a mixed audience, and obviously you're still, like Dr. Ching said, you're going to have kind of one foot in two different canoes sometimes. Sarah was kind enough to upload another additional resource yesterday to the resources that you have in the HCCI Learning Hub. So if you go to the Advanced Application My Resources, I did add a few different, a handout with different staffing model ratios, as well as productivity standards that we covered in Essential Elements. So if you want to kind of compare what we talk about today to fee-for-service, check that resource out. It's been uploaded for you. The other thing that it made me kind of reflect on is a while back, I don't remember how well, back I did this video for HCCI called The Five Most Important Things About Home-Based Primary Care Practice Management. And I think that kind of ties in some of the themes of the questions that I saw very well, and I think I would change a couple of things now. The first thing I said was, number one is keeping your costs down. And when I said that, I was thinking about flexibility of you don't need a huge physical office space, and you can utilize, you know, your staff to the top of scope to really make sure that the right people are doing the right work. And so I think especially as we think about what people can do, what roles, and have more flexibility and value, that that has a good tie-in. Number two, the second thing I said was hire the right people. And I would change that, especially with Amanda's talk yesterday, is not only hire the right people, but take care of your people, because that's really how it's going to pay off in the end, is if you're taking care of yourself and your team, and you have that continuity and you have really good people dedicated and who understand the mission and understand their impact in the mission and vision of the company, then that's certainly going to serve you well. Number three was regarding productivity standards, but I think it's setting expectations. You know, what are your performance and or productivity standards, and how are you going to deliver on those results? And that's kind of the comment that I would offer for number three. And then number four, which we're not talking about today, we talked about it extensively, is geographic scheduling, though. But just don't ever forget how important that is, regardless of what payment model you're in. That's what's so unique about home-based care. That can be or break you. Your provider is going to be dissatisfied if they're driving around, so, you know, optimize your service area, create scheduling guides, set provider zones, use route and map-based tools to do that. Really make sure that you're making the most of their time from a geographic scheduling standpoint. I'll put some additional resources in the chat, since we're not covering that today. So if geographic scheduling is something you didn't hear me talk about extensively in Essential Elements, you know where to go to find that information. And then kind of tying that all together with number five is, you know, making the most of your value. So tracking the right data to really be able to tell your story appropriately. So again, I'll come back to some of those questions in the chat if we move on to kind of how we're thinking about productivity and staffing for the objectives for this particular session. Go to the next slide. So how do you recognize factors and then be able to kind of think about different approaches? And then how are you going to measure the impact on the staff that that's having? Next slide. All right. So I'll start us off and then Amanda jump in. So I think these were just kind of some questions as I was thinking about, like, how do you go about even wrapping your mind around that? And I think we started talking about this a lot, but how do you really understand the population that you're caring for today? And so I'm talking about what attributes and similarities they have, even from a chronic disease standpoint, from a health status and a frailty and a social determinants of health standpoint. How do you truly get the information that you need to understand what population is it that I'm caring for? So that you can then go to identify the right resources and what roles you might need to effectively care for that population of patients. And then thinking about, you know, maybe you have a lot of behavioral health needs. Maybe you have a lot of wound needs. Those are very specific things that you're going to identify different resources and roles to support. And then going into kind of what are your payer contracts, your performance expectations? What is your clinical model have to deliver? Do you have to be able to deliver acute and urgent visits within a certain timeframe? Do you, you know, you're fulfilling TCM for someone? Maybe you have to, you know, do different things like that. So understanding what your clinical model expectations are. And then that's where kind of what Amanda talked about with those process measures are going to tie into that. And then that can really help you drive what your panel size and visit frequency should be. And pay for service, we see ranges more like, you know, eight to 10 visits a day. And value-based care, I would say I see averages closer to four to seven visits a day. Maybe you're spending longer time. Maybe they're doing other things. But again, that's going to vary. How many patients you have and what kind of quality do you want to deliver to be able to have one clinician, you know, take care of X amount of patients and then what resources do they need to do that? And that'll also go into kind of your volume goals and also your growth plans. Are you getting ready to take on a new facility and are going to be acquiring 100 or 500 patients? Now, that staffing plan is going to look very different based on your growth. So I'll pause there and Amanda, if you want to kind of jump in. Yeah, I just jump in like one of the things I like about value-based care is it does hone you down a little bit more. So when we think about home-based medicine, it's like some days it feels like every day I'm boiling the ocean, right? And where do I start? I got the process broke over here. I need something on the back office over here. We got a clinical thing that's not working right. And in two days, we attempt to kind of tie this all together. What value-based care is essentially doing and why I really like this slide is it says really make sure you're focusing on that population, right? And you clarify that piece and you clarify what quality measures am I actually being held to and what cost measures am I being held to? And then you dig deeper into solving those problems. And so it does make, it shrinks the ocean a little bit. And so this kind of walks you through and you may say, well, I know I'm caring for everybody. Well, if you sign a value-based contract, you know, unless you are like created just for one insurance product, now you have two populations. You have the population under value-based care and you have the population of fee-for-service. And so, and there is this kind of ethical discussion around what does everybody get? And then what does a value-based care contract and patients and beneficiaries in that contract get? And I think that's, this is really important. So again, now I have a new original Medicare REACH ACO contract, it's not for all my patients, that's for a subset of the patients. And that's where you, that's the group you actually put in the bubble and then you walk through that. And so, and then what are my quality measures? How are I being measured by cost? Again, you walk through that with that eye on that specific patient population. So I really just really like this slide and I can't emphasize enough, you know, having great clarity on what patients are in value-based care and what that population really looks like. And I'll say from an ethics standpoint, I've, you know, some people, providers maybe have a different approach than I have, but I hear providers in my practice say, well, I've gotten a medicine to treat everybody the same and to, you know, make sure I offered these things. And I say, well, you know, like Medicare specifically calls out these special programs because people, because they think they can apply more resources to them. So they give you additional dollars and they even create an acuity scale in which you get paid more under those models to take care of those patients, right? When you're under fee-for-service, everyone is equal. When you're under a risk-based contract, and again, you care about HCC scores and you, and you care about that. Medicare cares about that. Medicare saying, if you have a quadriplegic with HIV and depression stage, you know, five or in all of the things that you get more money for that patient to do the appropriate care. And then boom, boom, boom. You walk through what resources are needed. And that's not an equal, but it is an equity application or an equitable application of care because someone needs something more than someone else. Thanks for, you know. Yeah, we can jump to the next slide. Amanda, I'll let you kind of talk about on-site fiscal. Yeah, I would just make sure these are, and I won't, I won't spend a ton of time on it, but these are just three ways to think about your patient population. So at, you know, your active patient census, who are your total patients today, typically you would report that in some sort of kind of general idea like, you know, a month or every week, what's my patient census. You might even tie that to dollar amounts and how you're going to pay people like a panel size. So sometimes people call that a panel size. Total life served. I think that's a really helpful number. So you can use all these in payer negotiations and partner negotiations, but how many lives did you touch in that year? Right. And then you can get other detail out of it. How many died? How many transitioned? How many left your practice? You know, how many transitioned to another care, you know, site of service or something. And then your average daily census. And so your ADC is the one that you may often see, but is there a way to track that? Sometimes your systems can't track all of these things, but be really clear on what you're tracking, why, how you report it and how you talk about it with other people. We've gotten to a spot where we track these things. We track all of these things. So average daily census is a little too difficult to track for our whole population, for our patients and value-based care. We do track for that. So kind of thinking about some of the flexibility, I think one of the things that can be really vocationally rewarding for providers who are in practices that are practicing in value-based care is kind of the opportunity to innovate. So, right. If we, if this was a fee-for-service conversation, whether you're in fee-for-service or not, I think we've gotten away from work RVUs and visits when we talk about home-based primary care. So these are some metrics to kind of think about that, that more smaller part of the ocean that Amanda was talking about. How can I really understand this population that I'm caring for, but use the metrics that give me kind of a bigger picture of that rather than just focusing on visit productivity and RVUs and those kinds of things that we have no choice but to focus on in fee-for-service. So average length of stay, do you know how long, you know, we know that home-based primary care, I think the numbers that I've heard are close to 20 to 30% mortality rate of turnover in a year, right? So do you know how long on your service that you take, or maybe you have more of a transitional program approach where you're seeing patients on an average of three months, that's going to affect your care model. So what's your average length of stay, that's what I mean by that. Of course, you're still going to want to know how many visits you're making, you know, per month and also thinking about the patients, how many, based on your patient's clinical attributes, how many visits do they need in a month? Do you have a certain population of patients that's really, really high need, and you're seeing them maybe every two weeks, so they have multiple visits a month. So being able to understand visit frequency based on acuity, and then how are you using telehealth? Telehealth can be a tool to make you more efficient, it's of course never a replacement for in-person care, but are you using telehealth to address acute needs or to triage if a patient really needs to be seen that day before you send a provider out of the area, or maybe you're mixing it in for kind of those tuck-in, more social visits where it's more of a comfort to the patient to physically see their provider or have that phone call that's scheduled and they know that you're touching base with them. And then how are you recognizing the amount of time? And this gets into a little bit too of even taking care of your people too, you know, maybe you have certain days for your providers that are administrative days, or maybe you have days that they're doing more telehealth so they can catch up on documentation and callbacks and that non-face-to-face care, but you can pull some data from your EHR. You can look at the different inboxes that you have, you can look at the, you know, phone call links, you can look at a lot of information to try and, you know, the number of results that they're getting. I know Dr. Chang had a cool kind of analysis on the past where he actually looked at, you know, how much time he was getting on orders versus messages versus kind of some other things of those EHR baskets. So see what you can get to kind of understand how your providers are spending your time. And then of course, obviously, how does that relate to the total patient population that you're serving and what resources you need to address that. Amanda, would you add anything? All right, we can move on to the next slide. So thinking about, I'll start and Amanda jump in here, your staffing considerations as it relates to performance and what you have to deliver. So when you're partnering with anyone, whether it be a payer, you need to be a reliable partner. So again, thinking some, a little bit, maybe more of that process measure, how quickly are you seeing patients that had a recent utilization? Do you have really long wait lists? What is your staff retention percentage? So really thinking about how you're being a reliable partner and how your current staffing model and your current clinical model is delivering that reliability. And then when you want to think about kind of understanding your service model and making sure that you are working with the right partners, right? Don't just take every partnership. What are your expectations of care? You know, and then how are you making it easy for that partner to refer to you? You know, maybe you have an electronic referral path, they can call you, they can send out a secure email. Are you really setting expectations of these are the patients I want to take care of because this is what I do best and this is where I'm going to be successful to help you and then make it really easy for those referrals to come in so that you can have the resources and you're not providing, you know, all those expensive resources and supports maybe to a patient population that doesn't really need you that much, or that isn't really the right fit for your practice model. So that's when you do want to think about kind of eligibility and what patient do I really want to take care of, you know, who am I really best equipped to serve and who maybe can I provide some other resources to because another program might serve them better. So really thinking about that. And then also with consistency, you know, we know that quality, compassionate care is always going to be the goal. So how are you making sure that if you're making changes, especially to kind of your clinical model or your approach or some of these process things, that you're not sacrificing quality in those interactions, and you're getting that feedback, and that your staff really, you spend the time on education and skill building, I can't tell you the amount of times that I've kind of come into work with practices, and they're really struggling with workflows. And I'm like, okay, well, you know, what kind of onboarding training have we done? You know, what have we given? What resources have we given to that? And then they kind of look at me like, well, what are we talking about? So how are you investing in that staff competency and education consistently, and providing that, you know, professional development continuously throughout the year so that you don't sacrifice that quality? Yeah. And I would just add to that, like, as you grow, it becomes a bigger and bigger problem. It's easier if they're just a couple of you, and you can be elbow to elbow or talk through something pretty quickly, like, we realized that, you know, we'd cover something in a staff meeting, we'd send it out in an email, and a year later, someone asked about what's in the email? That's not very helpful, is it? You know, who's looking at emails from a year ago? And so we're, you know, to your point there around staff competency and retention in education, we are continuing to struggle on how to do that as we grow. That's a tricky one. So lots to learn there. Agree. Next slide. So this one I really like, because it talks about the volume versus the capacity. So as you think about your staffing component, as you move from kind of the fee for service to value based care, really on the fee for service, you know, you're focusing your business office and your staffing are focusing on very different things. Make sure you have a billable provider, make sure everybody's billable provider, and make sure that everybody's focused on the billable services. How do I make sure that every step of the process is managing that volume? And then it's, you know, if a provider hits a certain capacity, maybe we hire a next person, maybe we hire the next person, but they better be someone who's still billing, and then at the end of the day, you know, my contracts I care about, or can I get some points on top of Medicare? And what would that look like? Or how do I build in the Medicare reduction every year? And how many more visits does that translate to? Value based care is a totally different world, right? This is about how many patients can my providers ethically handle and do top of licensure work, and then you get a lot of creativity in utilizing staff in new ways. And then I know Brianna may have some thoughts on this too, but I'll give an example. And one of our value based contracts, you know, we're at full risk for the contract. And so we use RNs in a way that I haven't heard a lot of people do, but you know, I think it'll continue to grow. We use RNs really as acute visits, because we can't bill for them, it's value based contracts. So you could have used fee for service under like a CCM, but it's full risk. So we're not going to put through the time to do a CCM program. And we would just send them out. So it doesn't impact the provider schedule, the RNs doing the acute visits, they just make a telephone call. and if they have any follow-up to the provider, if they need the provider to come out there that day, or they can execute any orders, they can start home services, they can do all of that work as an RN, and they're a lower cost than a billing provider, but a billing provider can keep their same schedule. And so, and again, I don't care if I don't get paid fee-for-service because we're at full risk, and for that it's more how do I manage the whole panel of patients that I've been given, you know, or that I've carved out for myself. What does that capacity look like? It also allows us to have variability among providers. So when I was in the clinic setting, it was every provider had to perform to this WorkRVU standard, and if you didn't, you really were a low performer. In a value-based care, it really, for us, we get, providers get to decide how many days they want to work and how many patients they want to see inside those days. And so we might have a provider that sees, you know, twice as many patients in the same five days, but they're both very happy with their quality of life, and you adjust their pay to account for that volume and that panel size. And for us, that sounds great. We, you know, again, if as long as it's adjusted and there's not a straight salary, we get this opportunity to, to, you know, live in, they can, they can create their work inside of their life they want to live. If someone wants to be a three-day-a-week person, that's okay. Then we can adjust the volume and even adjust up or down within that, those days that they want to work. So I think some, some, some more flexibility on staffing and capacity and how you think about it. I wouldn't add anything to that. I think that's a great explanation. There were some questions in the chat too, about sometimes Medicare Advantage patients being difficult to find DME and home health and approved vendors too. And I would just encourage people to, a lot of times Medicare Advantage plans have assigned care navigators or care managers for those patients too. So if you're really struggling don't forget to call the health plan and ask them to provide you resources. They know who, who is in that work that now that can be very hit or miss. I'm not saying it's a, it's a great resource all the time, but sometimes I've been pleasantly surprised with the support that we can get from care managers or navigators that are actually employed by the health plan. And they certainly know what resources are available to them, to their members. So just one tip to consider there, if you haven't explored that. Yeah. And if you have a fee-for-service contract and you're having that, right, not a surprise, maybe you don't have a lot of leverage there. As you sign a value-based contract, you see, you know, it's okay to say your DME process stinks. We got to work on it. We have got to put some process in place where we can cut the line if we need X. So I think, you know, again, when you're looking at who do I even start to talk to, look at, you know, what's the value proposition for everybody involved? And then is there the low-hanging fruit of here's a good group that's pretty easy to work with that we just need to find the right person to get to? Yeah, absolutely. And I, again, when we think about adapting your care model and as you can kind of continue to transform and depending on your contract, it gives you that flexibility to think outside of the box and say, okay, how do I really want to use my most high cost providers? How do I make sure that the end, that my physicians are really doing things that require a physician? And, you know, maybe they're doing more oversight, you know, then how am I using minors, practitioners and physician assistants? And then that's when maybe you do have that flexibility for nurses and social workers to be able to work at the top of their licensure. And maybe you're using them for more kind of in-home visits or care management support or things like that. And then, you know, again, as you continue to develop and depending on your reimbursement and your payment model, then maybe that's when you can start adding some more specialty programs. Again, behavioral health, even in the fee-for-service, you know, there's the behavioral health integration services fee-for-service model. Maybe you have a specialty program with a social worker that serves as a behavioral health care manager, or maybe you have a psychiatric nurse practitioner specialist on your team, or maybe you, you know, use kind of, you know, someone specifically for cognitive assessments and supporting your dementia patients. So thinking about kind of how you can create more of those specialized opportunities to meet the need. And then thinking about, again, we know high-touch frequent visits and communication with your patients reduces utilizations and produces better outcomes. So how do you think about that in a process, in a systematic way? What things do you need to put in place to make sure that you're having very effective and manage, gave a great talk yesterday on care management. Are you providing that health education? How are you thinking about your caregivers? We, you know, Dr. Chang talks about the dyad. You're not just taking care of a patient, you're taking care of a caregiver. And if you're not, then that's affecting your patient and all of that too. So what resources and caregiver education and support might you be able to facilitate? But Amanda, I saw you came off mute. I would just say, as you think about all these things, the difference between fee-for-service and value-based care is fee-for-service. This is your whole list. This is all the things we're all trying to figure out. And again, you're boiling the ocean. Value-based care puts on a different cost and quality lens. And now we're solving a very specific problem. And so you get Medicare, you get your Medicare claims data and you say, gosh, I'm spending $200,000 on an outside behavioral health clinic. And I'm spending, you know, $50,000 to get the transportation to get everybody there and back. I think I can do that for cheaper, right? That's a focus area of let's lower the cost on some of these areas. I really need these mammograms done because it's worth $250,000. Now I have a special care management program just focused on that. And so it gives you this lens to say, where am I getting poor quality? How is it tying to cost? And then how do I address those things? And looking through that lens first is the way that you start thinking about staffing and programmatic work. And, you know, it kind of reminds me a little bit of like nonprofit grant funding, right? You get a grant for a certain idea and then you put new resources inside of that. We think of healthcare again, as everybody gets everything, I would continue to harp on Medicare saying patients who have higher acuity need more resources. They're falling through the cracks. You provider, I'm willing to put you at risk for this to go take care of those patients really well. Now everybody's not getting every thing the same, but again, they're having access to equitable care, not equal care, right? And if they progress to a spot and where they need that more high touch care, now you can put them into the program that you've already built. And I know you probably in some of your DEI work have seen the graphs that kind of have kind of the people standing at a fence, right? The person in a walker and the person or person, yeah, person in a walker, the older person, the younger person, everybody gets the same box to look over the fence and not everybody can see over the fence, but everybody gets different size boxes. And now they can see over the fence, right? Again, the idea of some people are sicker, they need more drill in here. And this is where you can get really creative and clever, I think. Yeah. And last time I'll make on the utilization staff, because I know someone yesterday brought up pharmacists too, which I think we've talked about community health workers and paramedics facilitating telehealth visits or maybe doing different things too. But yeah, I mean, especially if you, you know, we talked about deprescribing and all, you know, if you have access to a pharmacist to help you with medication reconciliation, again, even if you're still stuck in that fee for service quote, how are you utilizing, you know, even outpatient, you know, pharmacists for your patients when you need to have tough medication questions and interaction discussions and things like that too. So I think pharmacists is one resource that we might have not touched on. That certainly is a great resource to consider and how they might be involved, especially in value-based care. Next slide. So again, just to kind of sum up, and then I'll turn to Amanda for any closing thoughts, but really understand the population that you serve, and that should be driving your clinical model. And then obviously, like Amanda said, those qualities and those HEDIS measures, you know, what are your expectations? How are you going to produce that outcome? And that really should give you some insight into what your staffing and your productivity needs to look like. And I can't, you know, kind of emphasize enough the importance of the interdisciplinary team, right? This has to be a very diverse, different people have different skill sets. You know, medical is going to be focused on medical. How are you addressing that social, that, you know, psychosocial needs and those other kinds of things. Get creative, try different things, even if you bring someone on at a temporary or PRN contract basis, or maybe a pilot project and see how things go, so that you're really giving the patient the right care at the right time from the right person or right modality, even if that's a, you know, telehealth, for example, or something there. And then just continue to evaluate. There's a lot of opportunity, you know, maybe not right now as much as in the future, but I mean, we're moving towards value-based care. So keep up to date, you know, follow their resources, and relationships are a long game. So you may not have a value-based client contract tomorrow, but how can you continue to try and build those relationships and keep your eye on potential opportunities to kind of transform your growth in the future? Amanda, would you add anything to close us out? All right. I believe I'll let Melissa and friends chime in. I believe we have a break. I will go back and make sure I can't add any additional resources to the chat, too, when we either overbreak or when we come back. But if you have additional questions, please pop them in the chat. Okay, so yeah, there is a lot in the chat there. You'll review that, Brianna and Amanda, just to see if we're, yeah, just a reminder about your learning plan. We are scheduled for a 10 minute break. We will take a 10 minute break. So please return by 1020 central time, and we're going to dive into HCC coding and risk adjustment. And restart the recording. Thanks. Lots of moving parts to this on this Friday morning. So we can go ahead and get started. Brianna, I think you're getting this kicked off, right? Yes, I am. I am going to kick us off, and Dr. Sheng and I are going to talk about HCC and risk adjustment coding. And really, we have a lot of time for this session, so I encourage your participation and questions. But what does that mean? What are some best practices? Whether this is brand new to you, or you're pretty familiar with risk adjustment, hopefully my goal is to give you some different food for thought or perspective. So we can go to the objectives. So I'm going to explain what a risk score calculation is, what