About three hours ago, I was in a living room talking with an exhausted caregiver. He's taking care of not only his wife, who's got dementia, heart failure, now diagnosed with cancer, and he's taking care of mom in her 90s with dementia, heart failure, diabetes. And I was in the living room, and he just looked utterly wiped out. And because of her cancer, she's having increasing needs, increasing symptoms. How do we manage her symptoms of weakness and having more shortness of breath? How do you tackle that? How do we, as a team, help this poor caregiver who is really struggling to take care of wife and mom? The story is exactly, this journey, the next hour or so, it really highlights what can we do to help these patients at home with these complex needs, with increasing need of symptom management, and supporting the caregiver? How can we do it well? And you'll see it on later slides. It's about envisioning this full service model of care. So let's start by talking about what is home-based primary care, and how does it help patients with serious illness? It's a model of care that brings providers with modern technology into the living room to improve the quality of life of the patient and, of course, their caregivers, just like I showed you in a real-life case from three hours ago. We want to give them great care. We want to keep them at home, keep them out of the hospital and their nursing home and the emergency room. They don't want to go there. And we're going to do our best to keep them at home. And with all of that, we can really reduce the cost of medical care without compromising on quality. The quadruple aim, it's an expansion of the triple aim that talked about better outcome, improving patient experience, lowering the cost of care, and also improving job satisfaction for provider and staff. Because over the past year or two, with the COVID, with the great resignation and the hiring challenges, you've all heard this, the burnout and so on. It used to be said, what, no money, no mission? Now you can say, no staff, no mission. And we know, and I've lived this, and I talk with other practices locally and around the country, home-based medical care is an outstanding way for providers to have that sense of fulfillment. They're more than just data entry person at a laptop. You really have the opportunity to engage and talk and be in the moment, be in the experience with your patients and their loved ones. So is home-based primary care like one block? I'm with Northwestern, is that the only model? Well, you know the answer. It's not. I'm part of an academic medical center, but there are multiple other ways that home-based primary care can exist, from a community hospital, independent group practices, and I know they're out there today, VA operates a very robust and a long-standing house call program. They can be an extension of a hospice and palliative care organization, which we can talk more about today, and also, as Melissa said, in the additional series that are to come. And also, as we get into value-based care, they are also looking for ways to maintain quality while reducing cost. So what are some of the clinical application or clinical models of home-based care? What I do is the second one, is the long- well, I shouldn't say that. I do a little bit of both. We do longitudinal care. We provide oversight. Most of my patients are 65 and older, actually. We ran a study. I'm sure it will probably resonate with you from our internal data. We're about 82 and a half years of age, and predominantly women. About 66% versus the rest, men. But there are different models. There are other models out there that provides transitional care, short-term. I won't name any names, but they come in, for example, could be a post-hospital discharge patient where they come in and they do a transitional post-hospital tuck-in visit. It may be one, it may be several, to make sure that they're stable. And they often target those patients with multiple diagnoses and high readmission risks. Again, working backwards, this is pretty much what I do. Those with advanced illnesses, chronic conditions, and so forth. And they can take a lot of time in a PCP's office. We often talk about having an elevator speech. And James has talked about it in his writings and so forth. Having that speech that talks about the value that you bring. Whether it's for fee-for-service, whether it's under value-based care, whether you're talking to a care coordinator or the C-suite. In this case, I can help decompress the PCP. You know, access is an issue. We all know that. I can help decompress the PCP's office with these high-need, high-cost patients so that you have more openings to see the less complicated patients, therefore improving access. So that could be a talking point for you. So that's what I do. And then the other, as you can see there, again, it's about the transitional care, trying to reduce readmissions, those at high risk of readmissions. Any comments so far? Don't be shy. So feel free to just raise hands. Again, I want this, yes, I have a PowerPoint deck, but I want this to be very informal. All right. So why the interest in home-based care? What are the drivers behind this? Dr. Cornwell, our executive chairman, he published a white paper years ago that's been updated now. He talks about several drivers in home-based care, changing demographics, aging, the fiscal crisis of Medicare, the advancement in technology, and the whole COVID phenomenon, and the opportunity that we had, and having, to reimagine how we can deliver care outside of the brick-and-mortar hospitals. Patient didn't want to go there, right? Remember that? It's three years ago. I can't imagine, more than three years ago, where everything shut down, nobody wanted to go, we all huddled inside a house. That really was an opportunity. It really highlighted, it really supercharged the whole idea of house calls. COVID was horrible, don't get me wrong, but it really gave us the opportunity to shine in terms of what we can do for our patients at the location that they prefer. Aging demographics, none of this is going to be news to you guys, 20% of the population will be over the age of 65 soon, and that's 40 million additional Medicare-age patients. And we all know Medicare is in trouble. You can look at different people's projection on when it's going to run out of money or be in the negative territory. The surge, the number of people coming in, into the 65 years or older, are from at least two, possibly more. One is that we're living longer because of changes in advancement in medicine and so forth. Also the baby boomers that are aging into this particular group. When I was at a patient's house yesterday, they had the golden girls on, am I dating myself? So not all golden years are golden girls. This is what we see. Not everybody aged well, and those with complex illnesses, as they age, would add a complexity. The top 5% consumes over 50% of total Medicare