Demystifying Value-Based Care: Ensuring Success-Demystifying VBC

Demystifying VBC - Session 3 Ensuring Success recording

Video Transcription

Okay, well, welcome, everyone, and thank you for joining us for our third workshop of the series. Today, we will be discussing ensuring success in value-based care.  Just a few, again, my name is Margaret Cordes, I am the Director of Education at HCCI. Just to start this morning, or this afternoon, excuse me, a few housekeeping items.  This is a CME activity, so we wanted to disclose that none of the planners or faculty have any financial relationships with eligible companies, nothing to disclose.  This is the CME information on today's activity. We'll be sending out information after today's workshop about how to complete an evaluation and claim credit.  We also wanted to acknowledge the John A. Hartford Foundation, which supports today's workshop.  Some, again, housekeeping items on accessing the workshop materials through the HCCI Learning Hub.  You can do that by logging in with your username and password that you used to access the workshop today.  That's where you will also find the recording, which will be published, usually within 24 hours.  And if you have any questions, feel free to direct them to education at hccinstitute.org. And so I am going to introduce our faculty for today.  We have Ina Lee, she is the Clinical Director of Continuing Care and Home-Based Services and the Clinical Director of Geriatrics at ChristianaCare.  Amanda Tufano is the Chief Executive Officer at Genevieve, and she's also a board member  for the Minnesota American College of Healthcare Executives and Minnesota Association of Geriatric-Inspired Clinicians.  Lastly, we have Dr. Michael Helle, he's the Director of Clinical Programs in the Office of Population Health at University of California, San Francisco.  So, for today's workshop objectives, we are going to revisit the six top components for success in value-based care and elaborate a little bit more on what those are, applying  optimal practices to effectively manage transitions for complex patients, understanding how to  develop a clinical model based on your patient population, applying effective strategies  in the treatment of homebound patients with dementia and behavioral disturbances, recognizing  factors that impact staffing and productivity, how to approach and how different approaches  can vary based on payment model, and identifying coping strategies to provide high-quality care while avoiding burnout. And this is the agenda.  You know, as we've mentioned in the previous weeks, we do our best to estimate these times.  They are estimates, but we'll start with optimizing value-based care before moving on to managing care transitions.  About halfway through, we'll take a brief break before diving into evaluating productivity and staffing, dementia, and then hiring.  Again, just a reminder that you do have your HCCI Learning Hub, or excuse me, Learning Plan available in the Learning Hub.  This is a great resource just to jot down things that you've learned, things that you'd like to learn more, and we welcome you to share that with us.  We use that to help develop our learning materials to tailor the needs of our learners. So without further ado, I am going to pass it over to you, Amanda, and Ina, and Michael.  Great. Thanks so much. Well, we're going to try to kind of tie these last three, you know, three days, three sections  together, and this is going to be kind of a panel-sized format here. So I'll do a couple of slides to introduce the topic, and then Michael and Ina will join  me in some thoughts on that topic. But as we think about optimizing value-based care patients for homebound patients, there  are a couple of things we want to look at, you know, the top six components for success in value-based care, and offer how we each think about these things.  And if you have any other questions, you know, put your notes in the question and answer or in the chat. Slide.  So there are really, you know, six components for the top six components for success. We're going to go through each one.  We'll spend a little bit of time, but, you know, who are the patients? Where are your gaps? You know, how do you think about the cost of care?  How do we think about data and financial considerations? How do we think about revenue capture? And finally, payer negotiations.  And again, if you have any other questions as we go, throw them in there or anything you'd add. Slide.  I know this seems wild sometimes, but the first thing as we think about, you know, value-based care is patient identification, really flagging your patient.  Can you identify inside of your program who has a value-based care product? And it's sometimes easy to create workflow in it. And sometimes it's really not easy to create workflow.  Sometimes technology will help you. And sometimes it's really a barrier and you need to work with your EHR.  But there's this great value to everyone on the care team, knowing who's on the care team. What are the benefits? What are the services as we think about value-based care?  And let's say you can flag them, then it's also locating them. Do you know where they are at this moment? You know, do you have great ADT data?  Admissions, discharges, and transfer data. Can you say if they're at their house or are they in the hospital?  And so understanding individual and then aggregate locations of your patients is really important to be able to provide that kind of right resource at the right time. Slide.  One thing we really think about is technology. You know, I call EHRs often as clinical data repositories because they're just a place you store clinical data.  Like basic EHRs are not really for identifying value-based care patients and their services. Some have technology, you know, modules that you can add on or overlay to your existing  technology. Sometimes you have to purchase a brand new product and your EHR really is not the system that's going to track these patients.  It's going to manage all the things that we're going to talk about today, is manage care notes, manage the care team.  But population health technology takes time, dollars, energy, people, and really think about, you know, leveraging licensures when utilizing these platforms.  You know, what are we using and who's doing and who's interacting with the system? Is it all the team? And so as we kind of think about tech here.  One more slide on patient identification. So key information as you think about, again, patient identification, and it might seem  silly, but for those who are just getting into value-based care or just starting to build these structures inside of your program or inside your technology, again, what is  your patient flagging system? You know, what program are they enrolled in? What are the benefits and services available? This is also known as patient attribution.  Where is the patient located? You know, are they in another site of service where you could provide some impact for them? You know, med A, stay at a hospital.  What does your program look like when they're in those spots? And can you create a pattern of non-primary living, you know, local utilization, you know, monthly hospitalizations?  How do you step back and look at that bigger picture data? And you know, the final thing to think is the ability to get key information easily.  And so sometimes EHRs have buried things like advanced directive or key family members, guarantors, goals of care, because it's just another piece of data that gets put into the  system. But in reality, we need to kind of pull that information forward so every care member who touches it, the identified patient, can know those things.  So I'm going to open it up to Michael and Ina. Would you add anything to what I said? You know, any struggles in your practices with patient identification and how that has worked?  Yeah, I would just say, you know, just reiterating a few things that Amanda said is that, you know, depending on the types of value-based programs, so for instance, like in our pop  health division here at UCSF and our home-based primary care, you know, we have layers of contracts, right? We have contracts with commercial payers.  We have contracts with Medicare Advantage programs. We have Medicaid programs. And they all kind of expect us to manage patients differently.  You know, we have the over-encompassing utilization and that type of work.  But when it comes down to, like, the types of care gaps you have to close and things like that, you have to have a way in your system to know where your care management  team can identify that, yes, this is one of our Medicare Advantage patients. And in addition to all these care gaps, we also have to monitor medication adherence  and we have to monitor SNF stays and home health days and things like that. So it is really important to be able to identify that.  And you will find, especially like in our market here in San Francisco, that from year to year, people jump around to Medicare Advantage plans, right?  So this year, they were attributed to this contract we had. And then next year, all of a sudden, they fell off the UnitedHealthcare and now they  are showing up on the Anthem MA plan. And then you sometimes have to be able to shift because not all of those plans are HMOs versus PPOs and things like that.  So just having a good way to be able to identify and, you know, there are tons of bells and whistles out there.  I mean, it is great if you have an embedded Epic platform where you can see that one of your patients who, you know, maybe are in San Francisco now are going to Florida for  the winter, right? And during the winter months, they are doctoring and we got to kind of track their utilization while they are in Florida.  So sometimes having that integration either through a platform or a third-party company helps you manage some of those patients that you do have total cost risk for.  Yeah, I don't think I'm going to add anything more than what Michael and Amanda said. It's patient flag.  And, you know, I'm just trying to think like there's a lot of IT involved in this. So I think if it's something you have an IT, if you have the luxury of having an IT  person, this is the this is something that should be their main job really is to help you identify and track.  It really is a lot of tracking that needs to happen across the across the settings.  Yeah, no, that's great, you guys.  Thank you so much. And Michael kind of teed up our next conversation. If you go to the next slide, gaps in care quality, you'll see these things kind of build on each other, right?  If we don't know who the patients are, we can't run reports to say where are their gaps in our clinical care and our quality of care.  So really understanding what data you're getting today, you know, what is that information? Are you getting it out of your EHR? Are you getting ATT information from your HIE?  So if you identify the patient, the next step is analyze individual and population gaps in care and quality.  And we want to aggregate that again on both an individual, a regional, a provider specific, but also a population level.  And you may see different trends. Right. And here's just some examples. Right. Counties, facilities, you go into any facilities or certain disease facilities,  like assisted living, independent living or certain disease categories, you know, dementia patients or COPD patients.  You want to see if there's something we can do again at that aggregate level, if there's something we can do then on the individual level and how that then filters down to the  individual care team caring for that patient.  But really understand the potential data that you have. If you can interpret the information, you can create these really focused needs  assessment. So I'll give an example on really utilizing data in a practical way. So if you if you have a care report, for example, you know, a gaps report can say  something like COPD patients have a 20 percent chance of going to the hospital within the first year of being diagnosed.  So that may mean that you can set a new workflow or clinical pathway for a specific. This is an example of a specific disease where we say, OK, if you come in, if you're  admitted to our service with COPD, we do this clinical pathway to avoid that one in five chance of going to the hospital.  Another example would be in a facility is, you know, you know, and that's why I'm saying aggregate at that upper population regional level.  But look at that and say, you know, is a certain facility more likely to call the hospital for a fall versus your practice? And then how do you touch base with that facility?  How do you create a new workflow? How do you understand their regulations about what they're working with so you can provide the best patient care?  