really goes into that, and then why does it impact you? Why does it impact everyone, but home-based primary care providers in particular? And then how can you think about developing a workflow that ensures accurate HCC assignment and really optimize that process? And then think about some quality documentation strategies. So there's a pop-up on the screen if you go one more, but this is kind of, you know, when we're thinking about risk adjustment in the context of value-based care, really what this is doing is Medicare uses risk adjustment, and there's many different models for lots of different programs. But what they're saying is they're taking all of a patient's ICD-10 codes or all of a population's ICD-10 codes, and there are certain chronic conditions that they know cost more money to take care of that patient, like Amanda was saying. And so once annually, they're looking at all of the chronic conditions that a patient has to, it's predictive modeling, say, how much is healthcare going to cost for that patient? And this is directly tied to how Medicare Advantage plans are paid for their premiums, but the goal is really that the sickest patients get more, those plans get more resources and more money to better provide support for those patients. So sicker patients need more high quality resources. It's really predicting acuity in a way, you know, based on their patient's diagnosis codes. But unfortunately, that does come down to your ICD-10 diagnosis coding. But again, whether you're working with Medicare Advantage or you're in value-based care contracts or not, this really impacts everyone. Whether, even if you're in fee-for-service, they validate what the data that the Medicare Advantage plans are submitting based on your face-to-face progress note. So risk adjustment is going to be important no matter what, and I think we're going to see many different ways that this model is kind of used and evolved, but it impacts everyone, regardless if you're really working with Medicare Advantage. And what you're doing is really doing the best thing for your patients by making sure you're appropriately reflecting how sick they are. So you heard Amanda mention RAF score. So RAF score just stands for risk adjustment factor, and this is what goes into it. So your patient's demographics do play a role. You can't change that, you know, whether they're, you know, on Medicare because they're aged or disabled, male, female, those things do have a play. Again, those ICD-10 diagnosis codes, this is a once annual process. Your patient is reborn on the first every year. You have to code everything once a year. There are certain interactions, which I'll show you. Again, those are just kind of defined in the model. And then when CMS updated the model most recently in 2020, they assigned additional weight or additional kind of risk adjustment factors to if your patients had multiple HCCs, anywhere between 4 and 10 HCCs, that goes into that RAF score calculation. So, again, these are just some of the interactions. I think I have one more slide on this. It's just something for your awareness. Again, the, you know, like diabetes and heart failures together is a specified interaction that will impact the RAF score. So these are, again, what they are. Nothing you need to know besides, again, start getting So these are, again, what they are. Nothing you need to know besides, again, start getting familiar with what these chronic diseases are, which ones carry that risk adjustment weight, and which complications of diseases would be really important for you to make that causal relationship within your documentation and within your coding. Next slide. We, they are constantly trying to evolve the model. So dementia used to, before two years ago, not be an HCC, thank goodness they, you know, realized the impact that dementia has on patients and their health care costs, as well as, you know, pressure ulcers, all of the pressure sores are. But again, you have to code the stage of the pressure sore in that ICD-10 code, because a stage four pressure ulcer is going to carry a lot more risk than a stage one. So, you know, and if you're just using an unspecified diagnosis code for mild cognitive impairment, that's not when the patient really does have, you know, dementia or Alzheimer's or something more specified, that's a really big impact. So you really need to think about those things. Next slide. And Dr. Sheng, please chime in here with anything you want to add at any time. This is an example, these are kind of approximations, and this is more thinking about what the Medicare Advantage plan is going to get paid. But this is just, again, Medicare is looking at claims data and diagnosis, the difference of the story that it would tell. So let's say you saw a patient and maybe it was an acute add-on visit, and they really had kind of an upper respiratory infection or something going on. So you didn't code, if you didn't address it, I don't want you to code it, we're going to get into kind of that ethical thing too. But let's say you really did spend some time talking about their diabetes and their heart failures, and you didn't code for it. We'll look at the impact that that would have versus if you capture their diabetes and their heart failures, and that middle column is what I'm looking at. Again, also embryos and dementia now does carry a risk adjustment factor, you know, but the difference between not telling that story versus the middle column, and then even further, taking that step further to really maximize HCC. If your patient has any sort of amputation, seems kind of silly, right? A toe amputation and colostomy status, both of those are HCC. So if you're not capturing all of those diagnosis codes within a 12-month period, again, it does not have to be all of these every single visit. It's capturing all of the chronic conditions that your patient has at the most specified code, capturing all the complications and exacerbations when they do exist, but then maybe using your annual wellness visits to kind of capture those kind of silly, not silly things, but things you might not always think of like the toe amputations and the colostomy status that do impact your patient's overall risk score, because it is a big impact to their health status. Brianna, may I ask a question? Of course, please. On that previous slide? Yeah. In the third column, there's the disease interaction diabetes plus CHF. That's not separately coded, right? Is that there because you have type 2 diabetes with other circulatory complications? Correct. That's talking about the, like the specified risk adjustment interaction that exists between diabetes and CHF, but you would, you know, you would code separately the diabetes and the heart failure. Well, if you're addressing both and if there's diabetes with complications, like your example, you would absolutely code that. Yeah. It's just, it's not in the middle column and you do have diabetes and CHF coded in the middle column. Oh, that's a good point. Yeah. This is a little bit of an older slide, so let me take a note. We might want to take a look at that, but you're absolutely correct on that. Oh, so it would be in the middle column as well? If you were capturing it both, yes. It depends on how you would document. So like if you were saying that there was a complication or a reaction with those, but yeah, if that's a specified interaction, then it would be in the middle column as well. I'm sorry to bug you, but do you actually specify that there's the interaction or is the interaction assumed because you coded the two diseases? I would, so the specified interactions that I showed on the previous slide, that would just be assumed by the claims data. But if you said, you know, where that would matter is more like if you had diabetes with a circulatory complication, you would have to use the diabetes with that kind of thing to capture that. But if it's a specified interaction, there's nothing you need to do. They're just capturing that from the claims data. Thank you. Paul, I'm sorry. Are you going to chime in? Yeah. I think the hard part for us as we are still swimming in fee for service, as I talk with providers, we're still stuck in a mindset of, you know, RVUs and volume and all that kind of stuff and trying to really have, you know, Amanda talked about, you know, a mindset shift. This is a mindset shift. Providers like, you know, so does this impact my paycheck? Does this impact my RVU? The answer was, well, it doesn't. But getting them to understand that, look at the difference, annual payment, 6,000 versus 30,000. You know, I tried to tell them, it is so important because we take care of complex patient and this gets the practice more revenue to provide the additional care that our patients need. And it can help reduce some of the burden that you're carrying right now, having to, you know, make the phone calls or whatever. So this is revenue that helps your clinic take better care of your patient rather than directly say, you know, affecting my paycheck from week to week. Those are just my comments. Absolutely. I mean, this really is when we think about change management, right? Why is this important? And not only for the practice, but again, like I always like to remind patients you're doing a rate or providers that you're doing the right thing for the patients. Like the health plan is going to be paid more to have more resources, more supplemental benefits, more programs. If you're truly representing how sick that patient is. And we're going to talk about how to do that ethically, right? This is not gaming the system. This is appropriately capturing the risk and the diagnosis codes that your patients actually have. And really just showing when they're going through different exacerbations like that. Next slide. I'm sorry. I'm not sure what's going on with the lines. There we go. I was like, I promise I'm not drawing on the screen, hands up. But it was kind of fun to watch. Maybe someone was trying to draw a picture of the HCC. Okay. So actually, we're going to play a little game. I want you guys to tell me, this is a patient case. This is all the chronic conditions that the patient has and that were coded at a particular visit. Which one of these are HCCs? You can either share in a chat or just unmute yourself and shout it out. The ulcer, CHF, yeah, depression, the dementia, yeah. So the dementia is an HCC, the specified heart failure, definitely an HCC. You'll notice the depression, the major depressive disorder. If you would have coded depression unspecified, that is not an HCC. I need major depressive disorder. So really specifying that depression, it gets really important. Some of the other things that we could have potentially missed here, if you're thinking, but if you remember Minerva from yesterday, senile purpura is one that's an HCC and carries a risk adjustment weight. If the patient had a history of UTIs and that was actually leading to a circulatory complication or something like chronic cystitis, you would wanna code that and make sure that that's captured. For HCC coding purposes, but just some other food for thought examples. And the pressure ulcer, absolutely. Again, making sure that you're specifying those stages, but those are the HCCs for this patient. Again, those Z codes generally are not, GERD is not, hypothyroidism is not, but the other ones, again, dysphagia, following a CVA. There is a, if it's a late effect of a CVA, there is an HCC code for that that carries a risk adjustment weight. So again, kind of knowing those differences and your EHR can help you with that. Many EHRs now have kind of an HCC module that actually highlights or tells the provider which diagnosis codes are HCC. So some of that is spending time paying attention to that on the problem list. Yeah, Brianna, that is so important. There is no way for me to memorize or carry a cheat sheet that has all of the HCC scores or diagnoses as I'm busy taking care of patients. I don't have the time to go look at my list and say, okay, it's this one, this one. So as you work with your vendor, you're considering EHR, make sure they have this particular capability. For example, in my particular, we use Epic here in Northwestern. You're looking at UTI, but we take care of patients with catheter-associated urinary tract infection. That carries the HCC score rather than just UTI. And my software, when I type that in, pulls that little, it highlights the diagnosis for me. That is so helpful. So keep that in mind if you're looking at particular software to help you with this. I can't emphasize that enough. Having this available to me, it saves me a lot of time. So, absolutely. We move on to the next slide. This was, again, this was the primary care first PMPM or PVPP, you could call it a PMPM for member per month. You could call it a PVP for, you know, or per enrollee per month. There's lots of different terms, but it was showing you, again, the importance of capturing that risk adjustment as it's tied to payment, your payment for the practice. Again, it's taking the average risk score for all of your patients that are attributed to you. And then that's being tied to capitated payments in many cases under value-based care. And again, just kind of tying that patient case. For example, generally we consider a high risk score of a patient 2.0 or above. Minerva, for example, which is a very common home-based primary care patient, if we were really good at coding her HCCs throughout the year, her risk score would be 3.163, which really kind of accurately reflects the severity and the resources that she would need to take care of all her chronic diseases. So just kind of, you know, thinking about that. We can go on to the next slide. So again, this is where specificity matters. And I know that, like Dr. Chang said, you can take this in steps. You know, this is definitely a little bit of a change management shift. Your providers want to take good care, good clinical care. They don't always want to hear you talk to them about coding, but how can you kind of make it digestible and take it in smaller steps and just say, hey, you know, I know that the depression unspecified might be on that problem list from forever ago or it might pop up first, but how can you really understand that major depressive disorder is important to capture? Or for your COPD patients, respiratory failure, and if they have emphysema, for ICD-10 coding guidelines, you would code multiple codes to represent that respiratory failure, plus the COPD with the emphysema. You would capture all of those because respiratory failure is a big one for HCC. The combination codes, so if you were going to use something like hypertensive heart disease with chronic kidney disease and heart failure, we're going to talk in a future slide about the word with. I would need the provider to show me that in their documentation, you know, say the patient has hypertensive heart failure with chronic kidney disease and things like that. But again, that's a lot different story than if you're just coding hypertension. So especially if you're a little bit familiar with risk adjustment, how can you start to think about you're kind of taking your coding to the next level? Again, if you're just saying unspecified heart failure, it has to be congestive heart failure to be an HCC. So that could just be an easy mistake that providers may not realize that they're making. Cancer, you know, capturing those complications, if it's diabetic, you know, chronic kidney disease and things like that, super, super important. AFib is an HCC, but also, I think this was Dr. Carnwall's example of finding the super hypercoagulable state as another kind of higher HCC value. Paul, anything you would add here? I just encourage you to look at the diagnoses on the left. They're the kind of patients that we take care of. I know it might be easier just to put down COPD. I'm looking at my Epic chart on the patient I'm going to see next week. Chronic respiratory failure, hypoxemia, hypercarbia on home oxygen. That is much intense of a patient than just say a COPD alone. So we are taking care of patients who are complex on the left. And Brianna is going to talk about documentation later on, you know, clinical CDI, clinical documentation integrity is important here so that you can get the credit and your practice can get the credit for the kind of patients that we are taking care of. Absolutely. All right, we can go to the next slide. The other thing that's important is we talked about all the things that you need to capture, but also making sure that your providers understand ICD-10 guidelines. CVA is something that I constantly see done wrong and it would inappropriately inflate the risk score. How many of you have seen some of the articles that have come out in the last year about the Medicare Advantage audits for risk adjustment and the severe penalties that they're facing? And if that's your payer partner, that's, you know, going to come back down to you and have an impact. So CVA is only coded as an active CVA when the patient's in the acute phase of treatment. Otherwise you need to be using the history of stroke or again, if a patient has a late effect like hemiplegia due to that there is an HCC for that, the I-69, 359 example there. There's lots of tools out there. There's apps. Again, if you're EHR, if you're not paying for that HCC module yet, I'm going to show you the CMS resource at the end, but get creative. I'm kind of familiarizing yourself with that. Same thing with TIAs. TIAs, you would code, you know, again, during that acute phase and then it would need to be the code for personal history of a TIA. Myocardial infection is another one that can be coded up to four weeks of an active one. And then it would go to kind of that, that otherwise older healed. So there are some nuances with really high risk diseases that are important to be aware of. So let's, we talked about using your interdisciplinary team. Who else besides your providers can, you know, pull together some of this information. The ICD-10 guidelines are available on CMS's website. Who can create some tip sheets and maybe do some ongoing education at staff meetings to help your providers, you know, keep track of all this. So that's not a burden that they have to face. Next slide. Again, so just trying to paint the picture on why this matters. Again, this is really tied towards quality. It's good, you know, you're going to be, especially if you can go to a payer and say, hey, my average HCC score for patients is 2.5, but we have X, Y, and Z outcomes. And this is how we're managing that population. It becomes really, really important. The other reason to start thinking about this now is especially if you're newer to value-based care and you're trying to wrap your head around, you know, all of this and risk stratification. I think, I can't remember if I showed the example or not yesterday, but of some home-based primary care practices that really were taking care of much more high risk sicker patients, but because they weren't great at HCC coding, they got put into a lower risk tier for primary care first. So you'd rather learn some of those lessons now, because again, it's a prospective, it's always looking back at the previous 12 months, and then you would have to wait a whole nother year for them to annually re-stratify your patient. You could also think about this for proactive referral identification, maybe with some payers say, hey, you know, I want that top 5% or patients with that 2.0 risk or HCC risk or above. So I know some folks that have kind of used it to even identify potential patients is using kind of a high HCC scores as a piece of that algorithm. But again, you as the provider, your role is to just make sure that you're, you know, appropriately showing how sick your patients are so they get the additional resources that they need. And then hopefully that's tied eventually to a higher payment for you as a practice to recognize the time and resources that it takes to take care of really sick patients. Paul, were you gonna add something? Okay. No, I'm good. All right, next slide. So when we think about the documentation piece again, so we've talked about the diagnosis coding piece. We're gonna talk a little bit more now about the documentation piece. So all of these HCCs have to be validated through an appropriate source. So only a face-to-face progress note or procedure note or an actual encounter note is supporting evidence for an HCC. You can't just pull, you know, orders or lab results and things like that. It has to be documented within a face-to-face progress note. There were some issues with people data mining kind of inappropriately for HCCs. What you have to do as the provider is show that it, again, we're talking about the per visit level, because I'm not saying you have to do this every time. You have 12 months to just show me how sick your patient is. But did you evaluate or consider that specific HCC diagnosis code during your visit? The MEET acronym is a best practice. It's setting that really high bar. You know, you've probably heard of SOAP, but MEET stands for monitor, evaluate, assess and address and treat. Different payer contracts may even be more specified if you have some HCC contracts with how much documentation they want for the burden of proof to protect them from a compliance standpoint. But again, were you monitoring that, you know, or did you really not think about the, you know, maybe you had a last minute add-on and you didn't address their diabetes and heart failure. Then I wouldn't want it coded for that particular visit, but how did you in the care for that patient on that date of service evaluate and consider the diagnosis code and then be as specific as possible? And if you didn't, you know, you can, I think someone else put a comment in the chat about how their EHR gives them reports when they're missing an HCC. That's a great opportunity at that next visit or that annual wellness visit to maybe think about some of those other diagnosis codes. Yeah, Brianna, a couple of things. You don't have to, you already alluded to this. You don't have to address every single condition every single time just over the period of one year. The other thing is practice and patience. It has taken me, oh, I would guess this started about two years ago. I had received some ACC coaches who looked at my chart and it's exactly what Brianna said here. They're highlighting, you know, I did not do all the four, the ME, the MEET documentation. So through additional coaching, they came back about six or eight months later and just ongoing practice, you know, my score improved. My patients are the same. The scores improved. So I just want to maybe put that out there. I don't know if you have an auditor or somebody who can help you with coaching. You know, I'm a doctor. I'm not a coder. You know, I just go, you know, more Lasix, you know, that's what the patients need. But maybe just tinkering with how I worded can have a major impact in terms of ACC score. And Paul, I think, sorry to put you on the spot here, but didn't you kind of, for critical ischemia, didn't you kind of develop a smart phrase that you customize, or could you give maybe a specific example of how you're documenting certain conditions? Yeah. So again, it's a smart phrase. This gets back to efficiency and what your EHR can do. Now we're asking our EHR to do a lot, right? You know, alert me for this and ACC that and so on. So create your own smart phrases based on what Brianna has outlined here. You know, what are you monitoring? Evaluating? Is the patient stable, unstable or whatnot? Are you monitoring the blood tests? Are you monitoring x-rays and so on? Assessment. What are you addressing? Is the patient's leg swelling? For example, here I'm looking at my patient. This leg swelling is getting worse. And how did you address that? And treatment that's implemented. So having a smart phrase for each of the common diagnoses, you know, have a smart phrase for CHF, COPD, you get the idea. CKD, having a smart phrase that's in there so that you are alerted to what you need to cover and address to get the credit that you need. We're all sick and tired of, you know, keystroking and so on. So smart phrases or macro is one way that I'm trying to compensate for time or improve time efficiency, but also make sure my documentation is accurate. Yeah, absolutely. And if you go to the next one. What EHR am I using? I'm using Epic. A lot of the major health systems, Epic is certainly one of the biggest and most expensive out there. So if there's mid to small size practices and you're using something else, I encourage you to kind of share what you're using in the chat. But this is how you would show that in documentation, right? So what signs and symptoms are the disease? I always tell practices just using like one or two more words. Can I actually tell if their hypertension is stable or worsening or how you're monitoring that? How often they're, you know, checking their blood pressure or their blood sugars? Just a couple extra words is how you're going to tell me that, you know, and then, you know, if you're commenting on test results or the response to medications, all of those, you know, how they've responded to even physical therapy or something like that, that's kind of getting into that evaluate. But really important, not even just for HCC, even for medical decision making purposes, I need to understand the status of each disease listed in your assessment and plan, just a couple more words, say the status word, and then there needs to be a specific treatment plan and a specific in your assessment of plan, treatment plan and care plan for each ICD-10 diagnosis code that you're listing. And I don't want you to just say continue current medications, right? Avoid that big documentation. What medication for hypertension? What medication for the, you know, the heart failure or the other things? So why are you placing the referral? What specific modalities and care plan are you asking the home health agency to follow? So really thinking about being specific and, you know, staying on top of avoiding that, you know, I know it's hard when they have those 10 or 15 diagnosis codes, but avoiding that CPM or continue current medications without elaboration would not stand up when we're thinking about the meat methodology as a best practice. I need to understand what's the health status, how's the patient doing, and then how are you treating it? What is the specific care plan for that diagnosis code? You know, this is where, especially if you're in value-based care, you can, you know, not spend as much time in the history and all those other sections of the A&M, but spend maybe some more time down here in the investment and plan to really capture that and avoid kind of those big documentation habits. And Dr. Chang mentioned, you know, HCC coaches, even if you wanted to invest in your team, the AACC, the American Academy of Professional Coders, they have an HCC credential, but you could send your practice manager, someone that helps with billing, to training. Even if they don't want to get credentialed, there's a formal online training class for HCC. There's books by UnitedHealthcare that's co-published by the AMA for, you know, for understanding our risk adjustment in the HCC. So think about kind of some of those educational resources as well. Yeah, I think, Brianna, just to highlight, I think the old ways of doing things like HTN, BP Good, CPM, is that going to cut it? No, it's not. It's, you know, it's just because you're not telling me the full picture. I mean, even from a medical, let's take HCC out of it from, if I'm an auditor and I'm looking at that from a medical decision standpoint, I have no idea what really is going on with the patient and what you're doing to treat them. So we really do need to be more specific in our documentation. Next slide. So again, just giving you some more examples of what your plan might look like. Again, current to continue medications, that's like a bad example, right? Like, so be specific. But these are just the types of activities. A lot of the times you're doing all of these things, it's just not making it into the documentation. And I try and avoid things like resolved. Like, if I see an ICD-10 diagnosis code in your documentation that says resolved, that's telling me it's healed and I'm not even considering that diagnosis in your thing. So is it resolved or is it well managed or things like that? Another kind of interesting one that's not on the screen is, again, this is just the difference of how providers are trained in med school and how HCCs and auditors are going to look at things. Dr. Chang knows where I'm going with this. So when I see, it's a coachable moment when I'm doing an HCC audit and I see the patient has history of diabetes, heart failure, hypertension. Was it history of? Because to me, that means they don't have it. They had it in the past. Or the patient has multiple chronic conditions, including. So even just changing some wording and things like that in your documentation. Is it an active chronic disease or is it a history of a chronic disease? So I know that can be kind of frustrating, but it's really important, especially in value-based care, that you understand what the words in your documentation mean. And yeah, Paul and I had a good laugh, a little double advocate conversation about that one. Yeah. Brianna and I have had multiple conversations about this. I went to school to be a doctor, not to be whatever. Again, I think this is where the smart phrase is, whatever phrase that you come up with can really help you. So I don't have to re remind myself, I can't write history of diabetes. I have to put down active condition, including. Or just the patient has diabetes, right? You know, think of whatever is simple for you. But yeah, the history of is kind of a, that means a different thing to auditors than it does to providers, unfortunately. I would say another pitfall that I see more in the palliative care space is coding signs and symptoms, right? And in the inpatient setting, that might be okay because you're trying to differentiate from the hospital that the other care teams are providing. But if the patient has dysphagia or agitation, but that's really due to the dementia or the stroke or something else that's going on, the ICD-10 code that should be coded is the chronic condition. You can note in your documentation the signs and symptoms associated with that. That's an ICD-10 guideline that in the outpatient setting, if there's a confirmed chronic condition, then that's what's coded from an ICD-10 coding perspective and not the sign and symptom. So if you're using sign and symptom ICD-10 codes, that's another thing I see when I'm trying to focus on HCC. So when I used to be doing previous audits, that would come up a lot as well. You're coding the sign and