dollars, and the top 1% uses nearly 80%. This is where we are targeting our work. We have an incredible opportunity to bend this cost curve here. Healthcare reform, again, not news to you guys. Going away from fee-for-service. I was listening to a podcast on a way up here. Again, it's about value-based care, about hospitals, providers taking on contracts with up and, in the future, downside risk. It's no longer a transactional kind of approach to medicine. It is now, yes, you do your medicine, you better do it well, you better demonstrate quality because we're going to dangle the carrot here, and we might take your carrot away. And we might ask for you to give me carrots if you don't do it well, right? And models, and I'll talk about just two studies, there are more. Models of home-based medical care have shown to be effective and cost-saving. And I already talked about the issue with Medicare that many of us are aware and concerned about. This is a study published in JAGS in 2014 by Dr. Eades. I met him at the American Geriatric Society in Long Beach about a month ago. He published this study way back when. And if you look at just the top line, you can say, oh, my goodness, look at how much more money the VA is spending with the implement of house-call medicine. You spent 460% more. But wait, if you go all the way down, take out nursing home, hospital, outpatient, adds up to nearly $9,000 savings per veteran when they had home-based primary care, right? Just think about that for a minute. That's a lot of money. Baby boomers, aging, $40 million, do the math. The Independence at Home Medicare demonstration, arguably the most successful primary care demo that CM has operated, okay? They looked at patients with chronic conditions, ADL deficiencies, hospitalizations, and this is the cost or the savings that was split between practices and Medicare. And they were looking for experienced practices and who had 200 or more patients. Year 7, that was just released in, I do believe it was in JAGS. Look at the savings per beneficiary per year. Again, that's a lot of money when you multiply by how many, not veterans, how many Medicare beneficiary who can really use this type of care against what they want, what they need, good quality, and saving money. What about a palliative care program, all right? Does that make an impact? This was a study from 2017 looking at palliative medicine and their impact on the ACO. Cost of care, last three months, and I'll talk about the last three months' data later on in the slide deck. Reduce the last three months, part A cost is down by over a third, part B cost down by a third, hospital admissions down by a third in final months, hospice admission is up, and the length of stay on hospice increased a lot, right? Is there a question? Yes? It is really hard to change the Titanic. That's a bad illustration, a large ship, okay. A couple of things, one of the four things that we do at ACCI is advocacy, so we do work with others, Halperion is one, we do lobby Capitol Hill, and there has been increases in reimbursement under fee for service. Having said that, does that cover our cost? You know the answer to that, it doesn't, all right? When you're talking about Medicare and payment, and in some ways it's a zero-sum game. If you increase payment for us, there will be decreased payment elsewhere, right? And if you're an orthopod or cardiologist, you're going to fight, right? So it gets very complicated in terms of reimbursement. I would love to see, yes, it saves money, absolutely, you're right. But when it comes to reimbursement and all of that, it becomes a much larger discussion than what you and I can obviously solve here today. are working on that, you see when we report the findings. It's very frustrating. I know. I agree. It's ridiculous, right? You're reading stuff as far back as 2017, and it's looking like we've been at it for 10 years. Do new models like ACO reach, give you access to more funding? Absolutely. So the other thing I was going to say is that from, so it's not all for nothing. For example, what we've learned from IAH is put into, for example, a primary care first model or ACO reach model. So the learning is not just evaporated like, oh, this is just all academics. We are extract, CMS is extracting information and trying to implement it in their new ACO payment models, whether it's ACO reach or primary care first or whatnot. So yes, there are different payment models that are available, whether it's a augmented fee for service, meaning you get a fee for service plus a management fee, or if you're getting paid per member per month on a different payment model. So if you're getting paid per member per month, then obviously there's more money for you if you manage your patients well. And the money that you have, for me, under fee for service, we're fighting for every dollar, $5 for smoking cessation, $10 for warfarin management and so on. But under a different payment model, you have more money coming in, and you can therefore use that money to either grow your practice, hire a social worker, hire a pharmacist or who can help you better manage the complex patient, and then thereby saving money, reducing your exposure to downside risk. Yes? I just wanted to say one thing. Sarah, I know from LinkedIn, I saw, was just in DC doing advocacy. And I don't know if you're involved with, you know, some of the, there's two foundations All of those groups are doing advocacy work. Dr. Chang, I was just going to mention, so I was in Washington, DC last week for Hospice Advocacy Day representing Illinois Hospice and Polio Cure Organization. And there was a lot of talk around a new piece of legislation, the Expanding Access to Palliative Care Act, which would direct CMMI to create a palliative care demonstration project. Now, I'm not sure how, and maybe you could give some insight to this, how home-based primary care would fit into that. I think I understand palliative care and hospice, where that fits in. But I am a huge advocate of home-based primary care. And I think we have to do a better job in time to continue them together from the time of diagnosis where we were at primary care all the way through end-of-life. And I think we're still, in some ways, in our silos where we have to do a better job in pulling all of that together. And I don't know if through combined advocacy with the demonstration project we might be able to move the bar up a little bit. But I agree. I've run two community-based palliative care programs. And the reimbursement is a huge barrier to program growth. Yep, and it's a huge barrier to primary care program growth as well. And later on in the talk, I will talk about the different models of delivery, whether it's a co-management model or a different approach in terms of how to take care of these complex and sick patients and so forth. I had a comment I was going to make. But oh, yes, one thing that we, so there's a payment side and models