And it makes total sense to go to the hospital if that's what the patient wants, if that's what the family member wants.  It doesn't make total sense to go to the hospital if we're doing it because the facility is just nervous.  And, you know, we look at the polls ever the most or know the goals of care and we say, you know, this doesn't really make sense.  And so making sure that at least the the primary care providers are getting that call. And so what are the workflows you might change in that in that way?  Slide. So just some major limitations, I'd ask Ina and Michael to kind of join in with you here, too.  But, you know, the major limitations are often that the data is unavailable or it's really delayed. Right. It's claims data from Medicare.  And, you know, we guess we maybe get it monthly as part of a MSSP or REACH program.  But, you know, all the claims haven't come in. So it doesn't it's not really fully complete until maybe four months into the year.  So, you know, sometimes it's unavailable. It's incomplete. It's not showing the full picture. It's one portion of data, but not all the data.  Really what you're trying to think about in value based care contracting is make sure the data you need, at least from the payer or the partner that you're using in value  based care, you know, you write down and say, this is the information we want. So I'll actually put in my contracts, you know, we want clinical quality data. We want financial data.  We want it on a monthly basis and we want to meet about it quarterly and we want to have an assigned account rep.  You know, and again, Medicare provides this claim data, but it's a lot of information and you kind of need help sorting through it.  So to Ina's point about, you know, it's a lot of tech people. It's also a lot of data people.  That was one of those things that I didn't build in how much cost it was going to cost my system to to interpret data, just to have people to interpret and make it really usable.  But technology can support in doing that, you know, and there will be a lot of tech vendors that they say they have the perfect solution for you.  And it's just finding the one that really hones in again on what is actionable data you can get out of the system that will make a difference for cost and quality for your  patient population. So before we move to the next one, open it up to Michael, Ina, thoughts on gaps in care  and quality as kind of we're building these blocks towards towards what's needed in value based care system.  Yeah, I mean, Amanda, I think you're absolutely right that there is this I think I'm most frustrated with the lag in data that comes to us.  Just this morning, I was looking at some some of our attribution, patient attribution that CMS was, you know, we're part of a primary care first model in the attribution  that came through. And we were like, wait a second, what happened to all these people that we thought were supposed to get attributed? And they're like, they're not on CMS's list.  I'm like, OK, what's going on? And, you know, it was like three months ago. And so I feel like we're constantly playing a little bit of catch up about what we think  is reality and what they think is reality. So that that's absolutely a frustration with some of these value based contracts, you  know. But it is important to constantly be looking at their list because, you know, you do want to make sure that people who can't be attributed should be attributed.  And you have to do that legwork to get them attributed. So so it is a lot of kind of combing through their data sets and then comparing with your data sets.  Yeah, and I just add one thing again, that's why that, you know, clean patient attribution is so important, right, because then it's not building that that that  building block for the quality of care reports and the clinical data that you need that will impact the patient.  You know, one example is we're in an MSSP and, you know, we get our we get our patient attribution. The way we set up our program, some are different ways to set up  attribution. But the way we set up our program is, you know, prospective with a retrospective review.  And so, you know, three months later into the year, you know, really four months, we get their part of who was actually attributed during that quarter.  And one of you know, and you talked about your your issues with that. But one of it for us is understanding how they do patient attribution so we can look  forward and say these patients are likely to be on our on our program. And so, again, you know, adding to the patient contribution or attribution piece,  because once you can figure out that list or, you know, who's on it now, who's going to be on it, you can start looking and impacting clinical care because you're responsible  for the dollars, which we'll go into the dollars next. You're responsible for the dollars of this, you really want to know who is it and am I doing the right thing with them?  Right. Sorry, Mike. Yeah, no, I think the only thing I'd add in and just reiterate it, what Amanda said is is it's some of this stuff you have to negotiate in your contracts.  And believe me, these insurance companies have plenty of money and resources to help you build a platform.  And I've learned that in the last three, four years now that, you know, we used to have a product that we paid about four hundred thousand dollars a year for that tracked  patients that were in Epic, Cerner, McKesson. And it showed all their utilization. It showed all their hospitalizations at hospitals outside of our area.  And we stopped paying for it because it just got to be too expensive and too much to manage, only to find out that our payers were willing to buy this product for us and  actually manage some of it. We just had never talked about it in our first round of contracting.  So don't feel afraid to go back as you're negotiating some of this stuff and ask what the vendors are using for software.  I think another really big area for us this year is we've really moved into the predictive analytics and the AI world through our Digital Innovation Center here at  UCSF. And I'm starting to realize that a lot of stuff that that we were spending hours and hours and spreadsheets of our staff tracking.  And after phone calls, we'd log in in a spreadsheet to make sure it was done. And we checked the box off.  We've actually gotten automated now pretty so that we know when the annual hemoglobin A1Cs are coming up. We know when the annual, you know, mammos need to be done.  And it's actually the system is now reminding us like four or five months ahead of time. So our care teams can plan, you know, down the road on on on all the tasks that  we have to do to to maintain some of this stuff. So. Yeah, that's that's great. That's really cool. That's a great idea to keep going back to the payers on what you  need. So, OK, so as we think about this and we keep unpacking it slide, let's talk about some of the financial costs, as I said, you know, and we talked about on kind of  day one of these, the different types of value based care contracts. I'm just going to say generally you're responsible for care in this.  And so, you know, how much does the care you provide are responsible for actually cost? What are those expense reports?  You know, are you getting claims data? Are you getting expense reports? Are you getting utilization data and dig into the provider system specific information?  Sometimes certain providers are more likely to prescribe a high cost medication.  Certain hospitals may be like more likely to have an E.D. readmission, you know, and if you can't get this information, try to get it, try to  understand from the you know, from the person, the payer or again, the provider or system like in a in a delegated ACO model.  Right. What information we're all at risk for and and understand truly wrap your arms around the cost of that that expense side.  So when we think about those costs, the costs, you know, they're really typically in any contract, they're kind of two buckets, there's kind of expense, direct expense  and there's indirect and carve outs and things like that. I'm not going to go much into carve outs and indirect things, but I'm happy to talk about if anybody has any questions.  But when we think about kind of the bulk of your medical loss ratio or the bulk of the total expenses is really your medical loss ratio.  So it's understanding where are the clinical areas you're spending money. And again, getting that gaps in care quality data is helpful to identify that, because  typically if you can identify a clinical gap and you can fill that while it may cost a little bit in one of these buckets, like maybe a specialized stay, you'll be saving  money in another bucket, like an ED visit, like a hospitalization. So that's how those things link together is understand the clinical gaps in care and understand your categories.  Here are the main categories hospitalizations, you know, ED or observational observation care, med A stays, medication, specialty care, outpatient care.  You may not be at risk for all of these. Sometimes contracts will exclude Part D, so your medication, even if you're not, you still want to be aware of how much you're spending  and what you're spending on your medications because those will impact your other utilizations, right? That will impact your hospitalization, maybe your specialty care.  And so, you know, look at kind of the major spend categories for the cost of care. Slide.  And then here's where we introduce kind of a PDSA cycle. So try to, using that clinical data, using that broad financial data around where we're spending a lot of money.  Every year we see a 10% increase in Med A stays. You know, let's dig into that a little bit more. And one of kind of the easiest ways to kind of look at those  is a PDSA model, Plan, Do, Study, Act. And so kind of create a goal, see what the action's going to be, see if it worked. And then really our last thing is, you know, change it,  act on it and change it. And use this way to understand kind of you're controlling the cost in your work. Typically PDSA cycles are not really long either.  So you might make an intervention, you might make a clinical intervention and you're going to wait, you know, three months to see if that had an impact.  What did the data say after about three months? So I'm going to open it up to Ina and Michael. Thoughts on managing total cost of care, financial pieces.  We're going to talk a little bit more about like kind of financial books, but being at risk for total cost of care is really this bucket. Thoughts there?  Yeah, I would say one area I would just add into here is really starting to think about your leakage to audit network because those costs can creep up really, really quickly on you.  So just making sure that you just have a good plan in place. And I think we find this sometimes, like when we refer to a specialist from our practice  and then the specialist wants to order further testing instead of bringing it back to the primary care home-based office to say, hey, we want to get genetic testing  or we want to do this type of testing on the patient. What happens is a specialty office is pre-auth some of this stuff. It gets approved because it's a PPO plan perhaps.  And then we get penalized for this really high cost laboratory tests or these imagings that happen outside of our organization. So just making sure that you set those expectations  when you make referrals, especially if it's a referral to a specialist that you might not have in your immediate network that you're referring out to them  because they are considered in network that they're not leaking those costs out further to others. And then I think the other thing is, going back to utilization,  having some type of a triggering mechanism to know when people are utilizing services outside of what you would consider your in-network. So like the ED for instance,  I mean, we have patients that ambulances take them to certain hospitals because of a protocol. And then that ED is outside of a network and a very common one for us  is like a patient getting transported to Kaiser because Kaiser's the nearest emergency department  for somebody that's a cardiac arrest or an acute stroke and EMS has to take them to the nearest center to be stabilized. So just making sure that you can look at that leakage  and work with some of those partners to make sure that you can kind of keep it where you have some control over it.  