symptom and not the chronic disease, and that's really going to hurt your HCC scores. Any questions so far? Brianna, can I say, well, for example, the patient, you brought up the palliative example. Can you say, you know, shortness of breath, dyspnea, working diagnosis is exacerbation of COPD. Would that be a better way to phrase or add improved documentation to meet the HCC? So you as a clinician are the diagnostician, if you will, right? So if you know that those symptoms are from CHF, then what I would want to see in kind of your plan area is that CHF diagnosis, and then you're describing that associate, the dyspnea and the shortness of breath. That's just your meat, if you will, right? All of those things are telling me that you're monitoring and evaluating whatever the confirmed diagnosis is. If it's really not, if it's a probable diagnosis and it's not confirmed yet, then you can't code it, right? Then you would code the signs and symptoms. But again, you are the skilled clinician that can make that diagnosis and determination on if the patient really has the chronic disease or if they're experiencing symptoms that the diagnosis is unknown. Next slide. So here's what I was talking about with the word with. And so this gets into, we have a resource that I'll put the link in the chat too that I highlight at the end that's available on HCCI's website that kind of gives you some example combination codes and things like that. But what I would want to see is if you're using a diagnosis code like hypertension with heart disease. So Tony, different than the interactions that we talked about before, if you're going to code that diagnosis code, what I want from the provider is just them saying the word with and showing me a relationship between the hypertension, the heart disease, and the chronic kidney disease in their documentation. And then they would actually pick a different ICD-10 code that captures all three of those in one code. So just food for thought, this is in the ICD-10 guidelines. Again, I can put some of these links in the chat. But if the provider is documenting that causal relationship within their documentation with just with the word with, then we can use those combination codes. Next slide. All right, I'm going to turn it over to Dr. Cheng to talk through some more examples and maybe some things that you're not aware of at HCC. Yep. So again, you can see on the slides, I won't go through each one of them. You can review at your own time. Again, I think what I want out of this is as you are taking care of patients and so on, keep in mind the complexity that you're addressing and to translate that into your documentation so that you, your practice can get the appropriate support to take care of them. Okay. There are a few, I think we talked about having software helping you with the HCC, but I do want you to know at least some of them that you should keep in mind because these are the common ones you will encounter. You can read these and there are many more depending on the area that you practice or perhaps your patient population and so forth. So software to help you, yes, but there are some other diagnoses I think you should know by heart, if you will, and you can code it directly or correctly, not directly. Next slide, please. Really quick, Dr. Kaplan, just to answer your question in the chat. So if the symptom that is going on is associated with a different disease process that you already coded, then you don't also code the symptom from an ICD-10 point. Those would just be words within your documentation that you associate with the plan of whatever chronic disease it's associated with. Again, this is just a list here of the ICD diagnoses and the risk adjustment category and also the ACC value. Take a look. I'll give you a few minutes here. Take a look through the list. Again, combination codes, they're very important. Keep them in mind because I keep saying that they're just the kind of patients that we take care of. They not only have diabetes, not only have high blood pressure, they have high blood pressure with chronic kidney disease, with diabetes, and the chronic kidney disease is stage fill in the blank, let's just say four or five. Now you have anemia related to CKD. That's yet another category, a combination code that will get you a higher HCC value. So try to keep that in mind as you are taking care of your patients. And I think perhaps one other suggestion I will have is this. Depending on your EHR and so on and the capabilities, so forth, keep a good problem list available for you to look at. And also when you do put in a combination code, hypertension with CKD or whatever it might be, that you put that in the problem list for your future reference so that you don't forget it when you need to look at it rather than having to look that up another time. We all have seen problem lists that are like, you know, a page and a half long because everybody just puts another diagnosis in a problem list. Take the time to clean that up. And depending on your EHR, how it views on the screen, are you able to have multiple – not multiple screens, but panels that you can see on your EHR so you don't have to go back and forth between, you know, your problem list and documentation. And when some of my providers actually document directly off the problem list, that's another way that you are making sure that your documentation, your ACC, is being addressed accordingly. If you document directly off the problem list, that is clean and accurate. Next slide, please. So, I alluded to this a little bit earlier, but from a data validation standpoint, again, the Medicare Advantage plans have to provide face-to-face progress notes to support any HCC diagnosis codes that were coded and that they're reporting back when it comes to this premium. So, again, this is where you as the provider – you know, Dr. Cheng often talks about prioritization. You, most likely, you may in some visits, especially if it's like a new patient visit, but in follow-up visits, you may not address every single 20 diagnosis codes that are on the patient's problem list. The assessment and plan is not intended to be the problem list. It is really intended to only capture the diagnosis codes that you really considered or were meaningful – think of that MEAT acronym – at that specific visit because you have a full 12 calendar months. Like I said, I really love annual wellness visits as a way where you are going to spend the additional time and kind of capture up to HCCs. You know, the CMS 1500 form can capture up to 12 diagnosis codes. Your EHR may have other limitations, but really think about, you know, am I coding it? If I'm coding it, is it supported at the visit level or am I just clicking on every code that's on the problem list in my assessment and plan that's getting coded for that encounter? Next slide. So, I've given you some food for thought with some implementation considerations, but I'd love to hear from Paul a little bit. Paul, I know you've really been an HCC kind of champion, if you will, in your program. When you're thinking back to how you first approached educating the team on HCC and you were kind of optimizing this as a quality improvement project, how did you approach that or any best practices you can share? Yeah, I think first is, you know, we're talking about change management, right? We need to design a roadmap and get people to buy in and all that kind of stuff. I think the first thing I did is I needed to educate myself on, you know, what is HCC? Why do I need to know this if it doesn't make any impact on the providers' paycheck and so on? So, educate yourself on the importance and looking at the future of healthcare and so on. And the other thing is to share that information with your provider. I tell my office, there are no secrets. What I know is what I know. I'm not trying to come up with some whatever hocus pocus idea. This is where the future of care is going and this is why HCC scores are important to our practice. And the other things I would say is to give them practical tools and tip sheet. For example, print out handouts for them, print out a cheat sheet initially for HCC to get them accustomed to the idea of looking, documenting in their records so that they know, hey, this is not too difficult and I can do this. And having a dashboard. I talked about every morning I open my EPIC and whatnot. One of the things I look at is I look at my dashboard, Pop Health dashboard that looks at all the other stuff. On the side, there is that RAF score that I look at. Again, highlighting to your providers at your provider's regular meeting that we have monthly and say how is your annual wellness, how is HCC coming. Let's talk about the scores and so forth. So those are just some ideas that I have implemented in trying to get my providers, even though we're still pretty much fee for service, although we are definitely pivoting towards value-based care, getting them educated and getting them the tools to help them succeed in this. And I think final comment is make sure they understand why they're doing this. I'm not just trying to shoulder you with more work, more documentation, but this is important stuff because having that roadmap and telling them where we're going, hopefully they will understand why I'm making this request of them. Yeah. And I think those are all great points. And take it in baby steps. So you could run a diagnosis utilization report and say, okay, these are my top three or my top five chronic conditions that our patients have that I know are HCC. So let's focus on heart failure, diabetes, and COPD, and let's provide some education and cheat sheets. And hey, providers, these are the ones I really want you to focus on during the visit. So it doesn't seem quite so overwhelming or maybe having certain providers who are really skilled at this do the annual wellness visits and capturing all of them. So you can think about different strategies, but I would take it in baby steps, where you're asking a lot of them. So just focus on a couple of diagnosis codes at a time to clean up that problem list and to be more specified and get better at it. And the last bullet on here too, I think about is super important. So what other team members can you cross train to help you? So again, it has to be the provider that's actually supporting it with their documentation and coding it at the encounter level. But I've seen practices use even like residents, certain projects and students to help scrub charts and learn about HCC coding. I've seen people use MA and nurses to kind of help with some of this for their providers. So lots of different opportunities for you to engage the team in this work and kind of maybe challenge some other people to learn and help support your providers and kind of set up the charts or at least highlight for them, hey, these are the HCCs for this patient and kind of already do the work on finding those more specified diagnosis codes. Next slide. So I'm not going to go, I put, we went over these in essential elements, but I wanted to put some other, again, if you're developing those cheat sheets, if we go to the next slide, like what do I mean by being specified for some of the most common ones, right? So diabetes, you should be telling me what type of diabetes it has. I should understand the control, are they hypoglycemic or hyperglycemic? That's a different diagnosis code, if there's complications and then what the treatment, even if they're on insulin, there's a Z code for that. So this is kind of the guidelines in general, just ICD-10 coding guidelines for coding diabetes that I thought might be helpful. Next slide. Again, and here's just some examples of what those more specified diagnosis codes look like if they're supported by the documentation, but always code any complications and make sure you capture the type for the diabetes. No more E11.9, unspecified diabetes type 2, that's one we want to try and avoid. Next slide. Heart failure, again, unspecified heart failure is not an HCC. If it's congestive heart failure, is it diastolic? Is it systolic? Is it combined? Is it acute or is it chronic? Is it acute on chronic? There's different diagnosis codes for all of these different types of factors. Next slide. And then again, I'm really put these in here more for a resource for you all, hopefully trying to do some of this work for you so you can take these back to your practices. Next slide. So again, when we're thinking about COPD, the type, again, if they have asthma or emphysema, those again, those are additional diagnosis codes. Those complications of that, if they're having respiratory failure, if they use tobacco, all of those kinds of things. These are just the general guidelines for what's expected from an ICD-10 diagnosis coding standpoint when you're coding COPD. And then the next slide has some very specific examples for you and what you might use. All right, so I'm going to copy and paste this link in the chat, or actually two links. This is a CMS spreadsheet. It's updated every year, so not for your providers, but maybe someone that you appoint in the practice. What I would encourage you to do is once a year, what you want to look for is that document that I highlighted, the mid-year final mappings. What that has is a Excel spreadsheet of every single ICD-10 diagnosis code that risk adjusts. So I would encourage you, if you do want to spend, especially if you're in value-based care and you want to spend some time on HCCs, to look at that, look at what changed, think about what's most common for your practices, and kind of pick some of those out for your providers. And then that might guide you on what to focus on or give you some food for thought there. So this is the CMS Risk Adjustment website. I put the link in the chat, but that final mappings document is the document that you want to look for. Next slide. And then here is the link for this resource. It's just, again, kind of a cheat sheet. Dr. Chang and Dr. Cornwell worked on this with me, of what common diagnosis codes carry a risk adjustment weight, and then some implementation considerations that you can take back for your practice. So just wanted to leave you with some additional resources. So again, be specific. Remember, I like, even the meat, the meat, again, is a really good resource. Even the meat, the meat, again, is a really high bar. That's a best practice. An easier way that you can think about your assessment and plan documentation is, what is the condition or the diagnosis code? What is the status? Stable, worsening, you know, failing to change as expected, and then what's my treatment plan? If you think condition status plan, then you've always supported the diagnosis code. Keep your problem list up to date. You know, avoid those unspecified diagnosis codes. Remember that the assessment and plan is not the problem list at the same time you have a whole year. Think about how you can optimize certain visits so you're, you don't have to spend such extensive time worrying about HCCs during every visit. You could do some internal monitoring. You can do some of your own auditing and see how you're doing and get a baseline and then kind of create a quality improvement plan from there. But remember, your patient is reborn on January 1st every single year. Risk adjustment is an annual process. You have to code every chronic condition on an annual basis, even if it's a toe amputation or a colostomy status or something like that, to really effectively be doing HCCs. Paul, any closing thoughts from you? Documentation is so important. I think let's just pick CHF, for example. We talked about that yesterday. You know, all the different categories, HEF, REF, HEF, PEF. Not only is it important in, say, clinical care, but also, say, if you need prior auth for intresto, you need to tell them, you know, what kind of heart failure the patient has. And now it's translating down to getting appropriate reimbursement through HCC coding for your practice. So it's kind of all tying together. So whatever, smart phrases and whatnot, documentation, very important. Much more so now, I think, under value-based care than before, where I just kept typing CPM, which I no longer am doing. Bonus points for Dr. Cheng. It's a process, right? After two rounds of coaching, you can teach an old dog new tricks. Questions from you all. Comments, maybe, or if you want to share tips that you've all used. Questions or comments would encourage any food for thought here. All right, Melissa, where are we headed next? If you think of anything, feel free to put it in the chat, but would encourage you to think about that resource, some of those resources I shared, sorry. Yeah, so we can go ahead and advance to the start of the next session. And, okay, so wait, Gosha is asking, annual wellness visits can be done via video call, right? Yeah, so right now, annual wellness visits are on Medicare's approved list of telehealth services, and we know that because of the public health emergency, none of those, you know, it did just get extended this July. I know some regulatory experts think that it's going to be continued even through far into 2023. And then there's some legislation that extends it past that. So I don't think it's going away anytime soon. But right now, annual wellness visits can be done via video, because they are on Medicare's telehealth list. And actually, good point, Gosha. Thank you for pointing that out. There are certain services that can be audio only, very, very select few services on Medicare's telehealth list. An annual wellness visit is one of those that could be, you know, I guess that'd be kind of challenging, but it really is more of a questionnaire that technically could be audio only right now. Yeah. And then, Roseanne, thanks for sharing, you know, that you try to scrub up your charts and update codes on an annual, on those annual wellness visits, and agree it's a good opportunity to review problem lists and codes. All right. Any other questions for Brianna? Oh, Grace says, our institution has told us that annual wellness visits cannot be done by telephone, this is just video. And that, again, institutions may have very more specific compliance guidelines than what's allowed at the federal level. That could be more of a quality requirement. The audio only, like I said, is, again, we can do anything pre-COVID, if any of us can even remember back to then, because the home wasn't an approved originating site. So all of that is, there's going to be lots of things to follow with telehealth within the next couple of years. So I would encourage you to stay up to date with CMS and what the different legislation is with telehealth. All right, well, let's move on. We've got a really good session coming up, and this is before our lunch break, but on optimizing value-based care for homebound patients. And we've got Paul, we've got Amanda, we've got Brianna. So who's kicking us off? Who's kicking us off? Just me. Okay. Oh, you can't see me. I was like, I'm waving, but you can't. Oh, sorry, no, I only have one speaker box on each side. I know, you're running the piece. Well, thanks. We do, I recognize that I'm between you and lunch on day two, so I'm sorry about that. And I think this will be a way that we can kind of tie up these big six ideas that we talked about, components, including HCCs, and again, continue to apply application. And what we're going to do, the general ideas for each of these six, I'll have three slides just on background, things I think about, things we think about, and then open it up kind of to a panel size between me, Paul, and Brianna, and then open it up to the whole group for additional conversation. And so, you know, this would be the time if you have any interest to come off or to come onto camera and get really involved and let's make it a fun conversation. So we roughly, again, they're six, so we roughly have 10 minutes per section. These are all really key things to think about in your practice. We introduced them yesterday. Could I get the next slide? We introduced these six things yesterday at the beginning of the day. We've touched on these throughout our time together. We've gone deep on many, many of these things. And so, yeah, let's just kind of wrap up these top components, and then we'll spend the time after lunch for all you non-clinicians going through wounds and G-tubes and trachs. I remember my first provider meeting, they always did them at lunch. These were the old days. So 10 years ago, we'd go out to lunch, and there were like 10 of us around a room, and they would talk about the grossest stuff. And then my favorite one that I remember is the 10 years ago, there was a lot of hot buzz around, was it stool implants, stool transplants? Fecal transplants. Fecal transplants. And just a favorite topic to talk about over lunch. So again, we'll save all that good stuff for the end of the day, all the clinical stuff. Mike will bring out the wound, see more butts, and we'll take it from there. So let's wrap up kind of the success of night-based care. Okay. So I'll take a slide. First, I want to talk about, and I tried to kind of put these in order. So patient identification, flagging your patient. And I know some of this feels so silly, but it really is key to be able to flag your patient. Can you tell which patient is in a value-based program and what those benefits are? And it may not be easily created inside your workflow. I know we have some mixed bag on how technology works inside of this, but the ability to distinguish what program are they in and what resources do they have and benefits available to them is key. And then locating that patient. Do you know where the patient is at that exact moment? Right? And maybe they're in an apartment building. Maybe they're in a group home. Maybe they're in assisted living. Maybe they're in their own individual house. But if they have the ability to wander off, that is a question. And do you know then, are they in the hospital? So not even, well, they were out gardening and weren't ready for my visitor. They were, you know, eating lunch and weren't ready for my visit. But are they in the hospital? Are they in a Med-A-Stay? Or are they in an observational care? We don't know those things. And the understanding individual and aggregate location of your patient population. Can you open up your chart and see how many patients are in the hospital right now, what their names are, and you can dig deep. And then you can maybe see what interaction your team has had at that patient in the hospital. So again, identifying your patients. Slide. And then thinking about technology. Again, I think about EHRs as storing clinical data. They're not intrinsically built. And if you look back on the history of legislation around building EHRs, they're really just restoring data in the attempt to have the right data as you transition. That part never really got fully built out. So the identifying patients and their services available is not intrinsic to them. Now, you do have programs and modules inside of EHRs that you can start to put in there. And I would really think about looking at those and seeing how they can add value. And again, they can overlap already. Or you have to purchase additional services to say, how do I figure out where my patients are? Maybe I need to tap into an HIE. And how do I get that HIE information? And how do I mine it to, again, know that the patient's in the hospital? And it can take time, dollars, people, resources, all about how I utilize these practices. But I would say, again, your key, if I'm thinking about value-based care. I'm thinking about improved quality, lower cost. Improved quality, lower cost. And one of the biggest costs is again, these transitions. And I talked about that. Nobody's sitting in their living room probably really finds out, today I'm going to the hospital. They have an unexpected transition and now we don't know where they are. I think Elena put HIE tools is a great tool. So HIE is not a singular tool and it's different on each state. And so some major health systems participate in HIEs, some states participate in a statewide HIE. It is not uniform on how those can connect. You may need to tap into a number of HIE tools. And again, to your point, when you can, getting that information is incredibly helpful. Ideally, you don't find out when the patient's in the hospital, you find out before they're in the hospital. And again, how are you tracking that information? Slide. Okay, so final things, think about key information needed under patient identification. What's the flagging system? What benefits are available? This is also known as patron patient attribution. So you'll hear about that too, is I know who these patients are. The other thing about knowing who these patients are is truing that up every month and making sure that your patient attribution list and the patients you thought you were caring for match up with your Medicare or your delegated agreement. And I can't tell you, we're not yet in the Medicare direct contracting, we built the next year, but I can't tell you how many delegated provider agreements I've gone through the patient attribute. Well, that wasn't our patient this month. That wasn't our patient this month. And they just, they kind of auto assign because payers, big systems have backend technology just saying, okay, these are all your patients. And you really need to make sure that they're the true patients that you knew about and you were caring about and should be attributed to you. One example is I have one DSNP contract who we, and with dual patients, with all patients, but it's kind of an assignment model. I have one contract where we have over a hundred patients that we know are not in our care system, but they don't have a system to take them back and they auto tech assign us those patients. And so we've been keeping a list and we keep working with them about you really need to take these patients. We don't want the cost and quality data assigned to patients that are not our patients. And again, where are they located at this time? How do we understand where they are at any given time? And how do we create a pattern of non-primary living location utilization? How do we think about monthly hospitalization, falling patterns? And again, population health technology can help you with that. And even if you're not using a tech tool or they're too expensive, I talk with lots of groups who say, I just cannot afford the infrastructure of the technology. Well, I'll tell you what, it's not just purchasing the technology, it's also purchasing the people to do something with the technology and demand all of it. And so I totally get this. And smaller programs, startup programs, do this again in Excel, just track that I'm going through my high-risk utilizers and I know who's about to be on that list. And the final thing is the ability to get this key information easily as advanced directives and key family members. So how do I have at my tips if they're in a value-based care program? How do I get my fingertips this? Key, key things. How do I get their pulse the most? How do I get the access to the family members when I got to make that call? So I'm gonna stop there for a second. I'm gonna open it up to Brianna and Paul to share any stories around, horror stories or good stories around patient identification, importance of it, things we need to think about. You know, patient attribution is a problem. So even though, for example, I've been seeing the patient for whatever, let's just say a couple of months, in the system is still list another PCP as their, another doctor as their PCP. And we have to somehow go back in and rework the system and list myself as the PCP. So that's one of the issues that, you know, working with a very large health system, when we get patient referred from a PCP who is high need and high cost, when they come to us, the attribution doesn't necessarily follow to us, but you get the idea. The other point I was gonna make about key information easily. One way that I've made post most advanced directives easily accessible is actually putting it on my problem list. And I, under the heading advanced care planning, and that is a code. And then I can open up underneath and put in under the note section under advanced care planning. You know, the power of attorney is this, a finance person is that, and living will discuss patient has five wishes. You get the idea. If you know pulse, you can put in, you know, DNR selective treatment and no feeding tube, whatever it may be. That is one place where I think most providers would go and get information that they need, especially when it's urgent or kind of a crisis. I think that's really great. I would add to kind of the PCP piece as well around the, you know, I wanted to just add, oftentimes that's a manual process. And so we're actually working through trying to stand up a delegated provider arrangement with the Medicare Advantage plan. And they're like, well, these patients are attributed to community, you know, to these other community primary care providers. I said, well, where are their primary care? And the thing is, no, we didn't care about those patients. They were just fee for service buckets for us historically. So there was no one putting in the paperwork and the paperwork is actually going to be a physical piece of paper that needs to be signed by the family members. And so it's not that some of these pieces are totally easy. And then I would add one more thing about patient attribution. You know, when you're looking at the value-based care programs coming out of CMS or CMMI, so the MSSB or REACH ACO or primary care first, look at how they're attributing your patients. And sometimes we're exploring the MSSB, for example, they actually give you the option to choose if you want a retrospective attribution or retro, or excuse me, a prospective attribution or prospective attribution with retrospective true up. Those are really big differences. The requirements inside of those are really big and have a big impact on your volume. And I won't go down the rabbit hole necessarily, but how Medicare attributes patients to you and how they think about plurality and how they think about when you get your lists. Again, super key, because you are going to be applying resources to this. You want to make sure you know who everybody is and that you're doing the right services and you can track them easily. Yeah, and I think your point about patient attribution is so important too, because especially with the newer payment models, there's going to be kinks, right? Especially they were working with some primary care first practices. It was almost laughable. Some of the patient attribution reports that we got and they retired a lot of work. And then to your point, if they expect, if you don't want to wait for the automated process, right? That kind of prospective or retrospective