and management and so on. But also as providers, we ourselves need to clarify our lane. And we need to tell our, like three hours ago, I was in the living room talking with a patient. What's the difference between what you do? What is palliative care? It's huge. And how is that different from hospice? Your elevator speech has got to be ready for those. You can't sit there and then draw things, you know, with your toes in the sand. You've got to be polished and ready. Because if we're going to advocate for better payment, better service, and whatnot, you need to know exactly what you're doing, how you're doing. But what you're doing is similar and different from a palliative care service. And also what a hospice service provides. And be ready to dispel the typical urban legend of hospice care. Be comfortable with the M word, as I say. Morphine. All right. Be comfortable with the H word, hospice. Because people come with different ideas. They just give grandma morphine and let grandma die. We've all heard that. OK. Be ready to dispel some of the misconceptions that people have. Great comments. Anybody else? Well, your analogy about two canoes is actually wrong. It's two pontoons in the same boat. Two pontoons in the same boat? In the same catamaran. Oh, OK. Gotcha. Yeah. Thank you. I'll use that next time. Yes? I'm just curious. I mean, I don't know what anybody else, the accountable care organization, they're all set up and they're all going to save money. I haven't seen any ACOs save money yet. Does anybody else? There are ACOs and house call ACOs that have saved money. I'm not talking house calls. I'm talking just ACOs. ACOs have saved money. Yes. It is still hard business. It is still difficult to save money. It's not like you join an ACO, you drive a luxury European car all of a sudden. That's not the case. But there are successes story. And even in house calls, VPA would be. I was saying, we're starting out with ACOs and expecting to save a lot of money. It's been disappointing. Sure. Sure. We can probably talk about that in lessons two and three and so on, about how to structure it. What data do you need, such as your RAF score, your ACC score, how important that is for the providers to understand what that is, and for them to have a mindset shift. They need to link clinical diagnosis with the financial side of medicine. That's tough. I went to school to be a doctor. What is all this? But unfortunately, medicine is going this way. And I need to link part of our job, teaching, is to link clinical with the operational and the financial side. It will be hard to survive. Great questions. Anybody else? So demographics is pushing this. Technology, we all have smartphones. And we can do EKGs at home. You can do a point of care testing discussion apps to help with decision making, whether you use Hippocrates or MedCalc or Medscape or whatever. X-rays can be done at home. We don't have an iSTAT machine. That's what it is in the right upper corner there. We do blood draws, blood testing the traditional way. We draw blood, and we centrifuge. We spin the blood down in the car, and we send it off for processing overnight. So there's technology at home. And Melissa and I, and I don't know if Dana was there too, we were in Dallas showing our learners how to use a point of care ultrasound, or it's called POCUS, how that can help us with diagnosis and treatment of our patients. In particular, heart and lung related conditions. You can use POCUS to see if you have fluid in the lungs. Curly B, curly C lines. You can look at JVDs so much better that I don't know. I'll confess, I have a hard time doing JVDs at the bedside. I don't know about you, but POCUS can be a huge aid in terms of helping us making that accurate diagnosis. Does the patient need more diuretics or not? Is the shortness of breath from volume overload? Or maybe it's more COPD related. So technology is there to help us. And then the COVID pandemic, I talked about it already. Using telehealth, seeing, well, the patients, again, like what I said before, they didn't want to, many of them still don't want to go to the hospital, the emergency room. They want to be treated, diagnosed, taken care of at home, whether it's a face-to-face visit or by telehealth. For us, we use telehealth. When the COVID first hit, we did telemedicine for about a month. And then we went back to face-to-face, all geared up and ready for work. Because telehealth, telemedicine for us in our patient population, it was a good supplement for the care that we delivered. But it was not a substitute because of their complexity, of the symptoms, and the conditions that they have. I wish I could show you the picture. Two days ago, I did a telemedicine visit with a patient for follow-up after her fall. She's a longtime patient. She was 95. So we did a telemedicine visit. She had one of those birthday glasses on, really like an Elton John kind of thing. It was really thick rim. And it said, happy birthday on top. And she was so happy. She went out for the first time in like a year to celebrate her birthday. But then that's when she fell. The challenge with that video visit was all I could see was like nose up. And then she was laughing and giggling. I just said, can you turn the phone down a little bit so I can see your knee and your ankle? And it was like, how do you do that? How do you do that? So telemedicine was and still is helpful to a certain degree. But I only got to see her forehead for the most of the visit, but not the knee and the ankle, which I was more interested in. One trick you can do is have them reverse the camera so they can see what they're pointing at. Yeah, but where do I press? How do I do this? It's like, oh, dear. But that made a good story. Again, improving access to medical care and reducing barriers, especially when they don't want to come into the hospital, we can go out to them. They're happy. They want to be home. They don't want to be in a room waiting with 10 other people who's got COVID, cough. Parainfluenza is going around here in our community. A couple of weeks ago, it was the regular influenza and the human metapneumovirus. You get the idea. They want to be home. They want to be discharged to their living room, not to a facility. Home is better. The other key ingredient is I'm talking about this incredible need is that we need workers. We need people to do this kind of work, whether you're talking about home-based primary care or home-based palliative care. We need workers. This is just a demonstration of providers making house calls and what we call high-volume providers that are making 1,000 visits or more annually. So from 2013 to today, we've grown from 500 thereabouts to about 3,000-plus. Is that good? How many more do we need? We need that many more. 85% of patients who are homebound or home-limited, they are not able to access our care. If that was cancer care, orthopedic care, heart failure care, nobody would accept that. No