Yeah. Oh, go ahead, Vanda. I'm gonna add one more thing to that. For those who are independent practice and maybe don't have a system, to Michael's point,  understand where your patients are going,  which systems are they most likely going to, and do you feel like that's good quality of care? And then use that as an opportunity to partner with that system too,  and say, 50% of my patients are coming in, 50% of my total ED usage is coming into you. Can we have an interesting conversation about what our arrangement looks like,  what our payment model looks like, how we partner in a new way? Do you always admit my patient to the unit or can you call me when I hit the door, right?  And then I can come visit them in the hospital or I could do a telephonic visit, right? So there are all those things around if you understand that utilization  and the costs associated with it, you can kind of create a plan. Sorry, I know, please continue. Oh, no, I mean, I was saying that when you look at total cost of care for patients,  it's hospital costs is probably number one driver for total cost of care for your patient. So managing, I always tell people like,  when you're caring for geriatric patients and they show up to the hospital sick and they look sick, they almost always get admitted.  A lot of them, at least a lot of my home visit patients get admitted just like, cause they look sick. And I'm like, well, that's kind of their baseline. You can get them out.  But they're like, no, they look sick, they're gonna get admitted. And so the name of the game is really just to not have them go to the hospital.  And I know that's easier said than done, but anything you guys can do to, more frequent visits, phone calls, check-ins, making sure things don't escalate to that,  hosp ED or slash hospital visit or interventions you should try to institute because once they hit the hospital, it's like, all bets are off, at least for where I am.  So managing all the upstream stuff is highly important. And I know I'm gonna say a statement and maybe you could respond to me as a physician,  but I think one of the best ways to talk about that is in the prognostication phase, right? Understanding all of the, in those goals of care and advanced care planning  and all the conversations you've had, is also explaining what hospital care could look like  if this happened and put that in a more human perspective.  For folks, but that front-end work has an impact on the back-end financials and quality of care. So, I mean, it's a complete link here, but we talk a lot with our providers around,  how do we do even some scenario playing out? How do we understand? Sometimes you walk into a room and goals of care are clear, right?  They've said since the moment I was five years old, I want this no matter what, like I never want, no lifesaving interventions. And you go into a little bit of detail,  but it's like clear, you're never gonna have a problem with these folks no matter what happens. And then you go in and people are, and there are a lot of decision makers  and you're not quite sure, and you have to spend more time. And those are the ones you keep coming back to for advanced care planning  and prognosticating what could happen in the world. And sometimes that scenario planning and fully truly explaining what really scary  things could look like, or potentially end of life things could look like for loved ones. So is that kind of fair? Yeah, I think that's very fair.  And advanced care planning or goals of care discussions, like that kind of stuff, like you have to build rapport with patients to really, for them to trust that you're like,  they're like, why are you talking about this? And sometimes you're like, okay, maybe it's a little too early. Maybe you need to like know me, trust me,  trust our relationship that I am looking out for you to then launch into that. So again, I think also for them to be bonded to you,  I always talk to my providers, like go see your patients often, then you really get to know them. And then they actually bond with you and then actually think of you,  like they should, when they have a problem, they should call you. They shouldn't just like automatically pick up the phone and call 911. When they pick up the phone,  they should be calling your office and talking to you and having you help them figure out what to do next. So that bonding, that relationship  is really important to build, like invest time in that. Yeah, that's great. And you kind of saw us do a little PDSA cycle, right? Problem is hospitalizations are going up.  Are there some, can we do a root cause analysis to kind of figure out in a few patient examples of what's going on? Okay, let's see if we can do X, Y, Z. Can we do a front end,  more relationship building or something and see the results after three months? Is that having an impact? Who are the patients that are going to the hospital?  And so, I don't say you necessarily start with your financial data in all this, but there is a combination of clinical and financial data that can create then how you think  about managing the cost of care.  Okay, thank you both. Slide.  So I kind of want to talk a little bit about data and some financial considerations. So first is data. Let's just talk about, I mean, in some ways,  I talk about data as it's, there's a lot of it, it's really big, it's hard to understand,  or we can't figure out how to cut it all. And so really what you're attempting to do with data is create a focal point for your team. So really think about buckets, right?  Identification, who, how many patients, quality, what kind of care, what are our measures we are required by our program to manage breast cancer screening?  Are we looking at ED, hospitalizations? What are the things that are major drivers here? And what are the costs? And create kind of a dashboard for your value-based care population  because the system can give you a lot of information. And sometimes this is where I get a little bit on kind of remote patient monitoring,  too, you can find out just about anything you want. If you had a patient that had a whole house system with cameras and sensors and weight monitors  and bed alarms, like you can get a lot of that information. What's gonna make a meaningful clinical difference? What is gonna make a meaningful outcome difference  for these patients? And so really kind of bucket those kinds of things. Again, you gotta know who your patients are, you gotta know where they are,  you gotta know what kind of quality they're getting, and we gotta know how much it costs. We gotta know how much it costs and if the cost is where we want  or we think there's an opportunity there. So kind of think through those big buckets as you think about how you organize dashboards.  But generally, my general rule with a dashboard is I only put stuff on there that is actionable. If it's not actionable, and maybe it's not actionable for another 24 months,  so it goes on another dashboard as it's ready, but it needs to be actionable this year and when we're working on it and we're seeing it and we're monitoring it. Slide.  So I also wanna talk about financial statements. It may not be of the biggest interest here, but value-based care programs pay in very different ways.  So we're very used to kind of fee for service. I do a service, I get paid a fee, it happens within this timeframe, I reconcile my AR, I work my denials and we're done.  But direct Medicare programs can pay up to 18 months after the care has been provided. Value-based care programs can give you a monthly,  per member per month, per enrollee per month, they can give gain share, profit share, you could be waiting on HCC risk adjustment for Medicare, these things can delay payment.  And when you're especially in a smaller system or even a large system, but especially in a smaller system, you really need to create financial systems that understand cashflow  and are predictive of future payments. So how do you start thinking about  prospective kind of financial modeling? And so what does that look like? How do you use today's information that might not be very useful today,  but start to map out some predictive payments for future payments? Because you will have your either cash or accrual systems, but again, at the end of the day,  you'll also have all your cash flows and understanding when you're getting money to pay bills. So, just to note, we talk a lot with our board around the accrual financials,  that they look really good, but again, the end of the day, it comes down, especially in smaller companies, to cashflow because a lot, a significant amount of revenue is tied up  in the Medicare delays for risk adjustment. Slide.  So next steps and resources, all programs struggle with collecting meaningful data,  actionable data across value-based care practices. How does that make sense for financial sense? Some financial resources, there's certainly accounting firms,  there are actuarial firms, there are a number of actuarial firms who help with predictive modeling for data and for your financials. There are trade associations, MGMA, HFMA,  and certainly internal resources. But as you think about these things, again, as we progress along our six-point journey here,  if you can really get a handle on who the patients are, what's their quality of care, how much are we spending on it, now it's how do we create it actionable?  How do we create and understand our financials? So I'll open up to Michael and Ina, other thoughts, things I missed, build on that foundation for data and financial considerations.  Yeah, I might just loop back to when we talked about our HCC coding. This is really big in this arena and just making sure that as you're budgeting your finances  that you really are looking at where you have opportunities, where you might be underpaid for really sick patients that you're managing,  but they just haven't been coded out appropriately.  And I think, again, you always have to plan that you'll have some leakage out of your system and just always make sure that you're putting that into your financial considerations.  And again, a lot of times your data will drive understanding where that leakage is happening.  To Amanda's point, if you find that there's another health system that all of a sudden now your patients are going to, you might have to start thinking  about how do you link some partnership up with that organization to be able to manage and watch this stuff across your dashboards.  Yeah, I mean, I agree with everything Amanda and Michael said.  Mike said about the HCC coding, very, very important, like really important is so much of your payment is based on your HCC coding and the higher the score, the more you get paid.  So I can't emphasize that enough that if you don't have a robust way to track and capture your HCC coding, to track and capture your diagnosis codes  and making sure you have the right diagnosis codes on the patients, you really got to brush up on that.  Well, you guys are plants, go to the next slide.  Okay, so really, how do we think about revenue capture? And both my colleagues have touched on this, but if this is the one source of revenue that's,  or Medicare is one source of revenue is acuity-based, and I won't repeat everything, but right, have you coded all your patients? Is it truly based on their acuity and needs?  Really understand that HCC model and any annual updates that come, and sometimes they do, right now they're in the middle of working out big updates to the model  and understanding that. There are ways to stay updated on those things. Certainly Medicare releases quite a bit of information you get on their listservs.  Optum is a kind of free HCC education resource.  Are there others, throw them in the chat. I just tried to list a few here, but make sure you really translate this to the entire team.  HCCs is how Medicare pays more for higher levels of intervention based on patient acuity. So, we talk about it, but continuing to talk about how you translate this work  and how it is incredibly important to let other, let the providers know more about that translation. So, I'm gonna go back into it, but like how this program works, slide.  So, before we get to that, collect and interpret HCC and RAF scores for all value-based care patients.  Annually risk adjust your patients, could be an annual wellness visit, could be just a managed care visit, could be whatever program you have in place,  but make sure you're annually risk adjusting the patients. A lot of the tech systems have kind of the HCCs when you're going in and doing diagnoses, they pop out at you and stuff,  but make sure you definitely update HCCs if a transition occurs. So, they might be out of your care, but after a hospitalization or med A stay,  there might've been new ones that the hospital captured or there might be new ones that you could capture after a transition. So, think about a program or after a transition  where you might check in on that. Our practice is we do it annually and then after every transition, we do a new risk adjustment to see,  a risk adjustment review to see if there's any big changes that came out of that. And use that to Michael's point for financial predictive modeling, right?  