process that occurs, then you have to educate the patient and family how to go online or call Medicare or fill out the physical form. So understanding that process and what needs to go along with that. We had the issue where there were a handful of patients that had been discharged from the practice that were on their attribution list, rightfully so, because they care for them there. Well, trying to get a discharged patient to go through that process to update their PCP is maybe not always super realistic, but understanding those different processes. And then I know Michael shared about the health information exchange in the chat too. You know, do your research. If you're not using one, your EHR vendor even may be able to tell you if they can connect to one. You can look at that. You know, like Amanda said, if your state has one or else. I'm also one as far as the patient identification and the flagging. There's lots of different flags or tagging systems. I love to challenge EHR vendors because you would be so surprised if you just ask your question differently or maybe talk to a different representative or ask for additional training and additional clarity, the response that you might get when you're looking into some of these features of I need a tagging system, I need a flag or a pop-up for this or that. So really do some research and investing in what your EHR technology is capable of and even just try, I know that sounds silly, but you'd be surprised asking the question a little differently or pushing for a little bit of education or the different response that that might get you. I love that. Any thoughts from the group? Okay, we'll keep throwing stuff in the chat too. We'll keep moving along. Next slide. Okay, so you know who your patients are. Now, understanding the data. What data are you getting on your patients? If you can identify that patient, now you use that data to analyze the individual and population gaps in care and quality opportunities. And again, you think about aggregating this on the individual and the population level. You can see trends by county, state, You can see trends by counties. You know, if you're in assisted living facilities or ILs or group homes, you can see certain disease categories, dementia patients, COPD patients. There is the opportunity, if you can get good data, to aggregate it many different ways. Well, again, continue to think about how am I gonna look at it on an individual and a population level? So, you know, am I gonna look at my quality data of who's falling through the cracks of my dementia patients? How do I cross-reference my hospitalizations and my dementia patients? And I pull that list up. Or how am I really tracking how each county is doing or how the providers are doing in their quality of care? And utilizing data. How do you understand that? If you can interpret the information, you can create the focus needs assessment. And I think this requires a lot of opportunities to continue to look at how you're utilizing data and if it's meaningful. So those that are part or have been part of big systems, you'll hopefully relate to this comment around, sometimes in bigger systems, we just keep doing what we've always done. And it doesn't, it's not as helpful. It's not as focused. And so the ability to keep looking at data in a new way. Slide. So these gaps that you can create out of the data for our quality of care can create new staff or clinical pathways for specific disease intervention. So I gave a couple of examples. COPD, for example. COPD patients have a 20% chance of going to the hospital within the first year of being diagnosed. Great, we get that out of the data. We pull that out of the data. So now your intervention might be, let's provide a new clinical pathways and supplies for families on hand if there's a COP exacerbation. Certain ALIL facilities are more likely to call a hospital directly than call your practice. The intervention may be discussed with the facility but how to talk to you first, right? So again, if you start looking at data, start high level and then drill in deep about where are we having gaps in care? Where are we having quality, low performance and how do we connect those pieces together? Final slide, yeah. So final thoughts on major limitations and this is a tough one is the data is unavailable or it's not, or it's available, but it's not timely. So think about like even your claims data coming out of sometimes health systems, sometimes Medicare that can lag for a period of time. And so my understanding is Brianna can correct me on this. My understanding is Medicare releases a piece of data once a month, the delegated provider arrangements. So that information, they really wait for a 90 day run out. So I don't really get claims. I don't get financial data until 90 days after the end of that period. So you think about, well, gosh, Amanda you have some contracts where you're ending the year and you by December 31st, you might have through quarter three. Yeah, that's right. Wait, how do you make sure that's usable information? And make sure that the data you have is written in the contract. So you don't get that opportunity with Medicare directly but you certainly do with your local payers or your local ACOs. I write in all my contracts, I want a dedicated account representative. I'd like to meet quarterly to review financials, data, claims, and utilization, right? And it just is a separate piece in the contract that exists. And again, it's not a fee-for-service contract. So you're used to negotiating fee-for-service when you create your value-based contract. It's a separate clause that says, this is what we're going to do. And this is how we're going to interact together. And they may put a clause in, you're going to give me this and I'm going to give you this. We're going to look at our patient attribution. Great, every month, great. With Medicare, they're going to provide data but it's a lot of information. So you need help sorting it. That could be technology or again, just making sure you build some steady streams in Excel to pull up that dump of information and sort through it to make it meaningful. And technology again, can support interpreting this data or it can interpret this data and create a lot of different shiny objects. So focus in on your gaps of care, quality of care. Brianna, Paul's thoughts on this section? Paul, if you want to say something, go ahead. No? No, I mean, data for us, I think it's, you mentioned claims data and it comes so late and under value-based care, that's almost, it's just difficult to operate when you get information so far behind and the intervention, the time to intervene is already lost. So I think getting right data at the right time so you can intervene at the right place in the right time, so important. I don't have any magic solutions. Again, I work with a very large health system. So I work with what I have and what I can, but I do continue to bug my people about getting me data sooner than later so I can see who are the high utilizers and what's going on with them so that I can get to them in a timely fashion. There was a slide about assisted living place that are more likely to call and send patients to the hospital. One assisted living facility that I go to, they have a add-on telemedicine service. It's kind of, it's almost like a, it's kind of like, it's a box. It's almost like a robot. It has computer screen, it has light, it has an otoscope, it has, well, you get the idea, high definition cameras and so forth. So if the patient falls at night, they actually call this particular vendor and rather than sending the patient to the emergency room, the vendor and the doctor on the other side of this can do a basically a tele-visit and they can have that discussion with the family members saying, you know, I think grandma's okay. I think we can keep her here. And then they'll send a note to us and say, you know, we saw grandma and you might want to follow up with her, you know, the next day or so. That's one way this particular facility is trying to cut down on the ambulance run that happens so often with our patients. Yeah, I think that's great. I'd add one more thing about your first comment around the data comes really late. I just couldn't agree more. I will also say there are so many tech vendors standing on every corner saying, I'll sell you a predictive model. And I don't think those are bad. You know, what comes out of frailty score, predictive modeling, I don't, again, I don't think that's bad. I think you just need to sort through, is it really for my population? Is it really for, you know, do I really understand it? And if I know that information and I'm making those interventions, is it working? So I think predictive modeling, I think I mentioned something like this yesterday. I think predictive modeling and AI will get to a point where we're going to see some really cool stuff come out of that. And we really will be able to see not just the people falling off the cliff, but the people about to fall off the cliff. And I think that could be really cool. But for now I have what I call a healthy amount of, you know, suspicion that they don't have it all worked out. They're just continuing to repackage the same kind of idea and new tech pictures. So worth continuing to look at. Brianna, were you gonna say something? Yeah, no, I think the only thing I was adding for food for thought, if you're not really having a lot of data, if you're not used to quality, you know, depending on the size of your practice, you may not be required to participate in MIPS, but you can always voluntary participate. I mean, even just getting used to some MIPS quality reporting, you know, could be a good way to kind of dip your toe into trying to get, you know, some metrics and some quality. There's certainly many, many other ways to do it, but if you're not participating in MIPS, that might be one option for you to consider to start thinking about. And again, I'll throw a really big wrench in Amanda's hat. When you think about gaps in care and you think about remote patient monitoring, would getting real-time vitals or real-time monitoring on that patient be a potential solution? We can definitely as an advocate debate that all day, but there's lots of different solutions out there. There could be high-tech and there could be low-tech. Maybe it's just you keep track of your transition patients on a whiteboard or an Excel spreadsheet, and you talk about it in an IDT meeting. So I think there's high-tech and there's very low-tech solutions that can help you think about quality and gaps of care. Couldn't agree more. Other thoughts from the group? Okay, we'll keep going. Next slide. One second. Elena says, creating flow sheets in our EHR has been helpful. Absolutely, absolutely. Yep, internal processes, absolutely. So as you think about the managing the cost of care, so how much is the care you provide or you are responsible for actually costs? Utilized cost reports, claims data, other financial reports available, you don't really understand your internal costs and then your external costs. If you're at risk for the total cost of care for the patient, how much are you spending on total hospital care? But again, how much are you also spending internally on that care? And dig in to other cost reports, claims data, dig into provider or system-specific information. Certain providers may be more likely to prescribe a high-cost medication or certain hospitals may be more likely to have higher ED readmissions. And so if you can't get that information, try to get it. And sometimes they have to blind the data and you might get the cost, but you might not get the location. See if you can figure out how to kind of tie those together so you can at least connect who's costing you and your system more money. One example on medications I wanted to provide is, so we get from one of our, as a delegated provider on one of our D-SNPs and I-SNP plans, we get a list every quarter of the top highest prescribing providers in our network and so it's the whole network. So it's some of our providers and then it's some of not our providers under our roof. So the entire network, we get the list of, we get a percentage of our total generic utilization. We get then all the top five most expensive, most used, most expensive drugs, yeah, meds that people are on. And so we can kind of go back to our group and talk more about that. Hey, everybody's prescribing a lot of Advair. Let's talk about what that means. Everybody's prescribing a lot of Axe. Let's talk about what that means. And so for us having a high generic usage, we can directly tie to, that means we're doing well in our pharmacy spend. And so we can look at that medication piece. Slide, am I missing? Yeah. Okay, so managing the cost of care. Think about utilizing the gaps in care and quality to identify meaning interventions to improve that quality of care. So some places that are gonna be your highest spend in your population are gonna be your hospitalizations, your ED visits, your med A stay, your medication, specialty care and outpatient care. And it's just a place to start looking. So focus in on that. Your specialty care dermatology may be, even though dermatologists are very well-paid and they can be expensive, that may be a tiny little bucket. So let's not focus on that. We may say, my med A stays are very high. I send someone to the hospital and an X hospital is always sending someone for a 21 day med A stay. That's really important. X person is always filtering through my patients and only having them stay OBS care and it's costing my pool more because I'm not cost sharing in the same way with a patient, right? Generally, there's a lot of different ways Generally, the two or the three biggest places to start are kind of these hospitalizations, med A and medications. And again, with the regular Medicare programs, you're not gonna be at risk for the medications. You may not get that claims data, but you're not really, part D is not included in the risk portfolio, but we all know that medications have a deep impact on these other things. And so again, just looking at that and understanding the claims data. And so again, utilize those reports to dig into the high cost spend areas. Slide. Yeah, and if a provider's, Elena says if a provider's affiliated with the healthcare system, they can be obtained for that organization. Yes, and I do mean that I should have clarified, you know, when I talk about contracts, that's certainly if you're part of an ACO, if you're part of a Medicare Direct value-based contracting arrangement, if you're part of any sort of Part C program as the delegated provider. And so I think there are a lot of different ways that you can get that information, figure out who gets it, and then get the cost information back so you can tie it to quality. And finally, I wanna talk about managing the cost of care is think about these PDSA cycles, right? So now we're gonna put some process measures in place to improve the quality, or excuse me, to improve the cost of care and improve the quality. And let's talk about a PDSA cycle where we try something, maybe it's even on a small scale, maybe it's whole practice, but we go through the process of, you know, figure out what we're trying to solve for, try it, see if it worked, and if it didn't work, fix it. And so that way you can understand how you can, again, control your costs. And then in the study part, and I talked about this today or yesterday, is think about root cause analysis. Because if you're really trying to impact transitions, you're really trying to impact hospitalizations, go back in your study part and go back, yep, go in your study part and look at what was the root cause of why someone went to the hospital if we're trying to impact hospitalizations or rehospitalizations. That will be key in fixing the process around the cost of care. So they're kind of separate in that I kind of listed quality and cost separately because I do think it just takes a different mindset to tie this data together, but they're also intrinsically linked. I opened yesterday with, if we're doing the right thing and we're improving quality, we're lowering costs. And when we're trying to lower costs, we're putting new quality measures and processes in place to do those things, to better care for those patients. So again, they're, you know, chicken and the egg a little bit on this, but in intrinsically linked, but different lenses in which we're looking at the world. Rhianna, Paul, thoughts on this section, examples, things that I missed? I regularly have meetings with my providers to go over some of the stuff you talked about. And one thing I've learned is to, not only to have data, to separate feelings from facts. Sometimes, for example, the provider might say, I'm doing a great job, you know, my patients, whatever, and so forth. And if you show them the data, whether it's a patient volume issue compared to maybe other providers or say a readmission problem, it might be higher with one particular provider than another. So the feeling might be like, I'm doing great, or I'm so overwhelmed, I'm so exhausted. But when you show them the data, hopefully they will understand that, or maybe we can talk about, you know, what is driving your feeling either up or down and how can I help? So having meetings and having data and trying to get to the root cause, if you will, of either good performance or performance that could perhaps be improved. Yeah, the only comment I was gonna add too is like the PDFA cycle could be, I feel like sometimes people shy away from them because they feel like it's gonna be too much work. That could be a super small sample size. Like, for example, if you, your clinical standard of care is that a cognitive assessment screening and a fall risk assessment is done for every new patient, we'll pull five charts and see how, by different providers and see how much that's actually being done, or if the quality code is actually being dropped to capture those measures or things like that. And the root cause analysis, you know, there's tons of, you know, quality improvement tools, you know, the healthcare, oh, I'm blanking on the same quality improvement site. There's all sorts of tools and things that are available for you to actually take the time and do that when you think you have a problem that may help you identify, again, is it a process problem? Is it a people problem? Or what's really going on? So these things may seem like a lot of work, but I would encourage you to try it with a small sample size and take the time to do it when you're really having a problem and you might be surprised what you learn. Absolutely, absolutely. Thoughts from the group? Good morning, this is Karen. I thought I'd share, taking that same line and share an example of a PDSA we have in process right now, small. So leaning into the topic of the transition of care and transition of care management and timely visits. So we've done really well with meeting the metric about that phone call at 24 hours and completing the visit, we closed that. But the thing that was really falling out was were we notifying? Did you call us in the preceding days? Because most events, there's some lead up to this event, to the ER, to the 911. And so really trying to hone in on that. So that is where we are at present of leaning in during the interaction of, tell me about how did we get here? What happened in three days prior to the event to see if there are opportunities for us to put additional measures in? We're in the middle of this now. So hopefully we'll have something to report within a month's time, but really simple and just taking it one step at a time. That's a really good example. And it just, I think it really reiterates what Brianna was saying about, it's okay to start small and just look at those details and really ask the right questions and focus on the things you can make that big impact on. Paul, were you gonna say something too? No, just seeing the comments about having regular meetings is so important. I can't agree with you more. And the comments that people are posting here, meeting regularly to talk about our patients, what's going on, how come the patient's back in the hospital again and so forth, critical, especially in Valley-based care, right? Fee-for-service, it's not so much, go back to the ER, so what? It doesn't matter to me, but we're really looking at medicine through a different lens. Yeah, that's really great. You're also kind of a plant for my next slide. So thanks for sending me up, Paul. Slide. As we think about kind of meeting with teams too, and I won't go too deep because I know we've talked about this, you keep me here, I keep saying the same thing around, make sure your data that you're using is efficient and that you look at it, but there's those three buckets to think about when you're identifying data and putting them on a dashboard. Identification, so attribution, quality, and cost to create that dashboard for your population. And it is good to create a big picture dashboard. You want the ability to dig deep into a certain patient information and get that information and maybe the information you learn from one, two, five patients, you extrapolate to everybody and seeing that big picture dashboard. And so some examples about a dashboard to cover these three areas were really size and location of patients. And again, how many patients are in this county? How many patients are in this program? How many patients are under this provider? So again, shape that who and where and how they're kind of identified and attributed. And then the quality, what are the ones you're responsible or tracking and why? And again, those are things, they could be process or outcome measures inside the quality because you're building towards that. What are the measures you're financially responsible for and you're working towards improving? And then cost, total cost of care and high cost areas. And I mean that in, again, not high cost counties, but high cost spend, right? Medications, hospitalizations, and you're gonna see that intrinsic link between cost and quality. You're not gonna put your quality as mammograms and then your high cost is hospital readmissions, right? You probably have a couple of quality goals and you have the cost tied to those to try to work through those. So again, utilize that efficient information. Next slide. I wanted to provide one slide around financial statements and I might pause after this one to think about this, but value-based care programs can pay in very different ways. And so sometimes you might get a fully capitated amount of money that they're gonna, like the new REACH program, you can be in a fully capitated program where they're gonna reconcile at the end of the 18 months and you're getting the money on a regular basis. Or you could be in a program where it could be paid up to 18 months after that's been provided. So if I did a timeline here and I just would show it this way, like today we're halfway through 2022. I got my preliminary reporting for 2021 on my delegated provider agreements in April, May, and I'll get my final in October, November, December because Medicare will do the final HCC risk adjustment for last year in July, or excuse me, the second to final last year in July. And then they'll do August, we'll risk adjust this the first six months. And so by the time the end of the year comes I'll get updates on this first six months of this year and I'll get updates on all of last year. And technically the HCCs will also be reviewed January of the following year. And so those can show up on my financial statements. Any final pickups can show up on my financial statements as much as like two years after the fact. And you really need to understand how you're getting paid in that cashflow piece because it's a really different cashflow. And you might wanna create financial systems that can predict future payments. And some of that again is saying at these levels of utilization, right? At these levels of hospital utilization at this level of my MLR, I can see this financial payment based on a per member per month program. And I can extrapolate that to a per member per year. And so then now I'm gonna make some estimates of what my financial predictive future payment's gonna be. So I can build that into my budget and to my financial statements. And then I know a lot of smaller practices in a fee-for-service world, it makes sense to think about cash accruals. And so really when I get the cash, I book the cash and then it's done. And when you take a lot of risk and you're getting paid significantly later than when you delivered those services, you may think about transitioning to accrual financials because of these Medicare delays and risk adjustment true ups. So I'm just throwing it out there. I don't know how many are in cash or accrual financials. Again, typically smaller practices are starting in a cash system. Typically big systems are starting in accrual-based system. But even if you're a smaller medium-sized group and you've been cash your whole life, it's gonna be really hard if you can't recognize that cash for another 18 months. And think about the ability for you to have a positive net margin at the end of every year or project margin at the end of every year so you can keep your financing in place. So again, just another way to think about that. But I would take a pause because we haven't talked much about financial statement considerations. Any questions on this for me or others? Okay, you guys think about it. We have one more slide on this section and then we'll open it up to the panel here. Next slide. Okay, so we were trying to attend kind of to say everybody has a struggle with, and every and all practices, but in value-based care, you really care about this meaningful data and how you utilize it that makes financial sense. And everybody has struggles with how we think about data. Some financial resources to help, certainly your accounting firms, your actuarial firms, if you haven't engaged with one, but you're thinking about getting into a Medicare contract, you've probably engaged an actuary at this point, trade associations outside of kind of professional associations. So MGMA or HFMA, and then internal resources that you have, other people you can tap into to think about data and financial considerations, especially cashflow when you're in heavy and value-based care with Medicare, is thinking about your cashflow and how you build in meaningful pieces in your cashflow. And I'll give one final example and open it up to the panel, but in my contracts for being a delegated provider is I have a trigger point of over a certain amount, either way, upside, downside, but for us, it's been upside, over a certain amount on the upside would trigger a 50% release of cash out of that program. So I could have a regular cashflow built in. So, because we've done most of our work in value-based care, we really wouldn't survive in fee-for-service only. And so we've kind of need the cash flow to be figured out on a more regular basis than just annual. And it doesn't really make sense. I mean, we all know this from personal account, you know, accounting and financial work is, you know, you really don't want someone else to hold your money for a year. You could be doing so many other things with it. Paul, Brianna, other thoughts on data and financial considerations? Yeah, I think it's so important to know how you get paid under VBC, whether it's an immediate payment or there's a delayed payment. Look, we just went through the pandemic and for fee-for-service, I mean, the pandemic has been bad in many ways, but it also highlighted some opportunities for us. For example, it highlighted that, you know, fee-for-service under pandemic is really not a good operation model. So many practices suffered under fee-for-service because no patients came, went to them, or no operations in the operating room and so on and so forth. Again, you know, getting revenue at the right, and being able to project revenue and getting revenue coming at a regular basis, maybe that's why I'm trying to say it's so important. Those are just my comments. Paul, I would add, you said that, you know, fee-for-service was unsustainable during the pandemic, and I want to put the counter of that, you know, or the exact flip side of that is health plans made out like bandits during, because lower utilization meant that they had much bigger profits than they've ever had before. And so when we talk about, in value-based care, if someone's under a Medicare product, if someone's under a value-based care product, someone could make money or someone could lose money. Well, with lower utilization, health plans did very, very, very well. And those that were contracted to share in that did well. And so it's actually, you know, I'm not saying get into value-based care to prepare yourself for a future pandemic, get into value-based care, because I think it's the right thing to do when the market's heading there and all these reasons. And it really was the exact flip of the other side of the coin of someone else made money on lower utilization and it should have been us. Yeah, I think that's a great point. I mean, and the other risk with fee-for-service too is, right, the Medicare fee schedule and the conversion factor that's constantly being lowered and we're not going to have the COVID relief next year. So, you know, that small margin of, you know, I think it's going to be approximately 4% across the board that we're going to see a decrease in 2023. You know, that's a big hit for small to medium-sized practices in your profit margin if you're not prepared for that. So, but the counter to that would be really understanding what model or what contract you're getting into before you do it. And to Amanda and Paul's point about, you know, if there is a kind of wait for that cashflow, making sure you're in a position that's okay, because again, with even a lot of them, you can sign a letter of intent that's non-binding, right? And, but then they come back and they put you in a lower risk here. Well, maybe it's okay to walk away from that contract. Like primary care first, for example, if you were put in group three, well, you might make more in fee-for-service than group three primary care first. So really understanding kind of your options and the contract before you get into certain models. And again, a lot of these, you want to get your initial application and for the CMMI models in particular, I'm talking about when they first come out, but usually the letter of intents are completely non-binding. So take the time that you need when they give that data back to you to really evaluate and make sure it's the right decision for you moving forward. Yeah, very good, you guys. The group, thoughts? Comments? Financial data? So it's not really on financial data. It's