one. And there are a couple of states. I think it's South Dakota, Vermont, and Alaska. They don't have anybody. HCCI, we are here. We are all here to change this number, to make it better for our patients, for your neighbors, for people you know who really need this kind of care. People ask me, what are some of the characteristics of a successful house call provider? These are my eight C's, and they are competent with complexity. Our patients are complex. We did a study of our patients, the number of medical conditions, no, the number of medications, number of medications my patients took from our study, 17. That's horrible. I call that a sin. Not acceptable. You have to be competent with complexity. They're problem-less, they're huge, you know that. You have to be able to swim in that and be comfortable with it. You have to be able to communicate comprehensively. I already talked about that a little bit, being able to talk about hospice and palliative care, talk with the patient, talk to the caregiver, talk to the home health agency, talk to the hospice director and so on. Be able to communicate with different people at different levels, professionally and also at a personal level with patients and families. The other is character and composure. Character, I'm a guest in your house. Character is a non-negotiable. All right. Composure is when you step into the home and you're not quite sure where to put your bag or anything and you're not quite sure what you're stepping on. On top of the complexity, you have to have this inner strength to do the work that you've been called to do. All right. Charm and charisma. Charm in a winsome way because you are going to be talking with patients and families about some very serious things and you need to be able to lead and guide them in a winsome fashion. And then the charisma to lead them through. Like I'm gonna walk with you through, like the patient I saw three hours ago, I'm gonna walk with you and the caregiver through your cancer. We're gonna be there together. That energy, that determination that I'm gonna go and stick with you. And that also goes with your practice. We're going through a lot of changes. Even in my practice, whether we're talking about fee for service, trying to hire people, trying to make sure they don't leave, right? You need that charisma to lead. Lead your patients and lead your practice, obviously, with different lenses, if you wanna call it that. Questions, comments? Hi. I teach behavioral engineering and you just identified some great characteristics to look for centered around behavioral engineering. That was great. Thank you. Thank you so much. Thanks for sharing that. Could you repeat the question when you get them? Oh, behavioral interviewing? Melissa, did you wanna use the, we have a Phil Donahue. I'm dating myself again. Phil Donahue, Mike. Oh. Okay, we'll do it, yeah. You could do it. I wanna just continue to rephrase. Yeah, so the comment was made that she teaches behavioral interviewing and that these eight C's are really relevant to that kind of interviewing technique. Thank you. Other comments? Many of us are mission-driven people. We hear that calling to serve. I've been blessed to have been given this opportunity by the good Lord to do what I'm doing. And I'm here to take care of these patients with serious illnesses. You can see them, the stuff we talked about. Medication list, complex medical conditions. How many of you, when you check your blood test tomorrow morning for the results, I think they're all abnormal tomorrow. They're all gonna be red, right? Nobody's in the normal range, or seldom. Be able to navigate how do you manage this and that condition when all the labs are abnormal, and so on. Psychosocial complications, challenging family dynamics. Yesterday, I was with a patient, patient's son and a patient. Patient has advanced dementia, but she's actually still able to argue and articulate and so on. The pressure point came to be that this patient is currently at an assisted living facility. She wants out. She's miserable. She's getting more and more depressed every day. I need you and my son to come up with a plan to get me out of here. The son has already tried 24-hour caregiver at home. That was a crash and burn. How are we gonna solve this problem? How does primary care, how does palliative care come in to do the full service thing that we talked about, which we will talk about a little bit more later on? How do you deliver the care to the patient and take care of the son and carve a way out of this very vexing problem? Again, this is kind of different way looking at the eight Cs. You gotta have good clinical skills. Remember, you just can't consult somebody, right? You're the main, no, often you're the only provider at the home. There's not a cardiologist that's gonna come in behind or a pulmonologist. You have to have good knowledge, reasoning skills, competent in assessment and diagnosis, and being able to do procedures at home. We do procedures at home at ACC. I have courses on how to, I'm gonna be doing a tracheostomy change in a few weeks. We do that at home, yes. G-tube change, yes. Knee injections, we do that, and there are courses that's offered at ACCI, so feel free to check those out. Integrity, safe and quality care. You have, how do I put this? Confidently cavalier. You have to be independent, but you are able to test in a confident way the care plan that you're recommending for your patients, okay? Keen attention to time management. We talked about that. Whether you're on the fee-for-service or value-based care, you're out there, you know, we talk about windshield time, how much is a reasonable, well, what's a reasonable timeframe for a follow-up visit, for a new patient visit, and so on. Time management and organizational skills, very important. Obviously, written and verbal communication skills, which we talked about before. Questions, comments? I might add good computer skills, right? We're all on EHR. And, you know, how can you be efficient with a clunky name your EHR system, right? So what are, what members compose of a primary care team? Now, for me, we end at bullet point four. Remember, I'm under fee-for-service. They don't generate revenue under fee-for-service for the most part, okay? So I have to pay for them. And that adds to overhead. Under value-based care, it may be different. You're gonna be paid per member per month. You have extra dollars to hire a part-time pharmacist, for example, okay? For me, under fee-for-service, we are operating with a top four. Yes, I would love to have a social worker. I did a random poll with my nurses. How many of the medical questions that you get over the phone line, how many are truly medical? How many are social? Over 50%. 