So, once I get the HCCs and I understand those, then I understand my RAF scores, I understand my volume, I could pretty easily start translating that  to what my total revenue for Medicare is gonna be and then what's my expense here. And push top of licensure work in this collection. Who's collecting and how is it being captured?  We use our ends for this work. Some people really say, let's make our physicians the drivers of this. It just depends. But as you get bigger, continue to say,  who should be the right person who's collecting this data?  Slide. And I have one more thought on how you translate this to the team. So, again, it wasn't very articulate earlier, but again, translate this to the provider team.  The way we say it over and over again, this is how Medicare pays for the work that you do. This is how Medicare will pay more if the person needs more care.  And change management here is key.  Focusing on value-based care and collecting certain and specified codes is a massive switch from fee-for-service. Even if you've talked about it inside your organization,  there are people who still believe that this is just a money grab. This is not a money grab. This is truly lining up how often and how much Medicare should be paying  for this specific individual or this profile of individual for this disease cassette.  And so understanding how the system works and that this is not a way to work the system, this is a way to appropriately get paid for the work that you're doing.  And create an open-door policy to discuss the ethics of these new payment models. So even though maybe in fee-for-service models, this wasn't the case 10 years ago,  but in fee-for-service models, we're talking more about collecting these HTCs because new payment models are coming into place. When your organization actually adopts  the new payment model and gets into value-based care, there's a lot of ethics under that, right? It's gonna feel, it goes from maybe some ethics feeling  under fee-for-service model to an ethics feeling of potentially the feeling of, not the actual work of, care withholding. So how do you talk about that  and foster culture of compliance around HTC capture? What is your vision around how you capture, what you capture here? And what are the ethics inside of a new revenue model  for your healthcare system? So I'll open it up to Michael and Ina, thoughts. You gave some thoughts earlier on HTCs. Anything I missed on HTCs and revenue capture  that you'd add here?  I would just say also, as back to the contract negotiation, we have been able to collect some additional revenue because we now have brought on psych nurse practitioners  who are managing some of our patients in our practice that have severe substance abuse issues. So some of these areas where the payers  have started identifying some really, really high costs.  Another area is we hired a care management team that just manages oncology patients and monitors our oncology patients that are homebound that are still getting that level of care,  making sure that if they have early hydration, early nausea and vomiting, that we can actually get them to an outpatient center for hydration or get a home service in for hydration  and not bring them to the ED. So we have been getting some incentives from some of our value-based contracts because those are such high cost areas.  So sometimes you have the opportunity that if you could bring in some other specialty services, they will actually provide you a little bit of funding.  End-stage renal disease dialysis patients, that's another big one right now for us because we don't have many providers that are home-based primary care providers  that wanna manage diabetes patients and end-stage renal disease patients.  So we have had a couple of payers now say, we will pay you a higher per member per month to manage these patients and keep them out of the hospital.  Yeah, I don't have much more to add, but with the HCC, I have to say it was really,  one of my managers really kind of started banging the drum about HCC like two years ago.  And at first we were like, oh, just one more thing we have to do. But she really did a lot of intensive education and actually started chart auditing us  in making sure we were coding,  accurately coding, like Amanda said, it's like accurately coding for the disease that you're managing. So I think when we understood it that way,  it's like, you're not just managing hyperglycemia, you're managing diabetes with complications like their neuropathy, their retinopathy, that kind of stuff.  You're like, oh, right, like I am managing all that. And she's like, right, so if you're managing all that, you should code it that way.  And so that was a really good, like a hot moment for us. And then, so we really start to kind of really get more just specific about what we were  putting down as diagnosis and really describing what we're treating in that often translated. I mean, just being honest and like,  this is what we're treating diabetes with retinopathy, which is what we were doing that, you know, like we were like, oh, wow, that,  I didn't know that generated a higher ECC coding code. So just, you know, again, telling your story, like this is a group of people we are managing  and they can be very highly complex and we're gonna show you the complexity, you know, what we're doing. So yeah, definitely kind of lean into that. Yeah, I think that's great.  It's one of the reasons we kind of, you know, we kind of put the ethics discussion here. It's just, it's really a change for everyone, right? We've been paid under this other model.  I make total sense. I do this service, I get paid.  And, you know, there are ethics issues with the fee for service. I mean, you know, we all take fraud, waste and abuse training every year.  It might not be fraud or abuse to be on a fee for service model, but it certainly opens up to nobody managing waste if there is waste, right? And so as we think about the ethics,  there are ethics discussions on both sides of how these payment models work. And you just especially wanna be first and foremost open with your team, have this open door policy  and be really upfront and with, hey, I know this is how we've not been paid before. And I know this is really strange and I know it feels like it is a money grab  and it's really not. Now that we're gonna see the expense, you'll see how expensive, you know, Mr. Jones is. And all we're asking for is to get paid for Mr. Jones  appropriately to do this care. And so as we kind of think about those things,  don't overlook how important the change management piece is in revenue capture and in kind of the HCC work.  Okay, slide. So you might say, Amanda, why did you put payer negotiations at the end? My general belief is do all those things really well, then get a value-based contract.  Don't start putting it together after you signed the dotted line. You do all the right clinical work, you understand the financials, you can understand the revenue capture,  you know who your patient population is, you work with your payer to get the patient population, but you understand who they are, who you're targeting to start with,  and then go get a value-based care contract. And so really start to utilize these things in your contract relationships. Create this external story of impact  for market growth and partnerships. And we talked a little bit about that as we went along. I know that 50% of my ED visits are going to your hospital.  That's a partnership opportunity, right? I know that of my entire patient panel, 50% are Blue Cross Blue Shield patients. That's a partner opportunity. And so create kind of,  here's how I fit into your ecosystem. And we did a lot of that in day one of fitting in with your ecosystem. But then capture the individual patient stories  that highlight and tie directly with what you can prove you're doing and how you're delivering on the right clinical care. And you're exceptional at delivering on that slide.  So a couple of technical payer partners, and I would say HCCI has a fantastic half-hour module inside of their resource hub on how you think about value-based care,  contracting who to talk to. But as you're thinking about it, who are the right people to talk to? It's probably not the person you send the first email of interest to, right?  It probably is someone, especially if you have had really meaningful clinical stories, it's probably someone more clinical. It's a medical director, a CMO you can talk to.  Did you provide them with the right information? Have you, again, created that kind of two-minute elevator pitch of why us, how we make a difference in your ecosystem?  And then you create a contract where you can deliver on those results. And we talked a little bit about that again in day one, but you say, here's what I do, here's what you do.  And we all agree that it's not a one-year trial. We're gonna keep trying this and these are what we're committed to doing. And the commitment is really  where our missions are intersecting and we really call that out. It's not just, you will do this, you will grow our population by 20%.  No, it's really the commitment of mission alignment that we're creating a contract around. And then do you have a mechanism for revisiting if the initial efforts are not successful?  Hypothetically, what if you go into a pandemic and something happens and it didn't quite work your first year or the way you thought it was gonna work?  Have you built in some of those exit ramps or re-discussion ramps? If whatever your plan is didn't quite work. But payer partnerships are really successful  when you grow the relationship. Just like any other relationship, you need to work at it. You send them wins, when you win an award, how you're doing, send them regular updates,  take them to lunch, meet with people inside their organization. My payer partnerships are incredibly important to us. They generate quite a bit of revenue for us  and we utilize quite a bit of their expense. And so as we think about those relationships, one example I can give you is during COVID, for example,  our company was able to be pretty nimble and pretty responsive. And so as things were happening, I would shoot an email. As I had a meeting, I would talk about it.  I would carve out five minutes to say,  we hand sewed masks for everyone in our company and everybody inside their family household to make sure that they could be safe.  We recognize that we're nothing without our employees who are showing up every day. We were able to do this. We were part of a clinical partnership  in which we helped for 20,000 community vaccines. So every time there's an opportunity, I said, here's what we did, here's what we did. I sent them a note. Here's a picture of us.  Here's a picture we made in the paper. We got a top 200 company. I mean, I'd send it to them. And those things came out. Their VPs knew about those things.  They knew that we were a community good organization and that we were doing the right clinical work when it mattered. But that's, you keep growing it.  You don't sign a contract and never talk to them again or only talk to them at contract time. Grow that relationship like you would any other relationship.  Because when, hypothetically, if you look at that fourth bullet point, if something doesn't quite work the way you thought because you have that relationship,  I know I was talking about a clinical relationship, but because you have that business relationship and foundation, people are more lenient when something doesn't work  the way you thought it would work. Slide.  So I talked a lot about this. I think I've hit this idea home, but this is a soft skill. Continue to lean into advocacy and partnerships in this very relationship-based work.  There are a lot of resources available. So stay related to payer negotiation resources, HGCI, MGMA, MGMA has, HGCI has great resources and learning hubs and all these courses.  MGMA has a day-long seminar just on payer negotiations, right, and then connect with other value-based care, you know, practices, trying to deliver on these same things.  So before I go to our key takeaways, I'd open it up one more time to Michael and Ina. Anything I missed, anything you'd like to add  as we think about kind of the payer negotiation bucket?  No, I mean, I guess I would ask you, because I don't do as much payer negotiation, like how did you approach the payer that, hey, I would like to join forces with you?  And I guess I'm talking about like insurance payers, you know, not CMS maybe, because that's big, but like how do you get in the door and start talking to them about it?  Well, part of it is understanding kind of the market understanding. The market understanding of, you know, what is our overlap here?  