more like an overall, you know, for the past two days, I think everybody got a lot of information and I don't know if all practices are doing, you know, quality improvement or have ever done that. So this is kind of like a words of encouragement for, you know, those people in the group that have to go and have those conversations with their providers. You know, just from personal experience, you know, I delivered that message and did quality improvement for over eight years, you know, from talking to physicians, to their staff, and, you know, especially to physicians and, you know, coming in and providing those reports, quarterly reports and their readmissions and referrals in-network, out-network, you know, the readmissions and then their clinical data within their practices, right? You know, you're taking only 75% of your patients have blood pressure documented, the measure's over 80%, you know. So reviewing those reports, sometimes, you know, if you have never done that, I guess the words of encouragement for me, don't give up because a lot of times, you know, when I had those conversations with providers, it's sometimes not received very well, right? Because it's your practice, they're like, well, we are doing a good job and we're trying and they are, but data shows might show a little bit different. So implementing those PDSAs that Amanda talked about, they are very important, I think, and sometimes they're not also well-received because it's additional work that the practice has to do, but that's okay because within, you know, six months or three months of like little improvements, when you come back and have that conversation, say, you know what guys, look, now, you know, 90% of your patients have blood pressure documented or, you know, little wins go a long way. So, you know, if you get discouraged and it's something you're doing for the first time discussing these reports with providers and they're not received well or, you know, don't give up, it will pay off. Sometimes you have to have those crucial conversations, but they will pay off at the end. So just, you know, just a little encouragement. Yeah, I think that's great. You know, the other thing I'd add to that too is, you know, continue to tie the cost implications to things. You know, I just think that if we don't have a straight on ethics conversation, which is going to lead me straight into this next one, but if we don't have a straight on ethics conversation about, you know, we care about quality because it impacts cost and we care about cost because it's impacting quality. If we don't have that head on, we're going to miss it. And what I like to do is when I talk to anybody about anything, I try to relate it to the real lives. Like when I try to walk someone through a financial state and I say, well, think about how you budget in your life. And I say nine times out of 10, so this is why I don't budget my real life. I said, think about how you've always wished about budgeting your real life. And I think that's true here, right? Like, you know, I mean, oil changes are an easy one to kind of pick on. We always pick on them in healthcare, but you know, you can try to fit, you can try to streamline the oil change process. You can try to fit as many oil changes in as possible. But if you don't have good reviews, if you have people returning and you're, you know, you're covering that service and they're returning because you did something wrong, right? You're, it's gonna directly impact costs. There's no spot in the working world today where providing poor quality doesn't have an impact on cost or providing a high cost or super low cost may not have an impact on quality. So just think kind of through those things and try to make it really personal and say, look, like I care about all these things and our practice is moving in this direction. Karen, were you gonna say something that came on video? I was, thank you. Yes, my mind's kind of putting, connecting all the dots and putting the pieces together. So I was gonna give an example of my, one of my takeaways from today and yesterday for what to work with my team. So the comment Dr. Paul had made earlier about the why and the importance of understanding why and the comment, I was trained as a physician and I happened to be a nurse practitioner, but I was changed as a nurse practitioner. And I look at my own continuing education and learning, I typically deep dive into clinical, but in the world that is coming, the world that we're in, it has to be equal with this coding and understanding the financials because of the interrelationships with them. And the takeaway slide of kind of a project I'm planning here to deliver to my team will be to use that visual on COPD. So I think if we ran our panel and I ran diagnosis codes, I'm going to hypothesize 90% are going to come back as unspecified COPD. And I think that's a real opportunity that translates to dollars and cents. And when you're talking bonus and performance and those sorts of things, that ties everything together for not just the practice, but also the individual. So there's my takeaway for today. Yeah, I think that's awesome. I think that's really great. Actually, you're full plant for kind of my next slide about kind of continuing to tie it together. So we'll see if I can kind of tie it together. I'm going to check in with you after these next couple of slides and see if I kind of hit the nail on the head a little bit. But, you know, when we think about Medicare, this is the one source of revenue is acuity based. Medicare says the sicker you are, the more it's going to cost the system. Right. And I keep saying this, Karen, to your point around if you said the quality is exceptional in the United States and it's really expensive, I think we'd be having a different conversation. What we're saying is it's really expensive and we're not getting the quality results that we need out of the system. And I think that becomes all a collective unity of our problem. Right. It's and this is why Medicare is saying you're responsible for thinking about the intersection of these two things. And it doesn't necessarily mean you're going to code, you know, CHF, I think, CHF or CPD. I can't remember CHF differently. Or I mean, it doesn't mean you're going to not you're going to put like 10 more diagnoses. What it does mean is you're going to specify your diagnosis and you're going to get a little more clarity there. So I'm not going to do another HTC talk because I cannot do the fantastic. But I will say again, putting these things together, have you coded your patients truly based on their acuity of needs? How do you understand the model and any annual updates? They update every year and they will weight things differently and they will add new diagnoses and take off diagnoses. And that there are a lot of resources to stay updated. I actually my number one website is always into the Medicare, but there's a free Optum Health Educator. There are others, there are partners with your plans that you work today that can submit some of that data. And my delegated arrangements, I actually have a carve out of a payment to kind of a backend retrospective look. And so I can partner with them and say, well, what'd you find after the fact? But translate this to the entire team. HTCs is how Medicare pays more for higher level of interventions based on patient acuity. And so Karen, to your point of tying this together for other people, we care because they're not getting the care that they need for the cost that it's costing us. That's the idea behind value-based care. And then collect and interpret the HTC and the RAF scores for all value-based care. One note about technology in this space is make sure that they're collecting exactly that information. So hypothetically, they're probably collecting HTC data that you're pushing out. So make sure you capture that. And then your RAF score isn't just HTC data. It also includes some demographic data. And so make sure that you understand if that's included or not included when you look at that RAF score and make sure that you're getting a RAF score. And it's not like a frailty score. You want to make sure you understand the difference between all three. People say this all the time. And I was actually talking to a different practice. And they said, oh, our average HTCs is 2.4. And next year, it's going to be 2.5. And that's going to translate to this much in revenue. That's great. That's how you really utilize that data. I'm sorry, the RAF scores. That's the RAF scores. Make sure you annually risk adjust. So Brianna's already covered that. And then check the system for transition. So this is one thing that we've done differently in the last two years is we do an annual risk adjustment intervention on all of our patients. But if they have a transition at all, we then do a second review of annual and make sure that everything is accurate after that fact. And then utilize that data for financial predictive modeling. Again, in that one example of the difference between kind of 0.01 or 0.1 of a 2.4 RAF score last year, 2.5 this year, say, hey, what is that going to translate to my Medicare revenue coming in? And then push that top of licensure work. And I'll open this up for other examples in just one more slide here. But what we do is we actually hire nurses to mine the data. So our providers know that HTCs are important, but they don't have to have to know all the ins and outs. The RN will mine the data every year and then any updates and manage any transitions to make sure all the HTCs are accurate. And then they'll prepare the note and the physician or nurse practitioner will execute the note often with a regular jury visit if it's a SNF or an acute visit or a regular checkup on something else that they were looking at. So they'll just execute it. So we have RNs preparing them all year and then they just kind of push it in the EHR to the ribbon and it sits there until the provider sees the patient next. And then they can cross it out if it's not true, but they're going to capture all of that work. And so again, think about who's collecting the data, how it's being captured, who needs to be an expert in this. Slide. And then create that culture. And Karen, this is where I was hoping I'd bring it together for you. So of understanding the value of the Medicare revenue and translate that to the provider teams. HTCs is how Medicare pays more for higher level of intervention. We're getting paid to do this. And the change management is absolutely key in talking about that. Again, if you say, I care about HTCs and someone says, maybe I get this a lot being kind of on the business side, but like, you know, you're just money hungry. You just, you don't understand how it really works in the real field. You know, say, you know, this allows us to bring in this point. What'd you say? The average visits for fee for service versus you know, I mean, they could be one, two or three fewer a day of daily visits because you're taking this time to follow up on all these things of who needs you in this moment. So in terms of, I talk about a slow medicine in terms of slow medicine, where we can really apply all of the knowledge that you have as a provider correctly, I can slow down the pace of your day. If we can get paid for doing that work and the way we get paid is Medicare through these HTCs. So, and then create that open door policy to think about the ethics of these new payment models and foster a culture of compliance around HTC capture. Okay, Paul, Brianna, thoughts on revenue capture? Yeah, I actually love how you said that. And I think translating it in a way that will matter to your team. You know, it might be, you might need to translate that differently to your provider team versus your other team members and understanding what their role is. So I think that's super key. I think the other thing that could be encouraging, you know, for HTC specifically, when you're working on that is showing like the percentage of improvement or the overall RAF score improvement. Like, hey guys, you know, for six months now, we've been working on this. Look, now our average HTC score went from 1.5 to 2.0. You know, that's a little bit rewarding. You know, when we're talking about encouraging the team for kind of hard work and their efforts and showing that they're really paying off. And that's a great point. And that's on my last slide. That's why I said, make sure your dashboard has cost data on it. So they see it from the jump. They're not just saying, oh, you only care about quality. And then one day you care about costs. No, let's talk about both from the beginning together and how they can act. Sorry, Paul, go ahead. Oh, no, I was just going to say a regular check-ins are huge and have data to show them we're doing great or we can improve and celebrate successes. Have potlucks, have more potlucks. I'm just talking with my office. Celebrate little wins. This is hard work. This is complicated work. And then we talked about staffing and yesterday about hiring and retention and all of that. It's a delicate balance for us. Pushing our providers to do, pushing all of our staff to do great work, but at the same time, you know, value their work and celebrate when we do succeed. It could be a little thing. It doesn't have to be something monumental. Pick your metrics and celebrate and eat well. That's great. I will give one funny story to that. So we built, we kind of remodeled this spot when we moved in and we kind of built it the way we wanted. And I remember walking through and I'm originally from Texas and now live in Minnesota. And I was like, well, we need to have a dedicated outlet for the crock pots. And the builder was like, why? And I said, well, we have a lot of potlucks and people, the number one thing they do is they bring these crock pots full of like meatballs, you know? And so I said, I need, I need an outlet for that. So they actually like in our office, we have a fourplex that's on a dedicated electrical outlet line for crock pots. So hopefully the Midwesterners can find humor in that because there's a lot of potlucks in healthcare. I was thinking about your burpees comment yesterday too. So you eat well and then you do the burpees to work it off. Apparently, as you told everyone to do burpees during the break, we're getting restful in our chairs. So it's all about balance, right? Couldn't agree more. That's awesome. All right. One, one more slide or one more slide section, we're going to talk about payer negotiations. So putting it all together in the value-based care package. And we talked, we kind of opened the day with how do you demonstrate value? And so, you know, use these six components to create a meaningful story to impact those contracting relationships. And the external story of an impact is critical for market growth and partnership. These things that you do really well, when you actually collect the data, you move the dial, you're lowering the cost. These are things you put on your pamphlets. These are things you promote and you've talked about for your partners are saying, I'm really good at X and Y really partner with me in a new way here. And, and obviously always capture that individual patient story. I would say I never leave home without a patient story in my back pocket that directly ties with what I'm trying to get out of someone else, right? Because, and, and I, and don't feel bad about doing these things. Every relationship that we have period is the, and every time we do anything, it's just the exchanging of currency, right? And I'm building, or I'm spending currency. You do that with your spouse, you do that with your kids, you do that at work. And you certainly do that as you negotiate contracts is I'm building a relationship and I'm making it meaningful to you. And I'm building that currency. And one day I'm going to come to you and ask to create something really meaningful together. So key considerations with working with payers, who are the right people to talk to? Have you provided them the right information? Can you create a contract where you deliver those results? And do you have a mechanism if the initial efforts are not successful? Can we revisit it? And can we keep talking about it? And those things are really based on trust. And those partnerships are based on growing those relationships and maintain that close relationship. So you sign a contract, send them new updates. If I get an award or the company gets an award, send a little newsletter. Here's what we're doing really well. Send them regular updates, take them out to lunch, try to meet people in your organization. I'll give one example, but the payers made a lot of money this last year. Well, excuse me, in 2020, and then that was really paid out last year. And then now this year, they made a lot of money. And I continue to say, here's what we're doing during COVID. Here's all the things that we're doing. We're outfitting all of our staff with PPE, et cetera. And so I'd send them all these notes. This is all the patient stories. This is what I'm hearing. And I'd send them regular notes, regular emails. And then at the end of the year, last year, they said, we really heard you on, you were doing a great job and we're going to give you a little extra money for doing that. Now, to be clear, they have to distribute to community partners. They can't collect too much money as payers. There are legal laws of how much they actually get to keep. So I recognize it was part of that initiative that they were delivering some money back because they were required to reapply it to community-based efforts. And it was really great. I'd kept them up to date and that was the first time that really ever happened. And so I, again, grow that relationship. Don't just think I've just signed this and I met these key critical people and I've signed it and it's completely executed and I'm done with the legalese and I never want to see them again. No, you want to keep checking in. Slide. And my final thoughts on payer negotiation is this is unlike medicine or maybe unlike direct medicine, certainly the medicine we all practice. It's a soft scale. Find the goal where all boats are rising and continue to lean into that partnership and advocacy to create this new world where we're all getting better together. And then stay abreast of new payer negotiation resources. So HTCI, MGMA, they all offer additional resources on how to partner and contract with payers. And again, this is a little bit more if you're not contracting, payers can be the ACO, they can be Medicare Advantage, they can be specialties. This is not directly with Medicare. That's a big machine who doesn't care as much about the soft scale piece. But the opportunity to wrap these things up and continue to expand your value-based care. And we'll all have that. We'll all have potentially an original Medicare strategy and then an everyone else strategy. And what's that everyone else strategy going to look like? And I think some of these might be helpful, but Brianna, Paul, thoughts on payer negotiations? Yeah, I would say kind of my closing thoughts are too, if you don't have the relationships and you don't know who those people are, don't be afraid to be your own best investigator. Look at the plan websites for key peoples and names and email addresses, follow them on LinkedIn. There's lots of ways that you can go about trying to figure out who's the right person to try and get a conversation. And I mean, think about relationships in your own personal life. If you only call someone once a year or once every two years, is that going to be a good relationship? No, it's a long game. And you really need to put the time and the effort and the follow-up, even like your facility partnerships and things like that. So put the time in and understand the relationship-based work when it matters. And then I would just say, stay up to date. There's a lot of changing things and opportunities. So do what you need to to find the resources and support so that you can stay up to date and educate your team and not miss out on opportunities. But Paul? No, I don't have any other comments. Yeah. Oh, and open it up to the group. Any thoughts on payer negotiation? QPP website is a great one. Yeah, Elena, thank you. Great. Okay, next slide. So these are kind of the six ways I think about it. I didn't open, if you notice, with payer negotiation. Again, I'm a strong believer in get your practice organized, figure out what you do really well, make sure you can truly manage these patients, you know who they are, you know what their quality gaps are, you know where the costs are being spent. We can create meaningful processes, meaningful dashboards to understand this. We understand how to collect revenue. At the end of the day, I try to talk to my team and say, there are really two things that are coming into play here. It's expense and revenue. It's just like your personal life. You think about what is the income coming in? And how do I spend it? And where is that? Where is the most value at? And where are the places that I can cut? Right? It's the same idea as a practice to start thinking through this. You do all those things, right? You negotiate these payer contracts, because it really is a long game. And we didn't talk about the payer negotiations about being long game, but the entire value based care is kind of long game. But so are the payer contracts, you can start these conversations in two to three years have a really cool, meaningful contract. So, you know, kind of kind of stick with it and stick with what you do really well and continue to deliver on that value proposition. And other people will hear you because this is the space where people's ears are up, people are listening, and they want new ideas. And they want partnerships in this space, because you're managing, you know, you're managing, we are managing the patients, you know, in some ways that are the unmanageable and traditional healthcare. And I don't want to say people are unmanageable, but these the population is unmanageable. And it's unsustainable. If we continue in a traditional healthcare way, we have to think outside the box. And that's what this group does really well. So any final questions for me for the panelists? Anything that I can answer before lunch? Okay, well, thanks for your time. Yeah. Amanda, thanks so much to the whole team. That was a really great session. All right. We have a 30 minute lunch when we come back. We're talking about room care. So please come back at one o'clock Central Time and we'll see you then. Yeah, we'll wait. We'll wait for that. And I just want to call everybody back. Hope you had a good quick lunch. And yeah, we're going to just dive right in. Michael, why don't you take it away? All righty. So we're going to talk about wound care and a good bit about pressure ulcers, which we've talked about HCC coding already about that. And this will be a little more clinically focused with some coding details at the end. Next slide. Our objectives, we're going to talk about staging pressure injuries. That's the most current terminology for bedsores, decubitus ulcers, pressure ulcers. Now they're referred to as pressure injuries. Talk about wound care goals with serious illness and appropriate interventions with managing pressure injuries and review primary prevention of wounds. Next slide. So this just gives a little review of the anatomy of the skin. Remember the epidermal layer is the most outer layer. Below the epidermal layer is the dermal layer. And then below that is the subcutaneous layer. The cell makeup from the epidermal layer to the dermal layer can be just a few cell layers thick. So when you think about wound depth, it can very quickly go down to a full thickness wound. The epidermal layer has no blood supply. So nutrients are supplied osmotically from the lower levels of the skin. Next slide. Functions of the skin. Remember skin is a discrete body organ. Provides us protection from the outer environment, thermal regulation through perspiration in the hot weather, tactile sensation, excretion again through perspiration, synthesis of vitamin D, which we know that most of us don't get enough through the sun source anymore. And your skin provides everybody with their own unique body image. Next slide. So as in the elderly skin, there are skin changes. There's prolonged epidermal turnover that leads to epidermal thinning. By the age of 21, your epidermal layer doubles in time that it takes for that outermost layer to regenerate. So it's about 21 days. At the time of 21, at the time of 21, and then it gets progressively longer afterwards, which is why so many of those skincare products focus on exfoliation. The collagen bundles shrink, and this is what causes wrinkles. The sebaceous glands and the sweat glands dry up, which makes excretion and perspiration difficult. The loss of the sensory nerve function, loss of that tactile sense, which can lead to injury. Generally, the subcutaneous level layer of tissue will thin, decrease immunocompetence of the skin. So there are cells on the skin surface, Langerhorn cells that are the initial immune defense to pathogens on the skin, and those don't work quite as well as we could all learn. Cellular senescence is the slowing of the cell's turnover. And as the cells age, they don't multiply in the usual fashion, and they may become not as useful in immune response. There is, as we know, a decreased immune response, and that can also result in decreased inflammatory response or the inflammatory phase of wound healing. And those capillaries that are kind of close to the surface, they get really fragile and this is when you can see a lot of the blistering of skin because the capillaries are stretched and pulled and then they actually rupture and you can see those bruises or even tiki eye that you see on the extremities of older adults. That's really because of friction and the capillary fragility. Next slide. So when you're thinking about your patient and as Brianna talked about thinking about meat, remember monitor, evaluate, assess, and treat. When you're assessing any wound, you want to do it in a standardized fashion. And the first thing I recommend is the location that can give you an idea of the etiology of the wound and then if it's a pressure injury, you would stage it, which we're going to go through. Generally speaking, wounds of other etiology are not staged. I say generally because skin tears, there is a staging classification system, but it's really rarely used. So pressure injuries generally are the only ones you're going to stage. If the etiology is otherwise, it does not require staging. And then dimensions, dimensions, you know, we've talked a lot about data today and dimensions give you that concrete data of whether or not wounds are improving or worsening. And it's generally accepted length times width times depth and length is in head to toe fashion, width is side to side, so hip to hip, and depth is at the deepest point. And then describe tunneling and undermining, which we'll go over in more detail with the model. Exudate, exudate is the amount of fluid that the wound is producing. And then you also want to include the color, clarity, and quantity. Exudate is required for some of the advanced wound therapies to get Medicare to pay for them. And then the description of the wound base. Generally, I recommend describing this in color. If you're not sure what you're seeing, at least describe the colors and percent. So percent of healthy pink granular tissue or percent of avascular eschar, black brown eschar, or yellow slough, yellow white adherent slough. And then also you want to mention the appearance of the periwound, the tissue around the wound, and is it intact? Is it macerated? Is it red? Is it warm? Again, the model will help describe some of these. Next slide. So pressure injury, we still obviously see the term is interchanged, but the most recent is injury. Happens over an area of pressure, and it's usually over a bony prominence or caused by a piece of necessary medical equipment. And medical necessity is usually defined by life-sustaining like an ET tube, endotracheal tube, or maybe oxygen tubing. Next slide. So here's a cartoon describing where the areas of pressure are, and the most common cause, or the most common location of pressure injury is number one, sacrum, number two, heels, and number three, the occipital area. I like to remind everybody that heels are almost always preventable because you can ideally float those heels so that they are not in any, don't come in any contact with any surface, and that's what causes pressure. Remember the cartoon of the individual sitting in a wheelchair, the sacrum is bearing the full load of pressure, or largely the full load of pressure. Compared to the cartoon that's lying flat, the pressure is evenly distributed from the back of the head to the heels. So lying flat will always help to decrease pressure. Next slide. So stage one, I think there's maybe one more advance, but stage one is a reddened area over an area of bony prominence on the skin. The epidermal layer is intact. Keeping in mind in darker pigmented folks, it may be difficult to identify. It may appear darker than the usual pigmentation or lighter than usual pigmentation. There may be warmth in the area. They may complain of itching or pain. When you press on the reddened area, the color does not blanch. So keep in mind, failure to identify a stage one in a darker pigmented individual can lead to a full thickness wound very quickly. If pressure is relieved in this case, I like to say that there's cellular CPR kind of goes on and that redness goes away all on its own with no further concern. Next slide. Stage two, there's a break in the epidermal layer, and you see that yellow layer there, that's the subcutaneous layer. So a stage two is a partial thickness wound that remains in the epidermal or dermal layer. It's generally pretty superficial. There's no avascular tissue in this wound, no yellow, blue, brown, black slough or eschar. The wound bed should be a hundred percent pink. The one caveat with the stage two is the serous filled blister is considered a stage two and that serous filled blister, the goal would be to keep that blister intact. Remember when I'm talking about all of these stages, it's all expected that we're talking about over an area of bony prominence. In the cartoon image here, if you see that fuzzy line in the epidermal and dermal layer, that's where a blister forms. Those are called the root ridges that holds those epidermal and dermal layer together. And most of us have had a blister, so you can kind of get an idea of the depth that we're talking about there. All right, next slide. So a stage three pressure injury is a full thickness wound. It's now gone below the skin layers into the subcutaneous layer, but not below the fascia. There may be slough or eschar present, but