60-40, social versus medical. That was a random poll. Just asking my nurses. Gut feeling. So, in the previous slide where you said, we're currently at 3,000, we need to be at 12,000. Is that the top half of the list there, or is that everybody? Providers. Yeah, providers. Other comments? Palliative care team. I was talking about an ECAPSI that's Center to Advance Palliative Care, CAPSI. They actually publish a study on their, on the landscape of home-based palliative care. And you can see the staffing is a little bit different with the palliative medicine side, with emphasis on social work and chaplaincy. Almost a little bit like a hospice model, if you will. So, you can see, compared to a home-based primary care team, it's a little bit different in terms of, perhaps, the focus of what we do. I have the study here from CAPSI. They looked at the home-based palliative care services, and it was interesting. There are a lot of good highlights with the study. 44% of the palliative service at home patients stayed with palliative medicine only. 31% graduated to hospice. Meaning what? If you're on the palliative medicine, you're sticking with your patients, and they're gonna have the same kind of issues that I'm dealing with, pain, shortness of breath, depression, leg swelling, constipation. You get the idea. So, 44% of the patients remained on palliative care. There's a lot of similarity or synergy in terms of what we can do, yeah, separately, but imagine what we can do together. So, how do we? Yes? In both of those slides, the providers were physician, PA, APN. How much can PA and APN help with the staffing challenge that you talked about? So, I'll talk about it from my practice and then from a national level. My practice, I have four full-time APNs. The only 1.2 physician providers. Okay? On a national level, the growth is mainly APNs coming into the field, doing this work. The number of physician provider has remained relatively flat. Yes. Absolutely. What's the main, what are you experiencing in terms of the challenge with getting positions to get on the board? Yeah. Absolutely. And I'll have my comments. And then Julie and I just did a webinar on this. And that question was thrown to her so she can add her comments as well. I think the lack of understanding of what we do. OK? I think that's one. You know, your house call, how do you do that? I think we want to do things that we are comfortable with and have knowledge and have confidence in. When you're not quite sure, you know, what home care medicine, what is that about? I think there might be some hesitancy in that. The other is that there's not a lot of prestige. Right? Let's be honest. Or, you know, I'm a brain surgeon. You know, Paul, what do you do? I'm a house call doctor. You know? There's a difference there. And then the economic side of things, in terms of payment, a primary care doc, a house call doc versus a specialist. Julie, other comments? Yeah. One of the things is that, you know, Paul said earlier he went to medical school to be a doctor. Medical schools tend to teach doctors to be doctors in the hospital. If you think about a residency, you're in the hospital. So there's been this over the last, you know, decade or a little more, you know, this sort of focus on hospitalists. And I heard one doctor say, you know, it makes sense. That's where they learn to be a doctor. Well, how many are getting exposure to home-based primary care or home-based palliative care in their residency or in their nursing training program? One of the things that HCCI is doing is reaching out to training programs for both HCCI and the DO program to share some of our curriculum with them and try to advocate for students to get exposure to this, students to do a geriatric rotation and spend time with a doctor like Dr. Chang and go out on house calls. You know, I know of one doctor who became a house call physician because our founder, Dr. Cornwell, took care of her grandmother. And she saw him do that when she was young. And I know I've heard many other stories of students saying, you know, I didn't know this was a career option. We have to let people know this is a career option. Thank you, Julie. Even if they see a house call service in a residency or medical school, it's usually a little time to sliver. Correct. And HCCI, yes, like anything, payment reform, we're trying to change that slowly. Education awareness, if you want to call it that, we're trying to change that. Of course, getting in with ACGME, thank you. Is that right, acronym? Yes, ACGME. When the residents schedule, it's already so tight, okay, whether you're IM or FP. Trying to introduce another curriculum into their rotation. So there are other challenges related to how do we get the foot in the door in terms of educating and exposing residents and medical students to this type of care. But we're working on it. But it's like many things in health care, it's a slow change. Another problem you have is that in the residency, they try to expose you to as many patients as possible quickly. In a house call program, you're going to have, by its very nature, much smaller patient volume. Yep. Hopefully we can make up the lack of quantity by the quality of what does it mean to be a physician, to be a caring, compassionate physician? And also, how do you manage the complexity? So you can see one patient with one condition, or you can see one patient with 15. So the comments, we have residents that come with us from Northwestern that wrote that this is part of their geriatrics rotation. So the two comments I hear, I didn't know you can do so much at home. Number two, this is such a personal experience. I've never felt it anywhere else. I hear multiple comments, obviously, when I review their reports and so on. Those bubble easily to the top. So I think we just need to highlight the fact that this is so different from anything else you possibly experience. You are delivering care in a completely different setting that will stretch you, that will test you. At the same time, it will be immensely rewarding to you as a clinician and to you as a person. Yes? It's really just a great form of sensitivity training. Yes, absolutely. When you walk into the home, you are immediately hit with sights. How many different kinds of lures are there? That's for this and that. Just immediately, that gives you that layer of a patient understanding experience that you can't possibly get anywhere else. And then you add the, that smells really good. You know, you're making me hungry. You just add so much being at the home. Yes? On a standard. Yep. Other comments? A new residency program, HomeBranch Primary Care. What was that? I'm sorry? A new residency program, HomeBranch Primary Care. Let's hope that will come someday, maybe. Yes. Yep. Yep, hopefully that will be something that can happen. Yes? PAs. Less so PAs, more APNs. Yeah. Northwestern does have a PA program. And I've given talks there as well. But in terms of the number of PAs coming this way to do rotations. Do you think it's a reimbursement challenge? Or is it just a lack of interest? I don't know enough about that to comment. Sorry. People tell