And so we've had a new payer in the last 10 years, and it's really understanding, you know, for us is what is the overlap? How many of those patients do we have today?  Are we making a clinical impact? You know, I mean, we have the benefit of having other data from other value-based care, so we can kind of bring that forward.  We can kind of extrapolate that and say, this is the kind of clinical data we track for those. This is the kind of financial savings.  This is the kind of hospitalizations we track for those. But I also, I always encourage people to go to people's websites, you know, get interviews,  you know, find people at LinkedIn, find your, you always have a connection somewhere in, just to understand the tenor of the organization, right?  I got one, all payers, but patients are important. I got one payer here who is like, it's patient over anything else. It truly is. They are a community organization.  They feel like a community patient organization.  You see it in their commercials, you see it in their website, in their mission. So I don't ever start a conversation with them without talking about a patient story, ever.  I just, you know, and then I got one payer who, you know, who knows who my contract partner is going to be tomorrow. They change them in and out and people are moving around  and it's not really stable. And so I keep building these new relationships over and over again. You know, their goals are different. And so the patient stories matter.  They're not going to be here again, right? So that's not the key thing I try to hit home. The other thing is when you send in these notes, they're not, you're not actually,  you said you have a statement of interest, you send in online and you say, I'm interested in talking to you. It doesn't really go anywhere, right?  And so you have to kind of keep following up on people. So these, you know, payer relationships can take two plus years to build. What we're trying to figure out is  where do you fit in their system? What can you control? What problems are they having that you can fix for them? You know, people are pretty interested these days  in other people that were like, I can fix one of your problems. That is a business across industry interest is I can fix one of your problems.  Yeah, sign me up to hear about what you want to talk about. And we're not a tech company. I have no digs on tech, but everybody in the tech world says they can solve my problems.  But, you know, providers aren't coming every day to payers. You think they are, but they're not. If you're thinking this way,  trust me, they're not coming every day. So providers are not coming every day to payers saying, hey, I want to take more risk. Hey, I want to get more into value-based care.  Hey, I'm more interested in this. You become unique. So, you know, having that clear message and hitting home their mission work and how you tie together is really key.  I had a recent in the last couple of years, we had a patient, we had a value-based care contract on one product. We identified a need for another product.  And so we started this relationship, took two years to build all the contracting and the legal head review and how's the program going to work and all those things.  Well, it didn't work. We ran it for three years and it didn't work. And I'll tell you for a dissolution of that product, you know, value-based care product piece,  I was thrilled that we maintained a strong relationship because we had other things that we had to maintain the strong relationship.  But again, it's this like relationship-based work that you keep trying.  So. Who do you think is usually the entry point like in those pairs? Like, is it like the CFO? Is it an accounts manager? Like who do you usually like try to target?  Well, you know, those things are harder. They have different, it depends. This is why it takes a while to get to know who has the power. Typically you want a finance person  and a medical person who has the power. So they could be CFO at smaller organizations, but they could be directors of finance or medical directors at larger organizations  because of how large they are. They could have been delegated a significant amount of power. But, you know, if you have, you know,  I like to bring, as I'm starting a new relationship, a clinical person with me, who's gonna hit home a real clinical message that we practice.  And we have a clinical and a finance person in the room. And that's the pitch is the head, you know, the person who has some power, clinical and finance, both of those things.  Because I can speak to the business, the finance pieces, how those tie, how those relate to the mission. And the clinical person can answer the clinical questions.  I've never put a doctor in a room with another doctor where they didn't immediately get very specific about a patient case. So you don't wanna bring like a real general idea.  They wanna be able to, well, did you try this? You try, oh, I tried all the things. Okay, great. You did a great job. No, they test you just a little bit. So. That's true.  We get kind of nerdy. Yeah, but like instantaneously. So you have the right person who can kind of, ping pong that ball back and forth and you get so much respect, right?  Like everybody in the room respects the physician who is saying these things. And you have to remember in these payer organizations, almost everybody is not clinical.  Almost everybody's not. I mean, you might have like groups of nurses, but there are very few physicians that are employed by payers. So if you get in front of them,  bring your physician with you and have a really great conversation. And the other thing is there's so few of them in many of these organizations. I mean, proportionately,  that if you can convince one of those, they have a loud voice because when they talk, someone's listening. Yeah, that's a great point.  Thanks. Yeah. Thoughts, Michael?  Yeah, I think the only thing I would add is just, as you're doing these payer negotiations, make sure that your terms and stuff are clear bi-directionally. I mean, the minute,  you gotta remember the minute we are underperforming, they're all over us, right? But there are times, and I'll just use a really good example of,  we signed a new contract and our attribution list within their portal was supposed to be live January 1st. And all of a sudden, they couldn't get the feeds going through our tax ID.  And it was March, and they were gonna penalize us for the first quarter of the contract this year. And we pushed back and said, listen, we didn't even know who our patients were.  You promised us a list on January 1st, and we got the list on March 23rd. So we did push back on that. So make sure as you're negotiating that when payers can't come through  with their portion of what they're supposed to be giving you, I think a lot of times people just stand back and kind of take it because it's the payer,  when really you need to reconcile and be comfortable pushing back.  And that's really part of that relationship. And I have really found that people that are on top of that, the payers really respect that  because they know that you're really invested in to what your relationship's gonna be with them. And they know that you're comfortable coming to them and saying, wait a second,  we were promised this and we didn't get a deliverable from you. So that meant we couldn't deliver for you. So just making that part of that negotiation  when you're talking through these contracts and building that relationship, it goes both ways.  Fantastic point, fantastic point.  Well, we've come to the end of our session. We just kind of summarize it here. These are long game things. These things will keep us, this one slide will keep us employed  the rest of our careers. So that is very good news to keep trying to work on. But certainly throw any questions in the chat and in the Q&A  but I thank you for sitting through our panel. So yeah, and I'm looking forward to our next one. I'm gonna be turning it over to Ina and myself, I guess,  to talk about managing care transitions. So take it away.  Okay, I'm doing the first couple of slides. So we can, we'll just jump right into this, right? Okay, so I'm gonna ask you guys to give me a slides for me.  Okay, so this portion is to identify key risk factors  to effectively managing transitions for complex patients, discuss strategies for effective clinical model and identify the differences in flexibility  to approach care coordination in value-based care. Next slide.  Okay, so the factors that impact transitions,  I think the one thing that always, and this is not, you say prompt notification of discharge.  So the discharge happens, then like, where does it go? Like who is notified? I think this is one of my biggest frustrations and it's such a simple thing to say,  hey, can somebody just notify me that the patient's been discharged from the hospital or from a nursing home? Or from a nursing home? And that is easier said than done,  but those are things that really impact transitions because the thing that I hate the most is like a person gets out of the hospital and I don't know about it till five days later  and oh, guess what? They're back in the hospital because things that needed to happen when they left didn't get done. So, right, so the timeliness of follow-up is exactly right.  If you don't know when they're discharged, how are you gonna be timely in your follow-up?  And then when you get out there, there's usually a bunch of stuff that might be happening all at once. And so figuring out what is first and foremost that you have to take care of.  So really a triaging of what is important in, what did they go to the hospital with? Is that still an outstanding issue? Or what new issues came up  if they left the hospital or nursing home or whatever setting and trying to figure out  what is number one that I have to address and what is number two, number three, number four. Med rec is an absolute must in all care transitions. I think everyone knows that,  but med rec is just a beast. It's just a beast. I actually hate it when a patient goes from the hospital to the nursing home and then they come home  because it's like their medication shifts when they're in the hospital, they get discharged with a new medication list,  they go to a nursing home, nursing home doesn't have some of the medications on formulary, so they shift the medications again. And then when they get back home,  you're like this med list is, I don't even know what to make of this medication list. It's like three transitions and you're basically trying to sort through all three  and figure out what's what and what really needs to continue. It's just a beast and there's no way around it. And the last thing is the support at home  and what kind of really caregiver support is first and foremost, like if they're back home and living alone or unable to do things for themselves,  who's around them to help them, right? And that's oftentimes when I first walk in the door, I'm kind of scanning the room, I'm like, where's the caregiver?  And if they don't have one, I'm like, do they have aides that are coming in to help them at all? If there's no aides, I'm like, oh my God, I really hope this person can manage this  because if they don't manage this, then this might be a failure in selling the patient back into their home setting.  Okay, next one.  So readmissions is just a constant battle. And when I saw this, I was even surprised how high the readmission rate is in three days, seven days and 15 days  for congestive heart failure. So you can really see that when a person who has congestive heart failure comes out, you gotta get on them, right?  Because if you don't see them by week two, they're probably heading back into the hospital. So it's really, really important that you gotta get out there  and quickly start tying things up or cleaning things up or they're going to spiral down and come back into the hospital. Next one.  So never underestimate the importance of advanced care planning, absolutely. The five Ds, you should do it every decade. If there's a new diagnosis,  to think about re-engaging patients in advanced care planning. Deterioration is probably the biggest one. If a patient's going in and out of the hospital,  like my one dad told me, he's like, I think my son's been in the hospital more than he's been at home. Then he's been at home. I'm like, yep. And that's where we're going to talk  about advanced care planning, goals of care and hospice. So deterioration is a huge red flag for advanced care planning. Discharge.  Yeah, I think discharge itself is not a signal for advanced care planning, but again, it's the context of it.  How many times have they been in ED? How many times they have been in the hospital? How many times have they been in a nursing home? How long were they in the nursing home?  