that's not always the case or a hallmark sign of a stage three. Stage three is generally where folks get confused in staging. If you remember a two, it's always pink, and a three, sometimes there is slough or eschar, but it's not a hallmark sign of a stage three, extending down through all the layers of the skin into the subcutaneous tissue. Next slide. That also presents clinically as a, it's generally a thicker wound. A stage four, again, is a full thickness wound that extends down into the underlying structures, including muscle, tendon, ligament, or bone. It's usually pretty obvious when you see a stage four, they're usually pretty catastrophic. There's often undermining and tunneling present, which we'll show again with the model. Next slide. A deep tissue injury is probably sort of first was recognized as an additional stage, I don't know, maybe 15 years ago. And a deep tissue injury is caused by, generally caused by intense pressure over a short period of time, or lower pressure over a long period of time. And it usually presents as a bruise or a blood filled blister over an area of pressure. Thinking about these, you want to think about these types of injuries in folks that are found down on the bathroom floor, trapped between the tub and the toilet, on a very hard surface for either a short or long period of time. Or another common sort of scenario would be in an ambulance stretcher for a long period of time. The epidermal layer is generally intact, again, looks like a bruise, purple in color or red in color, and darker pigments. Folks, again, it can, it generally is darker in pigment, lesser, lesser likely to be lighter in their pigment. And the concern here is that the injury has extended down to the lower levels into the muscle. And the because of the short period of time, the tissue is just not dyed away yet. So if you see a deep tissue injury in the home, you want to prepare the family that this may quickly erode, tissue destruction may erode and create a very catastrophic wound over a generally short period of time. In some cases, if the pressure is relieved very quickly, the underlying structures may heal from the inside out, and that there may be no break in the epidermal layer. Remember that the underlying tissues, the muscle is the highest at risk for breakdown when oxygen is deprived, and the epidermal dermal subcutaneous layer are a little more resilient to loss of that healthy oxygenated nutrient-rich blood flow. So because of that, pressure injuries don't occur from the outside in, generally they occur from the inside out. And that's because of the layers that are at most risk for loss of blood supply caused by that pressure. Next slide. Unstageable is the last stage of pressure injury. And this is a wound that you can't determine a stage because greater than 60% of the wound bed is obscured by avascular tissue, typically slough or eschar. If you remember sort of the key words that I used in defining the stage, you'll remember that stage one and stage two do not have slough or eschar present. So you would know that once the avascular tissue is cleared away, debrided away by whatever source, that this is likely a stage three or a stage four. And you'd want to prepare your patient and your family, again, that a wound that is unstageable as it progresses through the healing may actually appear to get worse to the patient or family. Next slide. Next slide. So we've talked a little bit about Minerva yesterday, I think, and in our intro course for those of you that attended. And Minerva has a stage four coccygeal full thickness wound, four centimeters by four centimeters and two centimeters in depth. Four centimeters by four centimeters tells me that this wound is likely round and a round wound, the primary source is strictly pressure. A more oblong wound, the forces contributing to the wound are typically pressure and friction and shear. She doesn't have any undermining or tunneling, serious drainage with greater than 75 sat strike through drainage on the outermost dressing. There's no odor. There's 25% adherence slough and 75% granulation tissue. Next slide. So her margins are defined. We'll talk about these more again with the models. The surrounding tissue or the peri-wound skin is intact with no maceration or induration, no obvious signs of infection. She doesn't complain of pain or discomfort. She's incontinent and the daughter's doing dressing changes daily, checking for wetness throughout the day. This all sounds pretty good. Next slide. So when you're assessing the wound, you want to keep in mind the topical plan and is the topical plan working? And the thing I like to say about the topical plan is there's a lot of places to start, but continuing to do the same thing with no benefit is really kind of pointless. The caveat that I'll add there is you have to be sure that the patient, the family, home nursing, that they're actually providing the topical therapy that you expect that they're providing. If there's a delay in getting products in and you changed the plan last visit and the new products are in, there's no point in changing the plan. So good thorough assessment with each visit, again, to kind of think about is this wound progressing towards healing or is it getting worse? And the home nurses that I work with probably is very true for all of you. They're very good at keeping me well-informed and documenting on the chart how the wound is doing. Next slide. So the point of that comment is that we've managed them jointly. So if the goal is to heal the wound and there's any debris in the wound, the debris has to be removed before the wound will progress towards healing. And the debris can be black eschar or yellow slough or gravel if it's like a motor vehicle accident or something like that. If the wound does start to heal with debris in the wound bed, the wound bed will break down at some point and then you have to start over with the healing. The next thing you want to do is maintain a moist wound surface and wounds that are kept too dry will actually heal down to the layer of moisture. So if you ever see a scar on a patient that is a divot concave in nature, you know that that wound wasn't kept moist enough. The wound is kept too moist, that's when you see maceration of the peri-wound skin, which is why you want to pay attention to that area. You always want to minimize wound dressing changes whenever you can because each time the wound bed is open to the environment, wound healing goes down by 50%. So if you're opening the dressing, wound healing goes down until the wound can heat back up to a healing temperature. And if you're doing a dressing change twice a day, the wound healing in 24 hours goes down by 50%. You always want to prevent and manage infection. We'll talk a little bit more about topical options that you can use when you're not concerned for systemic infection or systemic involvement. Manage drainage and odor and you always want to prevent pain. For patients who may be at end of life, you'd want to minimize dressing changes frequency to as little as possible. Next slide. So end of life, I kind of talked about minimizing pain and perhaps minimizing the frequency of dressing changes. You also have to think about is this wound a healable wound? And if they are end of life, it's important to prepare family, caregivers, and the patient that this wound may never heal. For distal wounds, wounds of the lower extremities that have eschar intact, unstageable heal ulcers that are completely covered with adherent non-fluctuant, non-draining black eschar, you may decide to leave that intact as the outer layer is protective. And if you try to debride that, those wounds may never heal and would be a source of great infection for the patient. We talked about our older adults and their impaired immune response. And that may also be true and especially true in patients who are also on high-dose steroids, NSAIDs, chemotherapeutic agents, anti-rejection drugs, or immunosuppressed. Thinking about the stages of wound healing, wounds are often stalled in the inflammatory stage. This can lead to delayed healing or re-recurring slough, eschar, redness, exudate, and swelling. And sometimes you may need to sort of traumatize the wound to get it back to a healing state. And that can be done with changing topical therapy, adding different wound cleansers, those types of things to help get the wound back into a healable state. We talked a bit already about as you age, the impairments to wound healing, medications I've listed above. Infection is kind of difficult. Lots of times folks want to immediately go to an antibiotic, which I try to avoid unless the patient is systemically ill. And usually I'll try to change the topical therapy before adding an antibiotic. And nutritional compromise is definitely a contributor to wound healing. You have to think about, most importantly, sufficient protein intake. There is some literature on short-term use of vitamin C and zinc oral supplements. Next slide. So thinking about Minerva, we kind of reviewed her a little quickly. We'd want to do an assessment, nutritional assessment, and what can we do to maximize her nutritional intake? We may think about doing labs such as A1C, albumin, glucose, or H&H, prealbumin, total protein. I think most commonly what folks in wound care use is really mostly albumin regarding nutritional value, and less likely the prealbumin and the total protein. But if you're able to do a nutritional consult, your registered dietician may request some of those additional labs. Infection, we kind of talked about. A chronic wound you're going to expect is either colonized or critically colonized. So again, that's kind of why I try to avoid antibiotics whenever possible. If you do do a wound culture, you wanna make sure that it's done well. So I work, we try to work with the same home health nurses. So I know that they're good at doing swab cultures, but a more definitive culture would be a tissue biopsy or a punch biopsy if you can do those in the home. Sometimes you can't do that. And of course we would go to an empiric prescribing antibiotics if indicated. We would look through Minerva's meds and see if she's taking any of those high risk meds that may contribute to slowed wound healing. And I don't believe that she was on anything that would slow her wound healing. I remember she was on a couple of different supplements that maybe she doesn't need those, but maybe we'd add, actually think about adding vitamin C. Yeah, comorbid conditions we know are gonna affect wound healing. If she were to develop a wound of her lower extremity, she'd be at high risk for developing a wound of her lower extremity with her immobility and frequent edema. So we'd wanna try to manage, make sure we manage her heart failure to avoid that. And then thinking about goals of care you wanna incorporate in that conversation if this is a healable wound, is it traumatic with Minerva's dementia for her to participate in frequent dressing changes? So you may need to think about how you can decrease the frequency of dressings. And if you're not sure about how to do that, I always recommend getting home nursing involved because almost all the agencies have RN who specializes in wound care. Next slide. So for Minerva, she's getting daily dressing changes. We'll talk a little more about this. We'll talk a little bit more about this slide when I do my demonstration. So we can go ahead. I do think that someone already said in the chat that you also have a tip sheet that kind of gives you the highlights of what we're talking about right now. Preventing pressure injury is always the first step. And I always am careful to include this education with patients and families and caregivers because remember those lay family caregivers, some of them are experienced, but oftentimes it's the first time they're providing physical care. So they really need to know sort of the basics. And that's offloading pressure with turning, repositioning, offloading heels, managing moisture with incontinence care and frequent checks for wetness, maintaining adequate nutrition and hydration, involving your friends with home nursing, physical therapy. If you can get a registered dietitian involved, that would be great. If you have a provider on your team that has wound certification or background, that's great too. On my team, oftentimes they'll ask me questions and maybe not get nursing involved in some cases. And I can kind of give them a curbside consult without having to involve somebody else. We talked about early detection, especially in darker pigmented skin folks and the challenges with that. And the Braden scale is a tool that most are probably familiar with that predicts risk in six different categories. And any of the categories that is two or less is at risk and you need to provide interventions to decrease risk in that category and not just the total score. It's easy to find the scale. We don't honestly use it much in the home, but they do always use it in the hospital. Next slide. So defining the depth of a wound, depth of debridement refers to the depth of the tissue that was removed for coding guidelines. And I think the CPT manual says when performing depth of a single wound, you have to report the depth using the deepest level of tissue removed and multiple wounds, the sum of the surface area of those wounds are used. I think Brianna will talk about this a little bit more in the coding. Sorry, Michael. I know you're gonna do a demonstration. So I thought it might be best if I'm taking the slides down and video. And while you're getting that together, there was a question Latasha asked, from a risk standpoint, can we provide wound care in the home without wound care certification or training? Yeah, I think yes. The simple answer is yes. Whatever your provider entry level training is, I would expect that wound care, basic wound care is a component of your education and you don't need a certification to minimally start a topical plan. Yeah. So Sarah, I know you can do a spotlight on Michael so that he can go ahead and show his demo. All right. Awesome, thanks. Okay. Let's see. I think I have to blur my screen. Yeah, in the upper right-hand corner, there are those three dots. And then, what do you do now? Oh, I thought that's where you did it. Sarah, any ideas? Oh, it's not the participants? It's under the video settings. It's on your screen. There's a caret next to the start video button. Yeah. Thank you. Got it. Okay. So here's my model. And here, let's see. This would be a stage one of the left ischium. You see that it's pink in color. The epidermal layer is intact. If I blanched the tissue, the pinkness would not go away. Stage one epidermal layer is intact. This is an example of a stage two. So this is left ischium, right? Don't, I have to like double A, B. Don't quote me on my left and right as wrong. So here you see that the epidermal layer, there's a break in the epidermal layer. The wound is 100% pink, and it actually looks shiny on the model, which it will actually on your patient as well. There's no yellow, brown, blue, black eschar slough present in the wound. So this is a stage two. This is an example of a stage three left trochanteric wound. You notice here that it's mostly round in shape. And that's really what tells you that the primary force of this wound is pressure. If it was more oval or oblong, then friction and shear would be playing a role. The way I check for bone, if I'm concerned about bone is with a gloved finger, I just feel the wound surface for any sharp, sharpness. Especially if you can't see it. Sometimes you can't see the bone. You see the, you can see a subcutaneous layer. So the subcutaneous layer here, this is healthy pink granular tissue. This is adherent, probably slimy white slough. And then here you see how my finger extends beyond the outer most wound surface. This is undermining. And the undermining goes from 10 o'clock to two o'clock. And that's how you describe that undermining from 10 to two. And then you would document at the deepest point. And it's, I don't know, probably about four centimeters undermining. And then this here, which don't you wish you could do this to your patients? This is tunneling right here. And tunneling is a fingerling like projection that extends beyond the outer most dimension of the wound. And this, again, you describe using the face of the clock. 12 o'clock is the head, six o'clock are the feet. And you describe how deep the tunneling is. So this is at probably seven o'clock. And I can't, I don't have a tool, a cotton tip applicator to measure it, but it's probably about three centimeters. And undermining and tunneling is often seen with friction and shear. And it's the tearing of those skins, the skin and underlying structure, the tearing of those surfaces or moving of those surfaces independently from the lower level. And that shearing injury creates the undermining and tunneling. In your topical plan of care, you always have to fill those voids, the undermining and the tunneling. If you don't, it's gonna fill with that avascular slough. So stage three, and I would say 70% pink granular tissue with 30% adherent white slough, peri-wounds intact. The wound edges, I mentioned wound edges a little bit in your assessment. And the wound edges are, this is your wound edge. And in a healthy wound, the wound edges are gonna be a darker red or a more vibrant red than the bed of the wound. If they look like this, like the model, like skin surface, then the wound edges are healed, or that's called a piboli. It means that the wound edges have healed before the void can granulate to the surface. And what happens in that scenario is if the wound edges are healed, once the granular tissue fills the void, you're gonna have trouble getting re-epithelialization to close the wound. And a simple, relatively simple trick to do to avoid wound healing or rolling, sometimes people say rolled edges, is with each dressing change, gently abrade the outer layer of the wound with a dry gauze. And then oftentimes now what's common practice is to use a zinc-based barrier cream or petroleum zinc-based barrier cream to help keep those wound edges opened and moist. Okay, that's stage three. Does anyone wanna ask any questions about stage one, two, or three? Okay, we'll go on. So this is a stage four. And like I said, a stage four is usually pretty obvious to most folks because there's significant destruction of tissue. And right here you would see probable bone or you'd feel the sharpness of bone. And then again, you would describe this wound bed based on what you see, length times width times depth, and probably I'd say 55% granular tissue, 30% adherent white slough. And then we have to describe the eschar here and some yellow and white slough here. Again, there's undermining in this wound bed. Remember we said undermining as some, untunneling and undermining is sometime present in stage three and commonly present in stage four. And this undermining goes from about 10 to two. And we described the depth of the undermining at the deepest point. And there's also a tunnel right here. Okay, where was I? Unstageable. This is a left trochanteric unstageable pressure ulcer. And that's because the majority of the wound bed is obscured by avascular tissue. And you'll remember that we know that it can't be a stage one, can't be a stage two, but once this avascular tissue is removed, it's going to be a stage three or stage four. Once you can stage an unstageable, you would stage the wound. And again, you describe this based on the colors of avascular tissue that you're seeing. It's still acceptable to measure the wound where you can, depth at the deepest point. Anytime that there's a break in the skin, you should always try to assign depth, whether at 0.1 or 0.2 centimeters. Okay, this is a deep tissue injury. Again, in this case, the epidermal layer is intact. It's deep purple in color. And that's because destruction has likely occurred through the skin layers, through the subcutaneous layers, and possibly down the muscle. This one, you'd also do the dimensions. If the epidermal layer is intact, you can't assign depth. I'm just looking at the chat. Yes, so the unstageable, when you document it, if the majority of the wound bed is obscured by avascular tissue, you would describe it as unstageable. And once the majority of the wound bed is exposed, then you could theoretically stage it, and you should. And remember, we said that it's going to be a three, a stage three or a stage four. Stage four, if there's underlying structures present, bone, ligament, tendon. Okay, is this a pressure ulcer? Does anyone want to take a guess? The answer is no. So this is a dehist-surgical wound, probably a hip ORIF wound. And the clue is, you know, you see these dehist staple or suture punctures, and you describe this as such, dehist-surgical wound. And then you use all the other descriptors that we've, or assessment tips that we've already discussed. Length times width times depth, amount of exudate, and then what you're seeing. And this appears to be pretty a clean, healthy dehist-surgical wound. Okay, there's one more, believe it or not. And this is a tear of the gluteal cleft, and it's probably not a pressure ulcer. It's pretty common, and it's usually because of moisture, or moisture-associated dermatitis, or incontinence-associated dermatitis. Okay, so those are some assessment tips using the model. Does anybody have any questions about wound assessment before I go over thinking about a topical plan? Hey, Michael, it's Paul Chang. And maybe Brianna and you, maybe Brianna can talk about it later. When one of the demos, you said I felt bone. And if I'm gonna say bill for a sacral osteomyelitis, do you need either culture evidence, radiographic evidence to be able to bill for that? Or do you recommend just sticking with like a stage four pressure ulcer of the sacrum? Your thoughts. So generally anytime there's exposed bone, you would expect a chronic osteomyelitis, whether it's controlled or uncontrolled, they're ill or the wound's not progressing. But in my experience, once osteomyelitis is confirmed, either by imaging or biopsy, it's generally expected that it's chronic, and that the wound can open up or fail at any point. When that might not be true is if the bone is debrided. And in that case, I would say generally the osteomyelitis is cured. Good. Okay. So this is in your wound tips, but I don't think I have a slide to tell you about it. I categorize wounds in four categories, deep dry, deep wet, shallow dry, shallow wet. And remember the wound bed has to be kept adequately moist. So if it's deep dry, you have to donate moisture to the wound bed. And if it's deep or shallow wet, you have to manage the exudate. And that's what helps you pick what products you may or may not use for the wound bed. Deep dry, deep wet, shallow dry, shallow wet. I have some common products that I'm gonna show you, and these are also in your tip sheet. But the first, we'll make sure we get them in there for you, the tip sheet. Thank you. So the first thing that you wanna do is what are you gonna use to clean the wound bed? And generally I always recommend wound cleanser. It's readily available and cheap. And the reason is because there's surfactants in the wound cleanser that help debride any debris that's in the wound bed. And the other thing is there's PSI, pressure per square inch. The spray adds some PSI. So when you're spraying the wound bed, you also may help with debriding any debris in the wound bed. Generally you keep it, kind of keep it on the wound for a few minutes. There are higher functioning wound wash products. And the only one that I am familiar with by a brand name, other than a generic wound cleanser is Bosch, B-A-S-C-H. And it's sort of a step up in a wound that has a lot of avascular tissue. So that's just sort of a little bit of a pro tip. Okay, so for a deep wound, we already said that you always have to fill the void. And one option is gauze. It's cheap and readily available. So that's sort of something that's good about it. You can get, fibers can be released into the wound bed that can contribute to debris. So that's sort of a downside. The bigger downside is a gauze dressing, you're generally gonna have to do at least twice a day. And remember that's reducing wound healing by 50%. I will use gauze for a highly exudative wound sometimes, and I may add like chloropractin or Dakin's, you know, they're all derivative of bleach. If you're doing that, you should do that for a short period of time, reassess the wound, and then try to go to a more conventional product because those things kill the bad stuff, but they also kill the good stuff. So generally I recommend five to seven days reassess the wound and hopefully switch to something more conventional that will facilitate wound healing. So gauze can be used as a filler. So this is step two, the filler. Another option is a hydrofiber. This is hydrofiber, a brand name, boy, it just went out of my head, aquacel, so a brand name of a hydrofiber. I try to use generic names. Remember all home health agencies have their own formulary. So if you're using a brand, it may slow your products getting to the home. So hydrofiber, these are very good and highly absorptive wounds. They absorb their weight, like six times their weight in moisture, and they lock and gel the wound. So the dressing gets slimy, yucky, stinky. This one is actually has silver embedded in it. I'd mentioned if you're concerned about critical colonization or infection, you may go to an antimicrobial type wound dressing, and one of those options would be silver. You can use hydrofiber as your filler. If it's silver, remember the silver needs to be touching the skin. If you want to be really economical and the exudate's not a concern, you could use this on this wound surface and then fill with gauze. With some of the changes in reimbursement to nursing, they're getting really creative and trying to keep their costs down. So that's hydrofiber or hydrofiber with silver. It usually comes in a package that looks like aluminum foil. Another option for filler, this is metahyme, and it comes in sort of a sheet dressing. This is not a great example, but it does generally look like this. And you can't buy Manuka honey in a jar and put it in your wound bed. It needs to be medical grade. Patients and families get creative. That's not acceptable. Again, the Manuka honey needs to be touching the wound surface, and it also comes in paste. The honey is also bacteriostatic. So if you're worried about infection, you may switch to a honey-based dressing. Both the silver and the honey can stay in the wound bed for up to three days. And you'd want to keep it in as long as you can. So we talked a good bit about filler dressings. So that would be a deep wet or a deep dry wound. So the next thing you need is a cover. And most cover dressings look something like this. This is a bordered foam gauze. An example would be Aleven. Maybe an example for a branded name. It's got the bordered gauze in the middle and then the adhesive around the edge. And if you're using this, when I talk about when the dressing needs to be changed is when you see greater than 75% strike-through drainage on the outermost cover dressing. So if this gauze is full, more than three quarters full of strike-through drainage, then it's time to change the dressing regardless of your recommended frequency. So you always want to include a PRN. And the reason is because the dressing is going to be oversaturated with exudate. Transparent film is an example of a cover dressing. I've seen it with IV insertion. It's kind of an old school concept to use it for skin tears. It's no longer recommended. The reason is in a wound, these can trap exudate and exudate has protein that contributes to the bacterial growth and slough development. So in a wound, we would not generally use this as a primary dressing. You might use it as a cover dressing, but not as a primary dressing. And in the example of a skin tear, the simple, easiest, most cost-effective dressing to use would be a petroleum impregnated gauze dressing. Nepalex is another dressing that you might use as a cover dressing. And it's trademarked so that Nepalex is the only type you get. And it's sort of a sticky dressing that you can kind of take on and off without causing skin trauma. Both of these have low moisture vapor transfer rate. So they're going to help keep moisture in the wound bed, which is maybe beneficial. Okay, this is a hydrocolloid dressing. Most of us are probably familiar with this if you've been around for a while. A trade name is Duoderm. And this can be used as a primary dressing or a cover dressing. I generally don't recommend it be used in the perineal area because it's hard to get adhesion in that area. And that's going to result in repetitive removement and reapplication or removement and reapplication. And removing that partial adhesive may cause more trauma than benefit. So I generally don't recommend it in that area. If this can stay on a wound for two to three days, then I think it's great. It does give you some absorption in the hydrocolloid and this will turn kind of white and slimy looking. And that's when it would be time to change. They're more beneficial for protection, prevention with a protective dressing. That's all I have for products. I think I kind of talked. So if you're looking for additional debridement, there are topical agents that you can use. Collagenase or Santol is the trade name. It's the only manufacturer. That's a pharmaceutical agent. It's a daily dressing change. And if you're going to use collagenase, remember that ionic silver will actually kill the botulinum toxin that's in the collagenase that helps with debridement. So no silver products. And then a cheaper alternative may be, oh gosh. A white applicant that comes in a tub. It's coming to me. Sulfidine. Yeah, so sulfidine. Sulfidine is also a daily dressing change. And you may, in a deep wound, you may think about impregnating the gauze dressing and with the sulfidine and then filling the wound bed. It's not quite as common anymore because I think there's better products and the sulfidine can kind of liquefy in the wound bed. So it's not often used, but I do use it sometimes if I can't get collagenase covered. I think we have some slides that Brianna was going to cover, but before I do that, does anybody have any questions for me? If you do, put them in the chat. So everybody should be able to see the slides again. Yes, any questions for Michael? Please go ahead and put those in the chat, but let's move on. Brianna, I'm starting with this slide, which I think probably was one of yours. I don't know. Do you have anything you want to say on this one? This is just CPT definition. Sorry, first off, can you hear me okay? I had to switch to my headset due to some landscaping noise. Yeah, we