you a lot of things when they walk in. But when you see it for yourself, you can actually predict the SDOH very, very well and help them out that way. That is so important. A number of reasons. One, SDOH. We know social determinants of health impacts a patient's quality of health and ERs and readmission and all that. We know that. So being at the home, you get first-hand look at fall risk, at ramen noodles they shouldn't be eating, or the Dunkin' Donuts they should not be eating. You get the first-hand exposure. The other thing is, for 2024, SDOH is going to care. You can help me if I'm speaking out of terms here. There are going to be more emphasis on SDOH and equity when it comes to looking at the overall risk for your patients and so on. So stay tuned to HCCI 2024. There will be even more changes, I believe, to HCC coding and score than what we just went through in 2023. Any other comments? Great. I love this. I'm hearing other people talk other than me. Yeah. So when we bring the residents here, what do we base our teachings on? This is the 4M. You can read about where the 4Ms came from, and then the final 5M, which I will talk about here in a little bit. The 4M is a framework. The first is what matters most. It's about goals of care. It's about delivering the care that's consistent with what the patients want. Finding out what they want, setting goals, how realistic are those goals, completing the advanced care planning, how do you communicate this with all their kids, the hospital, and so on, and updating the preferences when they come. They might have been full code, but after the fourth CHF exacerbation, hospitalization, and now back home, they may have changed their mind. So it's important to find out what matters most, because I tell my patients, if I don't know where I'm going, I don't know how to get there. Or you can say any path will get you there. Mentation, it's about engaging the mind. COVID was so tough for our seniors when we lock them up. I can't believe we did that. Isolated them. No contact, or through a plexiglass, or through a window, or something. I personally think that was just a terrible thing we did to our seniors. And from that, we know that the isolation can be very damaging, and so on, for their well-being mentally and socially. So we need to pay attention to what can we do to engage their mind. What can we do to prevent delirium, or to treat their agitation and combativeness? We deal with patients with dementia, and sometimes they can get a little challenging, right? We've all been there, dealt with those patients. There's not an easy path for those patients, but what can we do in terms of maybe a medication change, or having activities for them that can keep them out of harm's way? Mobility, again, that's a huge benefit for us. I do what's called a walk-through when I do house call visits. Show me this patient that I saw today, a different patient with multiple sclerosis. Where do you sleep? Right here in the recliner. How do you get from here to there? And the wife demonstrated this really interesting gizmo that they bought on whatever, Walmart, Amazon. I've never seen it in 23 years I've been doing this. So I got a picture of that. Mobility, what are the barriers that they have at home? Do they have grab bars? Do they have toilet seats, risers? Do they have a stair lift? How do you get up to the first floor? How do you get out of this house? So mobility, use the advantage of being at the home. We have an opportunity to do things, to see things that no other office clinicians can possibly experience. That's a huge advantage, huge win for us, more importantly, for our patients. Lastly, medications. I already talked about 17 medications. That's ridiculous, right? How can we de-escalate, de-prescribe? In our courses, Melissa's Essential Elements or Advanced, we talk about polypharmacy and de-prescribing. There's a course that you can visit on how to do that. And some of the apps that you can use to help optimizing medications at a geriatric-friendly dosing, whether you're talking about a Pixaban or Eloquus dose at a kidney function, or even like antibiotics, Cefalexin or Keflex, at a geriatric-friendly dosing. Use the opportunity to review the medications. Again, when you're at the home, you have such a unique opportunity, right? So when you're at the office, the assistant will turn the screen to you. These are your meds. Are you taking them? What's the answer? Uh-huh. All right. So somebody once said, not many guarantees in life, death and taxes, and the medication listed in Epic is wrong. Thank you. OK. So you have the opportunity to say, what's in that bag? Is that everything? What are those in the back? You have the opportunity to see and clarify everything. All right. Where are these medicines? That's on my list. Oh, those are my night medicines. They're in the bedroom. They're not in the kitchen. OK. And then show me how to use your inhaler. How many of them? I saw a patient in the airport before getting on a plane. It's two squirts of their inhalers. One, two. Is that going to work? Do they need another inhaler? Do they need another LAMA, LAMA combination drug for their COPD? They just need to be taught on how to use their inhaler correctly, rather than the one, two, and then I'm boarding the plane. Right? Show me. I talk about medication reconciliation, justification. Justify why you're using this medication. Optimization, optimize for liver, kidney function, and so on. And the last is demonstration. Show me how you shoot the insulin. Show me how you use your inhaler. Show me where this is. OK. So you have an opportunity to do that at home. And then talk, walk with your patients. When you deprescribe, they get very fearful. They're very attached to their vitamins. And you're taking my multivitamin away? Walk with them. I'm not abandoning you. We'll walk through this together. If there are any changes from de-escalating these pills, I'll be right here with you. And if you have the money, you can have a pharmacist work with these patients. I'm deprescribing 17 pills. Multicomplexity is putting it all together, right? Help them manage multiple conditions. Assess the living conditions, which we talked about, optimizing therapy, getting other people involved. I'm only a doctor, I tell my patients. I need therapists. I need psychologists. I need nurses to come in and help me. And coordinate everything and integrate into the care plan for your patients, talking to them about their goals and also talking about the risk and benefits of, say, adding another medicine and what might be involved in terms of, say, blood testing and so forth. This is putting multicomplexity into action. You plan, you do. You don't say goodbye. You check, and you go back and adjust. The common scenario would be somebody with CHF. You add more diuretics. You reassess the patient. You check, uh-oh, now the BUN and creatinine is this and that. Might need to back down on the water