So I think it's kind of within the context of what settings and how often they're using  other settings other than the home that should prompt advanced care planning discussions.  And then just kind of changes in their social life, in their like personal social life. One of the things I always worry about, like with my patients,  like I'm just thinking about one of my patients had end-stage dementia. Wonderfully, wonderfully taken care of by his wife. Like the wife was an angel.  I just love her, but she got sick. She got sick and she needed to be admitted into the hospital like emergently. And all of a sudden, here's my gentleman  who has severe dementia and there's no way he can obviously be at home alone and they did not have any family around them. So he had to be admitted into the hospital too.  And it's like those kinds of things. And then, unfortunately he got COVID in the hospital. Oh, it was just a disaster, quite honestly.  So those kinds of things when you really feel like  if the caregiver or the spouse or daughter, somebody that is sick, what is the plan? Like what is the plan for them if the caregiver got sick?  And I often have these conversations with my caregivers of like, what's plan B?  If you are sick, who is gonna step in and take care of them? And there's often not a plan B and that's the sad thing. And so then you're like, okay, there's no plan B.  Let's think about plan B, and let's also nail down goals of care and advanced care planning conversations. So those are just kind of things to kind of keep in mind  as you take care of these patients. And next slide.  Oh, okay. It's Amanda's turn again about care coordination. Great. Well, let's talk a little bit about care coordination. First slide, please.  Let's talk about care management versus care coordination. These get used interchangeably. They might be used interchangeably at your organization.  They kind of have structurally different things. Care management is this more kind of episodic. There might be around a specific diagnosis where we really talk about that kind of,  that population and that targeted intervention, whereas care coordination generally means longer term, where we really think about the medical and the functional  and the socioeconomic and psychosocial, and think about kind of this broader, total whole person kind of care coordination. And so, you know, they're kind of,  both of these pieces are kind of involved. You know, we talk sometimes about how to build these titles or job descriptions as you're building them out.  One thing I would think about is, you know, can you use some of these terms, you know, as we're having new opportunities to kind of use them correctly  and really focus what your intentionality is gonna be on these things. Again, they're still interchangeably used in the community and you may need to kind of get those definitions.  HCCI offers a really great care coordination module that you can also do that includes some of these pieces, but this distinction between care management  and care coordination is in it. Slide.  So as we think about kind of the care coordination and care management, there are kind of five essential elements. You know, how do we think about, and we'll go through each one,  but how do we think about engagement, that trust, that relationship? You know, I know I was talking about that earlier.  You know, how do we think about our proactive strategies for preventative or team-based approach? How do we get everyone on the same page? That alone will keep us employed, I guess,  for the next a hundred years. How do we think about education and best practices? So we'll go through each one coming up here. Slide.  So first let's talk about kind of engagement and it could be a nurse or non-clinical person that, you know, is part of this building rapport. You might have the telehealth provider,  you might have the provider on site, but really how do you kind of create engagement because it's the foundation for all other care management activities.  So, you know, understanding the patient, following through, being consistent, you know, and Ina said this word for word, but how do you have that rapport  before you tackle the big and challenging conversations, whether it's, you know, what is plan B? What is our advanced care plan? What are our goals of care?  And definitely how do you create those boundaries? And so, you know, as you think about boundaries inside of your work, you know, maybe not giving out your cell phone number,  maybe if you do or don't take calls after hours, really define those early on as part of your rapport building, foundational building of engagement. Slide.  So there's also some proactive strategies. So how do we predict and act on things before they occur? We talked a little bit already about clinical pathways.  Can we think about using clinical data to maybe stratify risk? And so what I mean by that is, you know, do we have indicators through AI, through our tech system,  through our past history, right? You know, they've had two ED visits in the last month, right, they're at risk in the next month to go,  you know, at a higher risk than another person to go to the ED in the next month. And so how do you kind of create, or how do you stratify your patients?  What we're attempting to do is get that right resource at the right time. And so thinking about how we get in front of that is using the data at hand.  And then that might be clinical pathways as well. And we did talk a little bit about that, but how do we create those interventions if we know that they're more likely,  they're at higher risk to go to the hospital, to be admitted to the hospital? And then how do you talk about maintaining that communication? How do you make that first call  be the home-based medical practice? And so create care plans that are meaningful to the patient, you know, use their own words as you talk about what are your goals of care,  make sure you truly understand where they've been and what they would like to see, if they can share them what their family is telling you they wanna see.  And we did talk about advanced care planning, so I won't go into that, but this allows quicker response from the family and from the practice when the event does occur.  And so that's really nice is we're all on the same page if something happens because we have a plan in place.  Slide.  So as we think about the team-based approach and I joked a little bit about how, you know, this will keep us all employed for a while, but it will,  there are a lot of players on the team, provider, the nurse, maybe a social worker, maybe a medical assistant, an LPN, you might call pharmacy for a consult,  you might have someone who's helping with some specialists, some mental health work, you might have a say social worker, right? So who's part of the care team  and who owns each part of the care that's being provided and clarifying that reduces provider burden and increases job satisfaction. I know I get involved as a social worker  when this type of order is placed. I know that I'm a nurse in this scenario, right? And so, you know, it really only benefits the patient  when everybody's on the same page with the consistent goals and definitely supporting the caregiver. So that kind of everyone being on the same page  is really, really key, but it's key to coordinated care. Slide.  Let's talk about education. So as kind of the fifth tenant of things around care management, care coordination is prepare those families to be part of a proactive healthcare.  Empower them with knowledge and tools and resources, medical logs, weights, blood pressures, resources for the community. Make sure that it's in the patient's primary language.  Make sure if it's not a written language that you have a translator that you can activate. Education is proactive healthcare.  Assess the patient's literacy level. If they're speaking a certain language, you know, are they understanding the language or are they understanding the complicated language  in which it's written? Or do we need to figure out how to understand and explain and educate in a different way? Sometimes one method, and this is often used as medicine  is kind of the see, do, teach, where, you know, here you're gonna watch one, now you try it, and now you tell someone else and you teach it.  And so, you know, understand if that might be an opportunity especially for things that are a bit more didactic and we need the patient to really be involved  and do a repetitive task. Making sure we understand how that works. And we're very familiar with that in home-based primary care  if nothing else, you know, where are all your medications and how are you taking them? And how often are you taking them? So understanding that and saying,  okay, okay, I hear you on that. Can I watch you take that? And make sure that, you know, if their blood pressure continues to be elevated, not just saying, okay, just tell me  about how you're taking your blood pressure medicine. Let's watch you take that medicine. And so we are familiar in that observational period which is nice for our group too.  And then next slide.  And then really think about best practices. So how do we think about evidence-based strategies, evidence-based work, evidence-based education?  So review the evidence for actionable strategy. Know the population. Who are you serving? You know, is it a geriatric, a pediatric,  a mental health, largely mental health population?  And employ, you know, evidence-based practices and stay up to date on this information. You know, think about bringing your providers together  on a pretty regular basis to talk about case study review. It can get especially lonely, you know, being in the field and being dispersed.  And so being able to keep up on that information. What's being published? What are we seeing in the field?  How are other people interacting with us that we would partner with? And so configure the process in a way that can be easily changed if there's new evidence in that process.  And how do you, what are you going to do there? Some examples of things that we really are gonna have to think about is cannabis use.  What does cannabis use look like? Some of you are in states where it's legal. Some are legal for medical use. Some it's not legal at all. What does that look like?  How do you providers intersect there? So one thing that may be on the docket in the next, I don't know, 10 or 15 years is,  it's not called the city more someone might be able to jump in, but you know, provider assisted suicide, right? And so how would that, how would those things work?  So there are practices still inside of medicine, you know, outside of just their new blood pressure targets or new A1Cs things we got to take care of.  There are big picture questions of processes that we will have to kind of think through and think through as individual practices,  how we create strategies and action in those moments.  Slide.  And identify gaps in care. So we've talked a little bit about this, so I won't spend too much time, but you know, the health plan data is gonna get you  some data, you'll have some EHR data that will come through. And really we're trying to pull together. These are examples of transitions or admissions, meds, comorbidities.  These are things that pull together to potentially create something called risk stratification. And can you risk stratify your patients at every visit?  Include not just the provider, but the nurse social worker to create when we know we're elevating a risk or lowering a risk. So I'll give an example. There's a couple of,  there's a grid on the next slide here that will kind of show what that means. And so this says, okay, if you're high risk, here's the clinical presentation,  here's how often we see you and who is seeing you. And here's some care management strategies, how we're following up with you, how the transition management is going,  how the DME is going. You know, at this high risk, you're getting daily calls. You may be getting frequent nurse visits. The daily calls could be from a lay person,  it could be from an LPN, an RN. You know, that visit frequency is telling us how often are we seeing you? And again, who is the person seeing you?  And so you can get really specific in that. You can buy technology that will risk stratify for you, or you can risk stratify your own patients. So as a care coordination,  you don't have to buy an expensive package. You could take this, you could modify something like this. You can find other examples online and say,  how do I clarify that if I know someone is going down a path and it's getting worse, they were a low two months ago, and now they're a moderate, almost a high,  based on their clinical presentation, this is what I do. Okay, now they're in the high bucket. I'm really providing every resource I can at this moment.  