hear you great. Okay, great. So yeah, some of this was just, I think this slide got put out of place, but I often get questions about how to report the depth. So this was just some guidance there, but we can go ahead and move along to the first slide. Believe it or not, coding talk on wound care and all these procedures is going to be super short and sweet, so don't worry. We're going to get to the fun other procedure stuff first. This was just the definition for excisional debridement. Again, typically you're not doing much more than this in the home, but we can, Melissa, if you would advance one more for me, please. Okay, so these are the codes. Really what's important to remember here is that the coding for debridement, and again, this isn't if you're doing just basic wound care, this is only if you're actually debriding the wound, is based on the square centimeters of tissue that's removed and the type of it. So if you exceed 20 square centimeters, don't try and bill two units of 11042. That will get denied. There is a separate add-on code. I did put the debridement code for muscle or fascia on here, but I think that's pretty uncommon. Generally what we're doing in the home is the 11042 or 45. Michael, would you agree? Oh, sorry, yeah. Yeah, yes, I agree. And then if we go to the next one, what's more important is the documentation. I think Michael did a really great job of explaining kind of how he documents his assessment. And when we kind of think back to the meet and the necessary, I think the pitfall that I'll often see is they'll note the stage three pressure ulcer in the assessment and plan, and it'll just say continue current wound care or continue home health. So if you're gonna bill for debridement, it almost kind of needs to be, I don't wanna say a procedure note, but like it's a more expansive assessment and plan when you're billing for debridement again. So if there's multiple wounds, you need to number them. Again, these are all the CPT guidelines that are required to bill debridement separately. So you would need to provide wound member measurements, excuse me, both pre and post debridement and document the tissue removed and the type of tissue, and then what your actual care plan is. What are your current wound care orders? Don't just say that defer to home health. You know, continue home health is usually kind of the vague pitfall that I've seen in some documentation. Michael, do you have anything else to add on kind of tips as you've approached documentation for wounds? No, I don't, honestly. There are a couple of questions in the chat that I'll cover, and at least one is about debridement. Oh, perfect, yeah. So here's just the reimbursement and the coding for it. And I know a lot of people are commenting on pictures, which is great, but Michael, I'll turn it back to you for the questions. So regarding debridement, I mean, it's clinician comfort, and however your agency provides you privileges. So I just want to say that, you know, a lot of agencies will, they, we have to have the, be certified, be checked off on the ability to provide the treatment. So having said that, then it doesn't specifically mean anything about certification or not. But for me, you've decided for some reason that the wound, that sharp debridement is necessary to improve the wound. So maybe there's an acute change, or there's just debris in the wound that's making the dressing changes more difficult. It's sort of a call, but we're not doing, you know, major surgical debridement in the home in most cases. But if someone is acutely ill and you're really worried about a wound, an acute surgical consult may be indicated. And it's up to the clinician to sort of experience about when you refer, and is it within the goals of care? So that's kind of what I would say about sharp debridement. I think generally there's other alternatives that are just as good, but they're not gonna be as fast. You're not gonna get results as fast. And then the question regarding the metahoney, I think metahoney is always great, but thinking about utilization of resources, it is a high dollar product. So you wanna be sure that that's gonna be able to stay in the wound bed for several days. And if the wound is highly exudated, you may think about, like I mentioned, putting the metahoney in contact with the base of the wound and then just changing the filler and the cover dressing when the strike through drainage is more than 75%. If for some reason you can't get the exudate under control and, or the metahoney is just oozing out of the wound if they're using like a paste, then I would go to a different alternative until you can figure out why the wound is producing so much exudate. Hey, Michael and Brianna, I have a documentation and a billing question. I've been told that we don't downgrade wounds, meaning if you start with a stage four and you do great, you're now down to a stage two. You do not say there's a stage two ulcer. Once a stage four, it's always a stage four ulcer. Is that correct? If so, do I bill it as a stage four or do I bill it as a stage two? Yeah, so once a wound is declared a stage four or declared a stage three, it's forever a stage three or forever a stage four. And when it's healed, it's a healed stage four. We don't reverse stage. The caveat here, where you may see it, for those of you that go to long-term care facilities for acuity rating purposes, they may do like what appears to be reverse staging and the documentation that they use for acuity and assignment of staffing. But clinically, no, Paul, you're right. A stage four is a forever staged four, even when it's healed. And incidentally, if you see a scar form, you know that that wound of whatever etiology went below the skin surface. So you know it was a full thickness wound. And if the etiology is pressure, it has to be at least a stage three. Okay, so Brianna, did you have anything more to say on the RVU chart that's showing? I do not. We are done with the coding for wound care. Okay, all right. And Michael, key takeaways, anything more you want to say here? So I just add, remember wound management, healing and all that should be consistent with your patient's goals. You always want to do the best you can to manage pain. Prevention is key, although it may not be preventable. And for folks with a high burden of chronic illness, I often prepare patients and families that I wouldn't be surprised if they develop a bed sore is what my families often say, because it can really devastate the family when they happen. And you want to kind of prepare them so that they're not so upset. We talked about reducing the frequency of dressing changes to maximize wound healing. I'm trying to get rid of the leave it open, mama says, leave it open to air. That's not true. Wounds heal faster when covered. Just as an FYI, I sliced my thumb off June 23rd and it took 23 days to heal and it was covered every single day. So I'll give you a little personal caveat. It was very traumatic. And then for your topical plan of care, you will always want to clean, fill as appropriate, debride when appropriate, protect the margins and cover. Michael, I think I just have one comment or one more comment. As we are taking care of patients like this, like Minerva stage four, Michael mentioned if the patient is, and one of the risk factors is if the, are protein malnutrition or immunocompromised. So if the patient is malnutrition, put that as a diagnosis that carries ACC score. And also if you're, many of our patients are on chronic steroids and there's a code for immunosuppression from chronic steroid use. Again, keep other diagnoses in mind even as you're focusing on taking care of the wound. And if you did address those issues, protein issues or steroid issues, go ahead and document and do the meat documentation as Brianna coached us and did additional credit. Great reminder, Paul. Thank you. All right. Well, we're gonna just dive right in to, we don't have a break, right? Yeah. So, okay. We're gonna dive in here to our next set of procedures. And so these are the objectives. We are gonna start with G-Tube, but first I just, I don't know if Tom is on right now. I saw his name earlier. So we wanted to just welcome Tom Cornwell, who's gonna be our third faculty for this section. And. I am here. I've enjoyed the end of Michael's presentation and what a joy to see Brianna and you. So this is great. Thank you. All right. Well, thanks for that. I'm gonna get my video panel back. Okay. All right. Awesome. So we are gonna go ahead and start with G-Tube. And the way we're gonna do this is I'll play a video first and then the video is about less than, it's less than 10 minutes. And then we're gonna have a discussion and then each of our faculty will kind of answer any questions you have about the various procedures. So without further ado, I'll go ahead and launch the video. Hello, I am Dr. Paul Chang, senior medical and practice advisor for the Home Center Care Institute. Today, I will be demonstrating how to change a gastrostomy tube. Please note that I am not wearing PPE for the video to make it easier for you to hear the instructions. However, you should follow infection control guidelines and use appropriate personal protective equipment during the visit. This of course applies to the current COVID-19 pandemic. You can consider training caregivers and family members to perform the procedure in case of an emergency. This can help avoid costly and unnecessary visits to the emergency room. Please adhere to your own practice guideline if you do so. You will want to first gather the equipment and supplies for the procedure. I will now walk you through the procedure step-by-step. This is the point where you put on gloves, surgical mask, and eye protection. Again, please follow the guidelines and follow the instructions. I will now walk you through the procedure step-by-step. This is the point where you put on gloves, surgical mask, and eye protection. Again, please follow the guidelines and follow the guidelines. I will now walk you through the procedure step-by-step. This is the point where you put on gloves, surgical mask, and eye protection. Again, I am not wearing it for the purposes of the video. Examine the new gastrostomy tube for any defects and test the balloon for leakage by instilling 5 to 10 mls of sterile or distilled water. Deflate the balloon after testing and put it aside. Apply a small amount of lubricant to the end of the replacement gastrostomy tube. Make sure the external bumper slides up the tube for placement. Move the external bumper 3 to 4 cm above the previously noted distancing markings on the old tube. Note this does not apply to low-profile gastrostomy tubes. Set the replacement tube on a clean surface, usually back inside of the sterile package of the replacement tube. Place a paper towel or a cloth towel around the gastrostomy tube area to absorb any leakage of tube feeding or gastric secretions. The providers stand on either the right side or the left side of the patient. Before removal, review and identify the brand, type, size of the tube, and the external centimeter marking on the current gastrostomy tube so the replacement tube is placed in the correct position. A bumper bolster type gastrostomy tube can be changed or removed at home using traction removal without local anesthesia, although some patients and specialists prefer changing this type of tube endoscopically. Consider checking with the specialist who placed this type of gastrostomy tube for additional input. Remove the bumper or bolster type gastrostomy tube by placing the non-dominant hand flat against the abdomen for counter pressure. With the gastrostomy tube fitting in the web between the thumb and the index finger, wrap the gastrostomy tube around the fingers of the dominant hand until the hand is within a few centimeters of the abdominal wall and pull firmly on the gastrostomy tube to remove. Remove balloon type gastrostomy tube by first deflating the balloon in the old tube using a syringe. If no fluid can be aspirated from the balloon and there's concern that the valve may be malfunctioning, the valve can be cut off to allow any fluid in the balloon to escape. The valve can be cut off right here. Place the non-dominant hand against the abdomen for counter pressure. Gently pull out the old tube using the dominant hand. Discard the old tube. Insert the new gastrostomy tube into the stoma with gentle pressure beyond the previously noted distance marking on the gastrostomy tube. Inflate the balloon with appropriate amount, usually 7 to 10 ml of sterile or distilled water. Gently pull back on the gastrostomy tube until resistance is met. This ensures the retention balloon is secured against the stomach wall. Wipe any secretions off the tubing. Move the external bumper bolster down the gastrostomy tube until a snug fit is achieved. It should not compress the abdominal wall which can lead to pressure ulcer and the tube can be freely rotated. Note a low-profile gastrostomy tube does not have an external bumper or bolster. The tube can be rotated freely. The tube can be rotated freely. Note a low-profile gastrostomy tube does not have an external bumper or bolster. Verify the gastrostomy tube position by using a syringe to flush air or water into the stomach and listening with a stethoscope or by aspirating gastric content through the feeding port. Replace the gastrostomy tube dressing. Wash hands post-procedure and document the procedure including the brand and the type of the tube, the external centimeter marking of the bumper on the gastrostomy tube and the lot and expiration date. Here are some additional considerations. If a new gastrostomy tube that was placed surgically within the last two weeks becomes dislodged, the provider should contact a specialist who performed a procedure to reinsert as endoscopic or fluoroscopic replacement may be necessary. Order a replacement gastrostomy tube through the tube feeding supplier after the replacement so there will be a replacement tube at the home for emergencies. Balloon type gastrostomy tubes can be changed every three to four months although there is currently no consensus recommendations on the frequency of the gastrostomy tube change. I hope this video and practicing this procedure will help you gain confidence on how to safely change a gastrostomy tube at home. Any questions, comments? If you don't mind, I will share a couple of tips. There is no evidence-based recommendations for tube change which Paul mentioned in the video but looking at the literature, it is generally accepted to be every three to nine months, three to 12 months with the goal to avoid failure and an unnecessary trip to the ER. Replacing these tubes in the ER and the hospital is costly so for those of you that are interested in offering this procedure, it is a good way to save your health system money and you can get paid for the care that you provide. We do generally have a spare in the home as Paul mentioned in the event that it falls out. The only other thing I would recommend is confirmation can be sometimes tough of placement. We think about air bolus, gastric aspirate, the literature talks about pH of the gastric aspirate and x-ray, the radio peak line that is on the tube but none of those are fully confirmatory. You are only getting two dimensions so the tube can be overlaying the stomach. That is one of the risks of intraperitoneal placement that you just want to be aware of. You talk to your patients and families about that. One thing I tell providers when I am teaching this procedure, if something goes unexpected or you can't get the tube out, you just stop and you may need to go to the ER and prepare the patient and family for that. Do you have anything different to add about that, Paul? Thanks for those comments. They are great. I think that is one of the reasons in the video we talked about if the tube was placed recently that there has not been an established track. Therefore, we recommend that the tube be replaced either endoscopically or through interventional radiology to make sure that the placement is correct. Of all the procedures that we are going to teach this afternoon, this is probably the easiest one. It is so easy that we have taught many of our caregivers to do them at home. They don't even need me. You mentioned the ER thing. Tom knows who I am talking about. Imagine the hassle of transporting a quadriplegic to the ER during COVID, the cost, the ambulance, if you are under value-based care. I can do this at a fraction of the cost compared to the emergency room. This is a relatively straightforward procedure. It is essentially a catheter that goes into the stomach. I think many of us, after seeing and doing a tube, will feel pretty comfortable doing this at home since many of our caregivers do them already on their own. I remember, Paul, when you happened to be on call on a Sunday and one of my patients called that the G-tube had fallen out. On your way home from church, you stopped by and replaced it because, as you both said, all the stuff was in the home. We leave replacements there and stuff like that. The only other comment I would just say is, and it is nice that this picture is up as this syringe is pushing fluid into the balloon, sometimes, especially if you have a lure lock syringe, you actually cannot push it in far enough to break the seal of the valve that is in here. Sometimes, if you go to pull out the fluid and nothing comes out, that is either because the balloon is broken, and a lot of times they stay in even if the balloon breaks, but it also could be that the valve is not working and you are not able to pull out the fluid. What you can just do is you just cut off that valve, and then all the fluid comes out, and then you can just easily pull it out. It is just the only other little trick. Sometimes, I have had a hard time getting the fluid out of the balloon. Last thing, for what Michael said, in terms of the concern about not being in the right place, I do not know about you guys, but I have never heard, if it really has an established track, I have never heard of it being misplaced. I will just tell you, when you usually put these things in, make sure, as you can see, the caps are in place because I have forgotten at times. Gastric juice just comes flying out of it. It is pretty clear that you are in the right place, and that I would not overly worry about, but yes, Paul, you were going to say? Yes. Yesterday, we talked about when to refer to a specialist. I highlighted there is that line between being confident and cavalier. I cannot teach you that necessarily. It is based on experience, personal disposition, and so on and so forth. I see the comments there. Action plan, that is great in case there was a dislodgement, what to do. Maybe this is cavalier. Tom mentioned this patient. I had to go back recently. The mom could not get the tube back in. She has been doing it for years. The tube accidentally came out. She could not get the tube back in. She is begging for help. She does not want the circus of the ER. You get 911, all of that. I got there and tried to put it in. I could not. Maybe it is a little cavalier. Maybe it is trying something. What do we call it in home-based care? MacGyvering. I took an ear speculum. I put it into the tiny opening. I was able to force it through and basically used it as a dilator. I used that. After using that, I was easily able to get the tube back in. After mom saw me do that, she said, can you give me a couple of those ear pieces? Again, there is a little bit of a nuance here, a little bit of adventurism. Certainly, I do not want to hurt my patient. Michael is absolutely right. Mom, do you want to take him back to the ER? She absolutely said no. You are going to do your best to provide great care. The mom was just absolutely thrilled. We get to do this day in and day out, make a difference in our patients' lives. It is just simply amazing. I love that reminder of why we are doing this. Brianna, we have some slides here for you to cover on coding for G-tube changes. We can skip forward to the actual coding ones. I believe we included the internal nutrition coverage just for awareness on what Medicare covers and not. The only thing I will say from a practice management standpoint, and I think the other faculty already highlighted this, the importance of the patient having the supplies in the home as well as using the same DME vendor that they get their internal nutrition and their G-tube from. If they are different, it can sometimes cause coverage issues, which causes supply delays. Just helping to educate your patients on that. There may be a reveal on this slide, or maybe it is not. Here is the CPT code. There is a CPT code that exists for replacement of a G-tube in the home. This one says not requiring the revision of the gastrointestinal tract. Can we go to the next slide? Sorry, it is just not the one I am thinking of. Here we go. This is what I wanted. This particular one, the code definition does say without imaging. It highlights it as straightforward. Remember, if you are billing an E&M service with procedures, in order to support that modifier 25, you want to show separate and distinct work. Maybe there was an issue going on with the G-tube where you are using a different ICD-10 diagnosis code because there was a complication that just came up during the visit and you happened to change it while you were there addressing all of the chronic conditions. Things like that just paint the picture for medical necessity. Bottom line is, there is coding for it to exist. Again, in a value-based payment structure, this fee-for-service may look a little different, but it is just really amazing the work that can be done in the home that can avoid unnecessary ER, hospital, super large expenses that you would be at risk for under a risk-based contract. Next slide. Again, this is fee-for-service, which is showing you the reimbursement and the RBUs. All right. That brings us to TRAIC. Any remaining questions or comments on G-tube? It was probably in the slides, but there is, just for learners, there are slides that talk about what are the requirements for qualifying. It has to be that you need it for sole nutrition. It cannot be that you need a supplement. You have to be very careful about that. You can't order two cans a day because that will not be suggestive of it being the sole requirement. There are also slides on if you need a pump and what qualifies for you to have a pump versus doing gravity feeds. That is in the slides, I believe. Yeah. I think that may have been some of the slides that we went through quickly at the beginning. Yep. That is what I am just saying, just so people know. That can be helpful just in terms of some of those things that come up now and then. Great. I wanted to just call your attention to the fact that in your resources in the HCCI Learning Hub, you have for each of these procedures the step-by-step resources. I know Margaret put something in the chat to remind you, but it kind of goes through everything that we go through in the videos, the equipment, step-by-step, chronologically about the procedure itself with some images. This is a good teaching tool as well if you are going back to your practice and you want to share that. We have the videos. These individual videos will be available in your HCCI Learning Hub as well. We have some notes about billing in there as well. What we shared with you about billing is a little bit more updated than what is in your sheet here, but you get the idea. Without further ado, then, we will just move on to our trach video. Give me a sec here. Hello. I'm Dr. Paul Chang, Senior Medical and Practice Advisor for the Home Center Care Institute. Today, I will be demonstrating how to change a tracheostomy tube. Please note that I am not wearing PPE for the video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during the visit. This, of course, applies to the current COVID-19 pandemic. You can also consider training caregivers and family members to perform this procedure in case of an emergency. This can help avoid costly and unnecessary visits to the emergency room. Please adhere to your own practice guidelines if you do so. You'll want to first gather the equipment and supplies for the procedure as listed in the course materials. I will now walk you through the procedure step-by-step. Wash hands with soap and water and dry with paper towel. Ideally, position the patient supine or semi-recumbent and at a comfortable height for the provider. The provider should stand on the side of the patient that is most comfortable for the patient. The patient should stand on the side of the patient that is most comfortable for the provider in doing this procedure. Make sure there's good lighting available. The patient's neck area should be free of any clothing. If needed, suction the patient prior to the tracheostomy tube change. Place sterile field, usually glove packaging, on a clean table and place the new tracheostomy, obturator, tracheostomy tie, inner cannula, dressing, and water-soluble lubricant on the field. This is the point where you put on gloves, mask, and eye protection. Prior to insertion, examine all components of the new tracheostomy tube for defects and inject air into the cuff to test for leakage. Insert obturator into the tracheostomy tube and put a small amount of water-soluble lubricant on the tip of the tracheostomy tube and you can set the new tracheostomy tube aside. Remove the tracheostomy ties. As well as the dressing. Place the new tracheostomy tube on the patient's neck and place the new tracheostomy tube on the patient's neck as well as the dressing and clean the area with a clean washcloth if necessary. Prior to removal, deflate the balloon if the current tracheostomy tube is cuffed. If applicable, disconnect the ventilator tubing from the tracheostomy tube or remove oxygen mask over the tracheostomy site. Using a curved motion, remove the old tracheostomy tube and discard. Take a light and examine the tracheostomy tube site for any kind of granulating tissue ulcer, redness, or debris. Clean away any debris or mucus that might be present near the stoma. Now you're ready to insert a new tube. Now there are two ways we can go about doing this. One way is to use the curved motion directly down into the trachea. Note that there may be mild resistance as the balloon passes through the stoma. Do not advance the tracheostomy tube if there's market resistance is noted. If this occurs, remove the tube, reposition the patient, such as tilting the head back. Inspect the tracheostomy site, then attempt again to insert the tube. It may be helpful to rotate the tube 90 degrees, then slowly rotate back to a neutral position as the tube is advanced. If unable to insert, the smaller tracheostomy tube should be inserted instead. Remove the obturator once the tracheostomy tube is in place. Note, obturators should be available if the tracheostomy tube becomes accidentally dislodged and reinsertion is necessary. Insert the inner cannula into the tracheostomy tube and lock it into place. Tracheostomy field. Click as you secure the cannula to the tracheostomy tube. Inflate the tracheostomy tube cuff with the appropriate amount of air. This is typically what the patient caregiver has found to be most comfortable for the patient and preventing any air leak from occurring. Reconnect the ventilator tubing or place oxygen mask back over the tracheostomy tube. Wipe off any mucus or blood surrounding the area with a clean gauze. Secure the new tracheostomy tube with the new tracheostomy tie. Sometimes this is the trickiest part of the procedure because the opening on the neck plate can be small and challenging to find. And again, patient might be gagging and moving because we are irritating the trachea with this procedure. Do not secure the necktie too tightly. You should be able to insert one finger breadth underneath the necktie. Place gauze underneath the neck plate of the tracheostomy tube. If needed, suction the patient post-procedure. After the procedure, assess respiratory status, oxygen saturation and evaluate for any discomfort. Dispose of all used material in a trash can. Document the procedure including the type of the tube, lot number, expiration date. Order a replacement tracheostomy tube for the patient to have at home in case it is needed. Order replacement intercannula for the tracheostomy tube in case it is needed as well. If the provider is unable to insert the tracheostomy tube into the stoma, the following should be attempted. Reposition the patient. Try to insert a smaller size tube into the trachea opening. If the above is not successful, cover the stoma area and place face mask of the manual respiratory resuscitation mask over the patient's nose and mouth and give one breath every five seconds. Call 911 and begin CPR. Here are some additional considerations. While there are other procedures that can be done by a single provider, the tracheostomy tube change is one where an extra pair of hands is beneficial. The first tracheostomy tube change after initial placement, defined as three to seven days post-procedure, should be done in a hospital or other controlled environment due to increased risk of complications. There's currently no consensus recommendation for the frequency of tracheostomy tube changes. However, one study recommends tracheostomy tube change every three months due to biofilm formation on the tracheostomy tube, which may affect the integrity of the tube. I hope this video and practicing the procedure will help you gain confidence on how to safely change a tracheostomy tube in the home. Thank you for watching. Any comments, questions? Thanks Tony. No, I'll keep my day job. I don't have an agent. It's always scary to see myself on the big screen. I just can't get over, maybe I need to get over that, but it's just like, oh, good grief. Believe it or not, there are family members who do this, just like the G tube. They do this on their loved ones at home after some practice and teaching. This is obviously a more risky procedure. It still gives me a little bit of palpitation when I do this. I think I'll just highlight a couple of things. Extra pair of hands. It is so, so important. I do not think, well, I personally would not do it just by myself. Either a medical assistant or family member who can be there to assist you, I think is really important. And the other is preparation. Get all your stuff ready. Have all the equipment ready and then walk in your mind. I'm like, this is what I'm going to do. This is next. This is next. And have everything in place. And the final thing is, I think the hardest part actually is getting the necktie, that little Velcro piece through that. You see the neck plate right there? Those little holes. That's probably the hardest part because anytime, as you can imagine, this person's got a plastic piece in their throat and