pill. Putting, again, the whole context of what the patient is like. I'm going to introduce a patient to you all. And in a little bit, I want us to just, at our tables, talk about how we can meet, care for Christina and Veronica. Let me just talk about Christina. She lived in Romania until three years ago. Her daughter came to the States on her own. Three years ago, Christina became ill. And Veronica said, mom, you're coming over. Brought her over to the US. Diagnosed with stage 3 cancer, ovarian cancer. Debulking surgery was done. Underwent chemotherapy for about six months. She continued to live in the States with Veronica, her daughter, since the diagnosis. And she'd been doing OK. But her tumor markers started to go up. And she was in the hospital a few weeks ago for another surgery due to bowel obstruction caused by adhesions likely related to her first surgery. This is just kind of a summary. She's getting weak. You're seeing her now. Pretending you're making a house call, seeing Christina and Veronica. Weak fatigue after the hospital. Language translator, since patient only speaks Romanian. You can take a look at her past history there. Going down to family and social history, I want to note that immunization look at. It's no, no, no, no, no, and no. Home-based primary care. What can we do to intervene here? Surgery history, family history. And let me just turn to the next page here. So in terms of what we do for patients like Christina, we provide primary care, multiple disease management. We're available 24-7. If you look at the CAHPSY study, not all palliative service at home are available 24-7. We do post-hospital acute care, transitional care medicine. Like Christina, we do preventative care, like immunizations that she needs. If she had a need of wound management, we do wound care. And we coordinate with other ancillary services. And in terms of laboratory testing, if she's anemic, her kidney's this and that, we can arrange for those procedures to be done at home. What about palliative care? If you are, say, looking at Christina from more of a palliative lens, what do palliative medicines do? You can exist in a hospital, obviously outpatient nursing home. And as the CAHPSY studies show that there are more palliative medicine being at the home, we take care of patients there with refractory pain or other serious illness symptoms, talk about complex family issues. And we focus on financial and non-medical needs. And again, we provide, through palliative medicine, psychosocial and spiritual support through a interdisciplinary team. So there are some similarities with home-based primary and home-based palliative. But there are these intersections in the middle. Well, we do a lot of similar things. We support the family and the caregiver. We do social-spiritual support. We do care coordination. We do symptom management, prognosis support. Patients often want to talk to us about, how long does grandma have? Interdisciplinary team meeting. We do refer patients to hospice, even without, say, going to the next step of palliative medicine, per se, which I'll talk about that in a little bit. And we do talk about advanced care planning and end-of-life discussions. So both from a palliative and a primary side, we do some of the same things. But then, like the other circles, there are certain strengths related to more home-based primary care versus a palliative care approach. So what is the full service? That's what we're here. We're looking for a full-service solution for Christina. So Veronica, what are her hopes? She's a daughter. She's the power of attorney. She hopes for Christina to have more energy. Remember, she's really tired and weak. She wants to maybe restart chemotherapy, because the level is not going down, if anything is going up. Veronica, the social side, she needs to go back to work. She used all of her FMLA. But she needs health insurance. How do you help Christina? By helping Veronica. Remember, I talk about it's a dyad. It's always the patient and the caregiver. And I said it to my patients today when I was making it. I need you, the caregiver, to be well, because we work as a team. If you go down, mom's going to suffer. I have to take care of you indirectly, because it's really a team approach. Somebody brought up social determinants of health. And these are some of the concerns. Patient depends on Veronica to get the medications. Patient only speaks Romanian. Patient is dependent on daughter's income, but she's not been able to care for the patient. And she's feeling really exhausted from caring for mom. And it's become increasingly difficult to get patients out of the home, because of her increasing weakness. How can we come together to take care of Christina and Veronica? Again, looking at a full service solution. There are the ADLs. She's unsteady. Everything is slow. I talked about the walk-through. There are throw rugs in the hallway. No grab bars in the bathroom. There are no benches. Some DMEs that you notice when you walk through the house. You've got a walker and a wheelchair. Orthodox faith is very important to her. And then we talked about using a instrument to test for caregiver burden. That's the common one that we use. You can see that she's mildly to moderately burdened from caring for mom. All right. Thanks for your patience. We're almost there. So at your table, talk about, what does home-based primary care bring? What does a palliative service bring for Christina and Veronica? Are there other types of patients who may benefit from receiving both? And how may this full service solution for our sick and complex patients impact providers and other members of the care team? I'm going to leave this slide up there. I encourage you to discuss at your table, jot down some ideas. And in five or 10 minutes, five minutes or so, I'm going to ask for a brave volunteer from your table just to give us a feedback from what you all discussed at your table. So five minutes. It's great to hear conversation. I am very encouraged by the dialogue that's happening at the table. So any comments from any table, just feel free to raise your hand and so on. How could Christina be supported by a palliative care program at the home? How can Christina be supported by palliative medicine? Any comments? Palliative care for Christina. Well, I think palliative. Go ahead. So we came up basically with the four S's. We said that palliative would be able to support the patient as well as the caregiver, since the caregiver did indicate that she was feeling burnt out. So support. We also put down a symptom. Symptom management for the patient, as far as since she had the new bowel obstruction and things of that nature, trying to keep her pain at a tolerable level. We also indicated the aspect for the spiritual portion of it, because she did indicate that her faith was something that was of importance as well. And then maybe some psychosocial for the daughter, because again, she