Okay, now they're heading back toward moderate. It was a acute issue, it was a chronic flare up, and now they're heading back towards moderate,  but they're gonna stay at moderate for a while. Okay, great. And we're just gonna keep an eye on them here. This is part of the proactive strategies  that we can do in care management. This is how we start thinking about improving quality and cost is getting in front of what could be happening,  using data to help fund this type of chart, this type of information for us. And then this becomes a really rich spot where we pull out who's doing what.  Again, what are those roles that we're all doing? Slide.  And jump in at any point with questions. So as we talk about roles, here are some roles that we kind of outline. You have the roles on the top,  provider, RN, LPN, or MA, social worker. I'm not gonna go through it all, do not worry, but what is everybody's role? Have you laid it out?  Often roles are laid out only in job descriptions. Have you thought about laying out something like this, or even like a flow chart that's very clear of who gets involved and when,  and when is someone being triggered? These things then can be very clearly translated into your electronic medical record to try to send, okay, now I send it to this person  for my portion of my process is complete, now it goes to the LPN. And so really think about this type of kind of way to set up your care teams and your interdisciplinary care teams  is maybe a little bit different visual than we historically have.  And really, when you think about these positions,  think about top of licensure work. So licensure is run really by the states. And so you can go to the states, or I recommend even taking your different professional groups,  social worker, RN, and subscribing to their monthly newsletter to see if anything new is coming. Is there anything more they can do? Example of an RN is,  they can certainly do CCM, TCM, telephonic visits, and they can do quite a bit of hands-on care, right? They can set up meds, they can do casts, they can do ear lavages, right?  They can do suture removals. Are your RNs doing that? And we don't just want that again in the job description, we want a picture of here's what everybody's doing.  Here's a flow chart, here's a chart of what we're, who's on first.  Slide.  So a couple of things as we think about interventions for care coordination, really think about a comprehensive assessment,  functional, the cognitive, psychosocial, and home safety. Think about interdisciplinary rounds for these patients. You know, again, these, everybody's in the field,  these can be telephonic, they don't have to be in person. Maybe daily you're touching in on patients who are high risk, unstable, or who have had a transition,  maybe a certain type of transition to a hospital, you know, or they've been to a hospital and they've been there more than two days, that might be a trigger point.  You know, weekly for the whole caseload and who's leading the IDT meetings, what does that look like? And you want a kind of larger discussion for,  with team members for challenging cases, but you definitely want to be running your panel, you know, weekly on, for the whole caseload. Is everybody good? Is everybody tucked in?  Okay, nope, we need to focus on Mr. Jones, something has changed over there.  And also think about kind of transition management. These are based on Coleman's four pillars here, but, you know, med reconciliation, the personal health record,  this is not really that common to have a personal health record today, that may be more common in the future, you know, timely care and knowledgeable red flags  that indicate when something is worsening. That is really, really key. Education about conditions, prognostication of when something is getting worse.  And then the RN coordinates with the office to schedule primary care and follow-up visits  if they're going to be in the home or the social worker or the LPN, whoever might be the person designated to go out. But you're doing these kind of team rounds  to keep everybody on the same page.  Slide.  Okay, a couple other interventions here  on proactive communication. You know, weekly calls, everybody has the patient who's seeking validation or connection the Friday at five o'clock,  because they know they're going into the weekend  and if you don't get a call from, you know, if you don't talk to them or they don't talk to you, you know, they're going to be in the hospital, I don't know, Friday at eight,  10 a.m. by Saturday morning, just for that kind of connection. And so use, you know, create that list. Everybody has a small list and make sure you touch base,  make sure it's, it could be risk stratification, it could be clinical judgment, it could, again, just be a list and you have the MA to call, say, hey, I'm tucking you in,  are you good? Are we feeling really good? We'll talk again on Monday.  Think about kind of reliable communication channels. So how does the patient want to be communicated with? Are we reaching them in the easiest way or the family?  Reach out to specialists and service providers. You know, how do you communicate with your team? Do you have a process for what that looks like? What does your team want to know  and what does your partner, service provider, want to know? You know, use documentation templates if you need to, right, to set up between the two organizations  and to make sure you have all the information relayed, you know, correctly. But, you know, use these proactive communication devices to make sure that, you know,  we're building engagement, we're showing empathy, we're building that rapport, we're setting the boundaries, but we're structuring, so we're kind of tucking them in  and we know where everything's going into, especially in a transition over a week into holiday, those kinds of things.  Slide.  Okay, as we think about kind of interventions around education, think about, you know, a couple of different buckets here, chronic condition education.  I won't go through all of these because I'm not clinical, but, you know, how do we make sure that we kind of touch all the different bases around how someone lives,  how someone eats, how someone, you know, what's their support system? Who are they the support system for? And there are really clear clinical pathways  of things that we need to be kind of following here.  And here are just a couple of examples of chronic condition education, but how do we continue to follow up and make sure that if we are going down a route  with the diabetes, you know, that we have the understanding what a glucose monitoring might be if we have a high glucose or something.  Think about community support resource education. Where do you access these things? You know, there are resources for companion care,  shopping, homemaking, respite care, adult daycare. You know, can we tap into any of those things as we see a psychosocial need for those things?  And then self-management of health condition education is, you know, and that might be where the see one, do one, teach one comes into play is, okay, let's see, you watch me do it.  Now you try it. Now you tell me how you do it and how to do it again. Or you tell someone, so you tell your daughter how to do something like that.  And there might be a lot of different things there. Exercises, you know, remote patient monitoring things,  breathing supports in those cases. Certainly pop in with any questions. We're gonna keep going.  Slide.  Okay, so let's talk about a little bit tools to round some of things out, but care management tools. One thing to think about is a transition log. These are very common  in some structured value-based care programs, but really using something to measure existing interventions if a transition or if a transition pattern has occurred  and develop new care management strategies. This is again, where if you can use this data, you might develop a PDSA cycle off of this data,  but how do you create a visual, a dashboard, the right information and actionable information based on the work that you're doing? And you might identify a specific symptoms  or diagnoses that are participating in that transition, but the intervention could be to create a new protocol or pathway to proactively, again, you hear me say,  let's proactively get in front of these things, address the symptoms. And so if you did try to put something in place, you know, did something, did it work?  And you can look at the bottom, the transitions by day or time, right? Now we see one be a, you know, the day 7A to 7P be much larger than the evening.  Well, is there something we can do during the day? Where are we finding these pieces, a transition? It's a specific region. Are they going to a specific hospital?  And just keep digging into that data through the root cause analysis, and then say, can we put something proactive in place?  Is it specific to one person or all people in this bucket?  Slide.  Okay, so I know tools might seem like extra work, but they're about collecting data, and that can turn into more predictive information and pathways. Interact has a tool.  It's designed for long-term care, assisted living, home health, and free. Maybe some things for home-based primary care, certainly for, you know, facility-based care.  But, you know, think about pathways, this kind of consistent pathway or protocol. Think of, determine what's the standard of care. Who is in charge? Who's on first this checklist?  You know, what's the assessment, the documentation here? You know, weight goals, status, heart failure, action plan.  Do you need to procure any special equipment, right? Is there a breathing machine we need to keep on site? Is there a scale that we need to keep on site?  And how often are we going to be doing those things? And then provide that education for the providers and the care teams, and also the patient caregiver, right?  Because we need to empower the patients and families. You know, keep logs, stop and watch, a tool for non-clinical caregivers, right? What does that look like?  And when do you notify the provider? So these are just some examples of tools that care management can think through in transitions.  Slide.  Okay, we are wrapping this one up, but, you know, provide prompt attention and care interventions for patients during transitions.  There are many methods and approaches to care coordination, but make sure to put your own clinical model based on your patient population and leverage flexible payment models  to add to the services and support your payment needs. So, you know, that last bullet point really means if you're in a value-based care system  and, you know, your patients who have heart failure really need a scale in their house, think about how you partner with your payers  and your community partners to potentially get that and not have to buy that. And so think about adding a service, a clinical pathway, a referral, breaking down a prior auth,  if you needed a prior auth or something, build it into place with these flexible payment models. This is the kind of stuff that can be different under value-based care,  and otherwise it's maybe not as much talked about under fee-for-service. So Ina and I will take questions, any questions that you might have  about care coordination or transitions.  Well, we thank you for the opportunity. I think if Margaret would tell me, I think there's a break.  Am I close? I think that's right. I think you're right. Oh, Margaret, you're... Thank you.  Yeah, we're going to break for about 10 minutes right now. It's just after 2 p.m. Central. And then we'll, so we'll return about, let's say 2.10.  Central, and we'll get started with the evaluating productivity.  All right. Thank you. Okay, well, yeah, feel free to stay connected and we'll resume then.  Hi everyone, we're going to extend the break just a few more minutes, so take a minute to use the washroom, grab a snack, and we'll see you back at 2.15.  Hi everyone, just wanted to update you. Our presenter had to step away for a phone call, so we will be back in business in just a minute here. Thanks for your patience.  Can you see me? Yes, I can. Sorry about that. No worries. Okay, great.  Okay. All right, evaluating productivity and staffing. This is my last session with you guys today. I'm so excited to get into it a little bit.  You know, this is one in which it can be a little short. So if you could ask some questions, you know, that would be awesome. Let me know.  Okay, slide.  So we're going to talk about the factors that impact staffing and productivity and describe, you know, different approaches on how they vary on different payment models  and talk about how to measure impact and success. So, like I said, pop questions in the chat.  