I'm messing with it and trying to get that Velcro piece through that little opening and the patient is gagging, coughing, the tears are rolling because it's just so uncomfortable. So I think that might be the hardest part. But I'll stop there. Any questions? Paul, regarding the necktie, did you see Tom put something in the chat that says he usually puts the necktie under the neck at the beginning of the procedure so it's already in place? That's helpful. Very helpful. The other is, if you take a, if you, if you, I wish, I don't have the demonstration now, but as you can imagine, the Velcro piece, the little white strip, prior to the procedure, if you can just bend that, bend that tip a little bit, make it curl up on both sides so it will make that insertion a little bit easier. It's more like a hook rather than just a flat piece of fabric that you're trying to make it come, you know, thread it through that little opening there. So that's another little tip that I've learned. I'd often have the caregivers who are used to doing that kind of do it as I would kind of hold on to the trach. And that's a part where you said having another person to help. That's one of the things, if they're used to doing it, I would just have them do because you need kind of forehands to do, you know, when the trach's not tied down to get all that stuff done. So I agree, Paul. Well, yeah, go ahead. And if you have, if you have questions, go ahead and put those in the chat for our faculty. But Brianna, do you want to talk about, we have one coding slide for this. We do have just one coding slide because this is one where coding hasn't really caught up to innovation, I would say, yet in the home. There is a CPT code that exists for the trach tube replacement. When I had to go down a rabbit hole because some practices were getting a denial for this, kind of got clarification that because the code that exists has that prior to the establishment of the fistula track, it's really not appropriate for the kind of more routine changes that we're doing in the home. I would say the caveat to that, again, in a value-based care setting, like we've been talking about throughout this workshop, this really matters a lot less. I think the reimbursement ends up only being like $30 or $50 for this code anyway, so don't feel like you're missing out on a bunch. But definitely, number one, consider the additional time and complexity towards how, you know, either medical decision making or extended time if you are in fee-for-service on what you're having to do to care for that patient. And you could make an appeal to the MAC, your local Medicare administrative contractor, if you were really worried about this in fee-for-service, and give them a clinical documentation example and see if they would pay for it for you. But just wanted to highlight that this is the current coding that exists today, and it just really hasn't caught up to the innovation of doing these things at home. And that can be said for any of the procedures. Sometimes you might have payers that are just like, you're doing, you know, you might get denial. So, appeal it and work with them, but usually it's not too much of an issue, but with the exception of the trach change. Two quick comments. One is money, and one is care. Thank you, Brianna, for clarifying that. And you're absolutely right. Under value-based care, this might be, we'll probably look at all the procedures very differently, right? Your wounds, you don't have to send out, you don't have to pay a specialist who, maybe the specialist out of your network for a knee injection that Dr. Cuomo is going to talk about or for a G2 change that, you know, you send out, you know, ambulance to a GI doc. So, there is a money side to this, but there's also a care side. You know, again, this is what Amanda and I talked about. This is the soft part of medicine. Ultimately, we're dealing with people and their needs. This is a chance for us to make a difference in their lives. Tom's going to talk about relieving pain in the knee and so on. It's almost like, what's an analogy? I'm almost like being an interventionalist at home, bringing pain relief. You know, probably Tom has tried all kinds of stuff, you know, for the knee pain and nothing's working. So, what other interventions can you bring to the home to help relieve the pain and suffering of this patient? Tom's going to demonstrate the knee injection that could bring pain relief. You know, similarly to say, if our patient's pain is not well, cancer pain from pancreatic cancer or colon cancer, and you send them to say, to get a celiac axis blocks or a hypogastric block for pain relief. So, it's similar in the sense that we are there, we have the opportunity to make a difference and relieve pain and suffering for our patients. So, payment on one side and care and patient care on the other side. Very well said. Thank you. All right. So, our third procedure, knee joint aspiration and injection. So, give me a minute here and I will start the video. Hello, I am Dr. Thomas Cornwell, Executive Chairman of the Home Center Care Institute. Today, I will demonstrate how to aspirate and inject the knee joint. Please note that I am not wearing PPE for this video to make it easier for you to hear the instructions. However, you should follow all infection control guidelines and use appropriate personal protective equipment during your visit. This, of course, applies to the current COVID-19 pandemic. You want to first gather your equipment and supplies for the procedure as listed in the course materials. So, I will now walk you through the procedure step by step. Before starting, counsel the patient and caregivers on the risks and benefits of the procedure. A consistent and thorough way of doing this is by having the patient read HCCI's pre and post steroid injection instructions or by going over it with them. This useful HCCI patient resource describes the procedure, the risk and the benefits, the contraindications, and the post-procedure instructions. It can also serve as the written consent by having the patient sign it. Verbal or written patient consent needs to be documented in the medical record. A patient safety check should be done prior to any procedure to verify patient identity, the correct injection point, and the medication being used. I always have someone verify any injection I give, whether it be a steroid shot or a flu shot. This is often done by my medical assistant, but if alone, I will have the patient or caregiver read the label to verify. Now let's wash our hands and get started. Injections can be given lateral or medial and superior, mid patella with the legs straight or inferior with the knee bent at a 90 degree angle. We are going to demonstrate the most commonly used superolateral approach. It is preferred because, as you can see in the diagram, it provides easy access under the quadriceps tendon and patella. It is good for both aspiration and injection, and there are no other structures in the area to be concerned about. For the superior lateral approach, the patient should be in a supine position with the knee in a slightly flexed position at about 15 degrees. You can use a roll-up towel under the knee and cover with a disposable under pad to prevent stains. After putting your gloves on, mark the injection site one centimeter above and one centimeter lateral to the patella. You can do this by imprinting the pen in the area. Clean the injection site with three povidine iodine or chlorhexidine swabs, applying each swab in a circular manner, starting at the injection site and circling out. Wait a minimum of two minutes. Wipe the medication vials diaphragms with alcohol. Draw up a syringe of corticosteroid and 4-6 mLs of an anesthetic agent. If local anesthetic is desired, you can apply 3-4 mLs of an anesthetic agent to the injection site and along the anticipated needle trajectory. Alternatively, ethyl chloride spray can be applied from 6 inches away for 5-6 seconds. For aspiration, use a 10 mL empty syringe with an 18 or 20 gauge 1.5 inch needle. A 20 or 30 mL syringe can be used for larger effusions. Insert the needle, bevel up at a 45 degree angle distally and inferiorly under the patella and aspirate effusion if present. Compression of the opposite side of the joint may aid arthrocentesis. Once the syringe is filled, a hemostat can be placed on the hub of the needle to disconnect the aspiration syringe, then connect the corticosteroid syringe and inject into the synovial space. If no effusion is present that needs aspiration, the corticosteroid filled syringe with a 25 gauge 1.5 inch needle using the same technique can be done. When the aspiration injection is complete, withdraw the needle and apply pressure to the site with a 2x2 gauze. Clean the prep area with alcohol wipes and cover the site with an adhesive bandage. I now have my fluid in here. You have to check with your lab, but you want to send the fluid for gram stain and culture, RBC and WBC and differential and for crystals. You need to check with your lab which tubes they like. They usually want a sodium heparin green or a lavender tube for doing the test and you can use either a urine cup for the gram stain and culture or you can actually just send them the syringe without the needle on it. Depending on the cause of the knee pain, the local anesthetic should provide immediate pain relief which confirms the steroid was placed in the correct area. Prior to performing a knee aspiration or injection, you need to determine if there are any contraindications. Contraindications include infections such as bacteremia, if a septic effusion is suspected, overlying cellulitis or osteomyelitis. A severe coagulopathy is a contraindication, but being on warfarin with a therapeutic INR is not a contraindication. Injections also appear to be safe for patients taking direct-acting oral anticoagulants. A retrospective study of 1,050 joint injections at Mayo Clinic with patients on direct-acting oral anticoagulants did not have one bleeding complication. Other contraindications include having an osteochondral fracture, impending joint replacement surgery scheduled within days, a prosthetic joint, or poorly controlled diabetes. Patients should also not have more than three injections per year. Potential complications include rare iatrogenic infections occurring in only 1 in 14 to 77,000 injections. Hyperglycemia can occur especially with patients on insulin, and patients should be told to monitor their sugars closely for one week. Steroid flare occurs in 2-10% of injections and affects women more than men. It is caused by a steroid crystal-induced inflammatory synovitis. To treat, the patient can apply ice for 15 minutes every 3-4 hours and take acetaminophen or ibuprofen for pain. The steroid flare typically resolves within 1-2 days. Patients should call if not better in 2 days. Finally, facial flushing has been reported in 1-30% of patients. One of the things that I really like about this model is the needle is connected to a box here so that when I go in, it tells me, and this way I can have you do it 10, 20, 30 times if you'd like, so that you really know when you're in the right spot, so then you feel comfortable when you actually do it on your first patient. I hope your participation in this video simulation will help you gain confidence on how to safely perform a knee aspiration and injection in the home. When the injection is successful at reducing pain, not only does it improve quality of life, it also helps the patient be more functional while also being a blessing for the caregivers. Thank you for watching. Okay, any questions? I really don't have much to add. Just kudos to HCCI for developing these videos. Or maybe I will just say that the majority of these injections I did were actually in people that had had them before. Most of our LE patients, it's kind of bone on bone, and there's not a lot that these injections do. Sometimes they do. And so if I give them one and the pain is relieved for a couple months, great, I might do it again. If the pain is helped temporarily, but within a week or two, the pain is back, I usually don't, I try to get them to agree not to have them. There was a study that was done, published in JAMA, it's probably like five, six, seven years ago, that actually showed harm done if more than three of these steroid injections were done, knee injections were done a year, more than three. So four or more a year, there was actually a reduction in the cartilage. And so it is a temporizing thing, obviously, but you know, sometimes again, if it can help them be a little bit more functional, it really is a blessing. Any questions? I just asked Melissa, and she just replied that these videos are available to you learners, even after this, if you want to watch them again, I mean, the ones that Paul did, I found that especially the G-tube, I think that is the one in all these that, well, all of them are helpful, but I think the G-tube and the trach is by far more that is done than these knee injections. And the G-tube is just so simple. As Paul said, the trach can be a little nervy when they're vent-dependent, a lot of times people that are on trachs are not vent-dependent, and there you don't have to, you know, worry nearly as much, but I'll just stop there. Again, any questions? Tony Perry asked, do you do shoulders as well? You know, yes. And the reason why we don't teach that is, you know, even in the best of hands, orthopedists that do it all the time, when you look at the studies, they could miss 25 to 30% of the time. Ideally, you do ultrasound guidance for the shoulder. And so, you know, yes, you know, I definitely have done them, but it's not something that we teach for that reason, if that answers it. Oh, and yes, I have done, and not very often, but I'm thinking of one right now in the Western suburbs that she definitely had hip pain, it was isolated. And again, we don't, it doesn't come up that much, but it is super easy because, you know, it's just pain at the, at the bursa there, at the greater trochanter, which is very easy to palpate. You just, and the pain's right there. It's very superficial generally, and I have done that also. And Samantha asked about, you know, ordering the meds, do you do that from the pharmacy or how? Brianna, do you want to, you know, and so we, you know, we would just, because this was things that we would do regularly, you know, we would, it'd be like we order our flu vaccine, our pneumonia vaccine, our Benadryl just to have on hand for when we do our, you know, IM Benadryl just in case. And we would have Epi just in case during flu season and, you know, that we'd be prepared if they had a bad reaction and then you'd give it to them, the Epi and the Benadryl and then call 911. But we would just kind of order all that stuff. We would have Kenalog, that's the one that we used, 40 milligrams per ML, and you'd usually would give a half or one ML depending on the joint, along with the Lidocaine is what we use. And all that would just be ordered by our Brianna back then and, or whoever did orders for your practice. Does anyone have experience? I didn't even, you know, you know, I'm not, so I'm not experienced like actually ordering Kenalog directly from a pharmacy. Yeah, it would generally depend on who your supplier is, like, you know, who you get like actual medications for, like immunizations and things from, so I don't know that there's one right, you know, answer, but you, you know, like, there you go, Medline, again, it's not like your Walgreens or your CVS, right, you're not gonna be ordering Kenalog from them. It's your supplier that you would most likely be getting other medications from. They have refrigerator temperature considerations too, so, you know, if you are going to be doing procedures or injections or even giving immunizations, you would need to make sure that your practice is actually set up from a temperature log and, and that, you know, to actually store it. But Melissa, if you go to the coding slide for joint injections, it has the example J code for the medication. The other thing I'll say about the medication is if you're doing these and you're not billing for the medication and it's a practice expense, Amanda's probably laughing when I'm saying this, it's expensive, so you should do some internal auditing if you're billing, if your practice is purchasing this so that you can do it for your patients and it's actually not getting billed out. So, again, the 2610 is for that major joint, which would include if you were doing a knee injection or a shoulder injection. Again, if you're going to the home and you're doing this in combination with an E&M visit, we just always want to make sure the documentation supports two separate services, right? If you're just stopping by on your way home, you're on call, you'd just be billing for the procedure because that includes some pre and post work. Generally, just avoid putting it in your chief complaint if you're really, you know, it's kind of an add on, you're doing a full comprehensive in-home assessment like you normally would and then you also do the injection. Again, remember procedures need that kind of separate procedure note area in your documentation that says you explained the risks and benefits, you know, you got consent, there should be more elaborate documentation to support billing for these procedures and then I believe we have one slide just on the reimbursement for it, but anytime you're doing, you know, a procedure and something else, usually that's when that 25 comes in and just by definition it means that it's separate and distinct than the other service, so you just have to support that by your documentation. Yeah, McKesson, another huge one. There's lots of vendors out there, you just have to make sure your practice is actually set up to have everything needed from a practice logistics standpoint to perform and store these kinds of medications or immunizations. Yeah, and I think the video touched on the patient instructions pre and post, but Tom, I don't know if you wanted to share anything else about how you use this, you know, as sort of a signature form. Yeah, you know, my screen is blank. Can you guys actually see me? Yeah, we see you. Yeah, so I actually kind of created, you know, the information onto a one-page document where they can actually sign in the bottom and so again, it gives you like an explanation, if you can see this, an explanation, it gives you, please inform your provider if you've had any of these problems like allergies, like the contraindications, and then it gives post instructions, but by what we do is have them sign, I would take a picture of it as a scan for into the chart, and that way, not only did they get this full instruction, but also it serves as your consent form if you want to have one in the chart that you gave them all this information. It's a wonderful document. Yeah, so we have this document. It's not set up as a consent form. It's just a PDF, but what we're saying is you can convert, you know, the information here into a consent form, so. Yep. All right, so let me do that. And there we go. All right, so key takeaways. I don't know, you know, we covered the G-Tooth. Do our faculty want to say anything as we end this session? Yeah, think about what you're comfortable with, and we're not telling you you have to do all these procedures. You may be very comfortable with knee injections and so on, so go ahead and master that, or you may want to venture into, say, gastrostomy, too, because it really is not that hard of a procedure. We're here as a resource to help all of you and all of us as we venture more and more into value-based care, right? We want to be able to help our patients, give them quality care, and not adding to cost. Very well said, Paul. Next slide. All right, here's our Q&A and wrap up. You know, the last slide I think I have is just on reminders, but Paul and I know Brianna, you had a comment, too, so. Next slide, please. Yeah, Melissa, can you advance to the next slide, please? Okay, I think that's, yeah. It's really important. Think about, take a minute either now or when we're done to fill out and complete your learning plan. It's really helpful, I think, for your learning and also for us. In terms of, you know, Amanda said we not only, yes, we're faculty and we teach, but we learn from you and we hope you're learning from each other. And I've said before that in a class, oh, what is it saying? You get information from a lecture. You get wisdom from a community. So I hope that this is a community that you can rely on and come back and visit and visit with each other to get ongoing learning and tips on how to MacGyver things. Don't forget your CME credit. We're going to send that out to you by email. And please, please, we value your input. We so value, we want to make this better and better each and every time. So take a minute and give us a thumbs up or thumbs sideways regarding, you know, how we could potentially do better. And I just want to thank you on behalf of all of our faculty. Thank you for trusting us with helping you and trusting us with your time. I think, you know, we're all so busy. We're busy people. And you spent two days with us. And I know all of us hope that it's been time well spent, that you were able to get the information that you need to help you as you venture into a whole new world of value-based care for many of us in medicine. And often I close with a story. You know, we've hit you a lot with, you know, data, contracting, you know, DCE and all these hard stuff. But I'm going to come back to the soft stuff. Because I think many of us, we went into medicine to help people. It's the soft stuff. And just have these stories ready. You know, a couple of weeks ago, I was with a patient who's multi-complex. You know, CHF, CKD, all the stuff we talked about. She's a typical one of those patients with dementia and so forth. And as she was declining, and, you know, we were trying to help the daughter navigate goals of care, the next step, and so forth. And during the, you know, she was certainly declining. We were planning for contingencies and so forth. And on a follow-up visit, you know, I went up to their backyard, their sliding door. I opened the sliding door, and she just came, and she just hugged me, and she just started to sob. And I'm getting teary, just reliving the story. And I was tearing up, and my medical assistant, we were all tearing up. And she just hugged me for, I don't know, the longest time. And, you know, when she let go, she said, you know, thanks for being here. I don't know what I would do without you. Okay. It's not about me. This story is not about me. It's about all of us. Have these stories, you know. Tell your payers what are they going to do without services like this at home. Okay. Have the data. Go after the, you know, the emotion. You know, we are service. We're mission-oriented people. We need to know our numbers to be sure. But collect these stories. Share with the people who will give you two minutes, five minutes, and make a difference in the lives of their patients. So that's, any other comments from other faculty members? Brianna, I know you had something to add. Now, I like, after that tear-jerking story, it's like, yeah, that should have been our closer. But just a couple words of encouragement. Thank you, Paul, for that. I don't think there's ever a workshop that I'm almost not tearing up from the patient stories from just all of you. And again, to Paul's point, you all have that. I mean, you really make such a huge difference. So honestly, just thank you all for being here and the work that you all do. But as a words of encouragement, as we've talked about, you know, through value-based care at U and how hard these relationships can get, I had heard a kind of an exciting update. There was a practice that HHCI was working with just to offer support and guidance and try and help them sell this to some C-suite. They were a long-established house-call practice in the Texas area that was affiliated with an ACO. And they were trying to kind of make the case to the ACO on why, you know, they should give them a shot and help out with more patients. And it was probably a good six months to a year that this practice went back and forth with, you know, talking with them and then having them look at the data. But when the data did just finally come in there, now the ACO has had this independent house-call practice put in front of a health system to start taking on house-call patients. And then they want a public and academic paper on just the success because the numbers from the small pilot, they started with a very small pilot of patients that the ACO gave them to take care of. And the outcomes were just so fantastic from giving these patients home-based primary care that it turned into a really awesome, exciting opportunity. So just thought that was kind of a fun and exciting story to share that, again, there are opportunities out there. Thanks so much. And, you know, we're aware that a lot of you are nurse practitioners, full practice authority MPs. I know Sarah Brubacher asked, any advice on handling consulting relationships with physicians for writing Schedule II drugs? So, I mean, either our faculty or other MPs on the call? Yeah, I'll just say that, you know, so the American Academy of Home Care Medicine, as well as HCCI has really been supportive of full practice for APPs. It has been frustrating. I'm thinking of one in Florida that it was just very upsetting that even to get home health orders signed, she was spending, I think it was 25 or 50,000, Brianna, you might know who I'm talking about, you know, just to have these signatures that, and, but so they're really, you know, you have to, you know, have that relationship. Oftentimes it does cost, you know, money, and they have to feel comfortable signing narcotics for patients that they are not seeing. And so there needs to be that relationship, but it usually is a financial relationship with a physician that is willing to sign documents for you. Tom, I think my favorite one, I was telling this joke yesterday is the home practice where the NP is married to a physician. And so I just gave that advice. It's just marry a physician and it's a lot cheaper. I've got another one like that, but I'm not going to, yeah, exactly. So yeah, we're not, yeah, strike that from the, yeah, in the recording. Michael, I think you were going to chime in and I'd be open. Obviously as a practicing NPR experience, I was just going to say, be resourceful too. I've heard of lots of NPs being super creative and okay, but this is really how much time or this is, you know, building that relationship, all I need from you. And then they're able to work out more fair arrangements or check with your NP society. Sometimes they have negotiated if you're a member, lower cost rates with like a collaborating doc organization that that's all they do. So be resourceful. Yeah, that's all I had. Everything I was going to say, Maryland's full scope. But it's kind of like Paul said, building relationships in the community, check with your state NP association would be kind of where I'd start. Yeah, I've met at least one NP who barters and you know, she'll do some on-call hours for the physician in exchange for that collaboration. And I would just have a good program in place where you can show them that you are doing contracts and you are doing, you know, appropriate drug screens as appropriate. And you are checking the state's, you know, drug list in terms of where they're getting things, you know, that so that they can feel comfortable in terms of that. You can say, look, I already done all this. You know, this is appropriate. You know, please, please sign it. All right. So Amanda, other than saying marry a physician, if you're an NP, did you have any other final closing remarks? I want to give you a chance. I did. And it's easy because I'm not, you know, an employee of HCCI, but what I always love about these is, is the conversation doesn't end and there's so many resources at HCCI and there's so many different ways to learn. And, you know, there's so many things you have access to now, you know, and I think one of the biggest things you have access to is kind of a network when we first started teaching. And even today, usually we hear something like, oh, I feel like I've come home. And I love hearing that, hearing that and that feeling. But the support, again, doesn't stop. HCCI has tons of resources. The Academy has a lot of resources. We sent out that yesterday. And so, you know, keep, keep digging in and keep asking for help. There's, you know, HCCI can be reached out to and said, you know, everybody was doing this and they do, right. They know someone and they can connect to you. So, and thanks for a fun two days. All right. So let me just kind of wrap everything up. We did the motivational story, like why we do this and our patients and, and reminders about completing your evaluation. We take those super seriously. You're going to get information about that very shortly. And it's important for, you know, if you're planning your CME, CE credit. One more plug for Illinois House Call Champions. You have a full day training in person in Schaumburg on Friday, August 19th. Please register for that in our HCCI Learning Hub. If you have trouble doing that, contact Sarah or email us at education at hccinstitute.org. We really need to know if you're coming. And I, I think that's it. I want to thank our faculty who are absolutely the best in the business and we just cannot do this without them. So thank you to all of the faculty. Thank you to the learners for giving your time and your expertise and your, and, and your, you know, sharing your, your experiences with us. So until we meet again, have a wonderful weekend. Thank you, everybody. And Melissa, if I can have one more ask being on the board of the, of HCCI, you know, we have amazing donors that have enabled us to get to this point, enabled us to have all these free resources on the thing. And, and we want to hear, you know, what, what we can do better. But if this was really helpful to you, I can tell you in virtually all board meetings, we have some quotes from our learners. And so if this really was special, one of the things that you can kind of, you know, do for us is, is really let us know so we can let our donors know they love hearing that, the impact that we're having. And so that's just my last little ask, but just thank you so much for participating in this. Thank you. Okay. Thank you, guys. All right. Have a wonderful weekend. Bye-bye. Bye, everyone. Thank you. Bye.

productivity

staffing

value-based care

home-based primary care

patient population

quality metrics

expectations

data tracking

staff well-being

resource identification

payer contracts

patient identification

cost of care

aquacel dressings

ICD-10 coding