is feeling burnt out. So she would have to be poured back into so that she could continue. And then social services would be able to help the daughter, indicated that she had to work because of the insurance piece. There are certain things in a home, possibly, or services in a home that couldn't be provided if the insurance is not taken care of. So social services would have to step in. I love the four S's. I love it. You know me and my four C's or eight C's or whatever. I love your four S's. I love it. I was going to say the same thing. She said it much better. So in your learning plan, you could put down the four S's. Yes. What else? Anybody else? The other tables? Or has she done a great job summarizing? You can't beat the four S's. Summarized. Great. OK. I learned a few things from our table mate over here. And it sounds like teamwork makes the dream work. Yes? The primary care physicians really benefit from the palliative care specialists really offloading a lot of the challenging communication that comes with supporting someone with palliative care needs, is what I learned. Yes. Those conversations, they take a lot of time. And I don't know about you. I often get a little weary, a little tired after those conversations. And I need, I don't know, a Kit Kat bar or whatever to pick me up. All right. What about primary care? What can we do to help Christina and Veronica at home with primary care? Anybody? Can you go back to the video? Absolutely. Am I going the right way? Yep. Here's primary care. No, that would be under specialty care. Now, side effects related to chemo may fall under my care. Acute urgent radiation esophagitis, for example, or shingles from immunosuppression. Those would be me. So that's primary care. You have four E's? I'll give you some time to think about it. You did the four S's so beautifully, I need the four E's. Okay. What about some of the ancillary services that home-based primary care need to provide? Sure. Social worker, what services are available? How to obtain them? Yeah. Physical therapy, strengthening exercises? Yeah, she's weak. She may need some strengthening exercise. She may need some blood work. Maybe she's anemic. Maybe her potassium's low. Those are perhaps more primary. You can argue that it's more primary care side than strictly the palliative, or it's more about symptom management. Yes. Great. Thank you. All right. I just want you to, for the sake of time, we're coming up on six. I'm just going to skip to the next slide about applying this complex, this full-service model in managing in our patients. It gives us the opportunity, primary, palliative, to serve additional patients. There may be additional revenue opportunities through, say, CCM or TCM visits. If you want to know more about all that, we have Superbill at HCCI that talks about all the RVUs and the reimbursement and how much do I get for CCM or TCM and so on. It's there. Again, visit our website. With the combined model, if you will, we can fully meet the needs of patients and their caregivers by coordinating medical services with maybe different perspective on the same patients, focusing on what matters most to our patients, managing their symptoms, one of the S's, supporting the caregivers, advanced care planning, having that difficult conversation with Christina and Veronica down the road. Right? It sounds like her tumor's coming back. And the daughter wants full-court press. At some point, we're going to have that one serious or multiple serious conversations with the patient and the daughter. And then appropriate timely referral to hospice services. Again, we don't want... And we've all heard this story, right? Mom was on hospice for three days and died. Too bad. Hospice is great. Hospice provides great services. People have been paying into hospice under their Medicare Part A payment, right? And they only use it for three days. When they have such amazing support with people, with medications and the equipment, that could be this package of supporting the patient and their caregivers at the end of life. Part of the problem is the general doctor does not know at what point hospice should be appropriate. Yeah. Remember the elevator speech. You have to be ready. The difference between primary care, palliative care, and hospice care, right? You could develop... And I encourage all of you to have that elevator speech ready, okay? You don't hesitate when a common question like this comes up. For example, one of the... Well, two of the difference would... Between palliative and hospice care, one could be the focus, if you will. Under palliative care, you can still focus on curative treatment, right? Whereas hospice is more on symptom management even more. And the other will be timing. Whereas palliative care can come in any time during a person's serious illness diagnosis. Whereas hospice is, by Medicare definition, it's the last six months, right? So it's timing and focus. That's just one part of the speech. Yes? Part of the issue has to do with our artificial separation. Yes. In Europe, it's very different. Whereas hospice can start much earlier and it's more like palliative care and hospice combined. Yeah. Yes. So, one of the slides talks about... In terms of model, you can have co-service model, like you can have a palliative care APN and a primary care APN coming in and taking care of the patient, all right? That's one model. The other model, which is our practice, is that one provider does... We do it all. We do primary care and we're all very well-versed in hospice and palliative management. So there are different models that you can think about. If you're a primary care service, can you graduate and do some of the palliative care on your own? If you're a palliative care service, do you want to network with a primary care service? Or maybe you can branch and develop your own clinicians to do primary care at home. So they're just different ways for you to kind of imagine your work. I'll finish with this. Remember, they talked about reducing under the palliative care slide that was published in 2017, about the last three months of care. Those are costly months for our patients. They're in the hospital a lot and they're in the ED a lot and they're in the ICU a lot. If you look at the national data that's up on top, ICU stay, 30 days before death, 29%. Hospitalizations, three months before they passed, 69%. Come down here to my practice. Look at the difference. Okay. Where do patients want to pass away? Here? No. They want to be home. We're delivering the care that's consistent with their wish without sacrificing quality at a fraction of the cost. Elevator speech, be ready. What's your value proposition? This is just one of them. Okay.

home-based primary care

palliative care

patients with serious illnesses

caregivers

symptom management

quality care

full-service model of care

complex needs

patient outcomes

healthcare costs

reimbursement challenges

home-based care