So we talked about this on attribution, but what population do I care for today? Thinking about the populations, are there attributes, similarities, common conditions  that kind of connect these things for LT status? You know, then based on that information, what resources and supports and partnerships do you need to address the population needs  and produce good outcomes or high quality care?  Expectations might be imposed on you by the model or the payer that you're working with. And so really understand what those things are  and how you're logistically going to meet those expectations because those clinical model expectations are really key to understanding. I'll give an example in for HEDIS,  those measures are very specific. So if you're say you're going to meet breast cancer screening understand your numerator and your denominator,  how often it's updated, what that information looks like. Consider how large your panel size is and how often your patients typically need to be seen. So at the aggregate level,  are we seeing one patient twice a year? Are we seeing them six times a year? Are we seeing them in that risk stratification model,  the high six times a year, the low two times a year, how many is in there and how many visits are coming after that?  But also remember, as you transition from fee-for-service to value-based care, your value-based care visits tend to be lower than fee-for-service because you have that flexibility  to address more in a day. So it's okay if you're not seeing eight, but you're seeing seven, but you're spending extra time with a value-based care patient.  And then think about the patient volume goals that change. So that flexibility in the next one to kind of three years. If you have a growth plan  or going to acquire a new large volume of patients from a partnership, how are you gonna account for that? What resources do you need? Who do you ramp up as needed?  How do you onboard and provide the right training time so you can have full productivity? So as you're thinking about staffing and productivity, think about it as a cycle.  Once you can answer what's my future, keep testing that. What just happened? What was my last year? Was my model correct? What tweaks do I need to make to my model? Slide.  These are a couple of different ways to collect census numbers. You don't necessarily have to collect all, but just make sure when you're talking to someone  or you're reporting it out that it's apples to apples. So what's my average daily census? How many patients do I have today? How many patients do I have tomorrow?  And then what's the average of that? How many total patients did I touch this year? And then what's my active patient census?  So maybe it's my panel that I'm caring for as a provider. Maybe it's the total patient population.  And it's not a daily census that you're looking at. And so I'll give an example. In our practice, we do the active patient census. It's really only polled once a month.  It represents the entire month.  And that is how many patients are kind of for that month. So if the day before we had two fewer or the day after we had five fewer, the day we pulled it is the kind of pages census  and it's looked at by month. You could pull it by a week. Again, if you're looking at it every day, then it would be a daily census. You might average that and say,  well, my average daily census for the month of April is X. And then it is important, I think, I'd like the number of total lives served.  How many total lives do I have in my patient panel? Or how many total people, individuals, did I touch throughout that year? Excuse me.  So total individuals I touched throughout that year. That's a really great number to share with payer partners, with community partners and say,  my average panel size is 1,000 patients, but this year I touched 2,500 patients, right? Or this year I touched 1,500 patients.  Since the start of my practice 10 years ago, I've touched, you heard Paul say this, right? I've touched 37,000 home visits, right? So that's a total.  Those numbers keep accumulating as your practice grows. And that's really important to think about the annual and then the cumulative of total life served.  Slide.  So as we think about measures inside of productivity, think about the average length of stay in the home-based primary care program. Think about the average number of visits.  So your per member, per patient. Again, how are you seeing them? And you can re-stratify that. Six visits for the high risk, two for the low risk, maybe annually,  and then divide that to get a per visit per month amount. Think about your telehealth versus your in-person encounters. And think about your provider time.  So how long is it actually taking, right? A new patient, an established patient, prep time, travel. Think about if you're breaking into a new geography,  where's your central point for your provider? How many non-face-to-face interactions are we having? Documentation, and then your total patients served.  Those things are really, really, really key when you start thinking about how do we think about productivity? Because we're not just looking at kind of total visits  or total work RVUs, because it's not a fee-for-service world, right? We're actually trying to staff based on how often we need to touch the patient  and what kind of health or what kind of care they need and what kind of utilization or time that they'll take of ours. Slide.  You have to maintain performance to succeed in any value-based care contract. And so really, are you delivering on those results? And so some staffing considerations  to think about the delivery of that is, and these are things, again, you can pitch back to the payer. How long does it take to be a new patient, a transitional care visit?  How long is your wait list? Is your wait list geography-based? You're in two counties. There's a new county you're growing, but you need to get to 50% penetration.  50% are signing on before you enter that county and kind of staff up. And then what's your staff retention? These are things you can use on dashboards internally  and share externally. And make sure you understand your service model. Clear expectations and multiple pathways to promote ease of referrals. Primary care, facilities, hospitals.  Can they give you hospice? Can they give you patients?  Resources and responses provided to those. You can't serve. Here's why. We don't go to that geography yet, but we'll keep you on a list  because we're thinking about going to that county in the next 12 to 18 months. And really think about the eligibility targets without being too restrictive.  So I work with an interesting home-based primary care patient program here that's kind of a competitor. And they're very, very restrictive. You've had this many chronic conditions,  this many medications, this many visits. All of those things combined together, then you get in the program. And it's like, can we back up a little bit  and see what the big pictures are?  And they're, you know, the big question now is how do we grow that program? Well, maybe loosen up on some of the restrictions, right? As long as maybe the county restriction  we don't loosen up on. Maybe the age we don't loosen up on because we have the specialty focus, something like that. And then think about quality of care in each interaction  and your staff competency and retention. So just some staffing considerations as you're going into, again, your move to value-based care. Slide.  So the symptoms of fee-for-service is that you have a lot of expensive staff making a lot of visits to high acuity patients. And it maximizes billing,  but it may not always result in high quality care. And it creates kind of a ceiling for services. So you need to adapt your model, but with caution, right?  So as we move from fee-for-service and all patients or all providers are used to kind of this fee-for-service billing to a value-based care model,  managing the capacity really means, you know, thinking about top-of-licensure, think about leveraging technology, thinking about maybe higher cost services  that don't need hands-on care. How do we utilize technology in between visits? And how do we think about potentially virtual care? So in a fee-for-service world,  we're really thinking about managing that volume in a value-based care. We're trying not to burn out the providers. We're trying to use top-of-licensure work.  We're trying to make it vocationally rewarding. We're trying to think about value-based care. We're trying to think about the total cost of care.  And so it's really more about managing capacity. How much can we handle before pushing the whole system over the edge or we need to hire again? What does that look like?  And does it make sense for our mission?  So, as you think about kind of adapting these models, you know, think about who is your primary provider. We talked a lot about in previous programs around, you know, using APPs  and thinking about their involvement, you know, thinking about nurses, social workers, potentially hiring out part-time pharmacists if needed for med reviews.  Think about specialty programs. Do we partner? Do we start our own around maybe behavioral health or a certain aspect of behavioral health?  You know, think about kind of proactive, high-frequent communication. And we talked about kind of those frequent flyers, the high touch, tucking people in.  That really is on care management, care coordination, health education, caregiver support. Because what we're looking to do is provide the best quality of care,  the best patient experience at the lowest cost and not burn out our providers, right? That quadruple aim from IHI. And so there are a lot of ways to keep thinking about that.  A couple others expand virtual care. And we talked about kind of non-traditional staff. That means utilize, not necessarily purchase.  You could, you don't have to buy all of a pharmacist or a paramedic. You could partner with organizations that are doing this work. But think about adapting different care models  for your staffing structure because you're not focusing on as much throughput as you can. Now you're focusing on the quality of the throughput. And there is a volume component.  I don't want to totally undermine the concept of volume and value-based care. You can treat 10 patients really, really, really, really, really, really well.  And you don't have a business. Or you can treat more than 10, right? Whatever that right number is for your panel size, for your providers, for your organization.  But you're not pushing that fee-for-service where we just got to keep getting more people in or we just got to keep visiting people.  It's really, we're understanding what someone needs, when they need it. Can we have the capacity to give that to them? That modeling, moving from fee-for-service  to value-based care, to a different non-volume-based structure is really key about how we adapt that model and how we think about resourcing and staffing. So, next slide.  So a couple of key takeaways, again, understand that population, understand what your clinical model expectations, what the outcomes are, utilize your IDT teams  and ensure, and I use IDT teams, but the interdisciplinary teams, not just, you know.  And ensure patients receive the right care at the right time. And evaluate opportunities for transformation in the future. So some of you are already all in on value-based care  and some of you are still dipping your toes into that. You know, keep pushing that piece on value-based care. You know, if you have a thousand person practice  and you have 10 patients of value-based care, you're not transforming the practice for 10 patients. But if you have 50% of your practice in value-based care,  now you're transforming your practice and you're looking at, how do I get more value-based care, right? And so how do we think about those pieces for this transformation?  But then it requires, again, this different thinking about the workforce and the staffing and what is productive. And I'll give one final example before I open it up for questions.  But we started a wound care company and we built it really as a fee-for-service company. And it just really has not succeeded as fee-for-service company.  There are a thousand reasons why, but we thought it'd be a good idea to start a wholly owned subsidiary. We built this wound care company and it's really cool and it's really great.  It's not succeeding financially under a fee-for-service model. Well, we're a value-based care organization. I thought it would be doing both,  like that CEO perspective, as I thought. We'll build a fee-for-service company that could produce value to a value-based care organization.  We're not pushing margins to the end of the extreme, but we think there's enough volume component in wound care that we could make that fee-for-service threshold  to at least break even on the product. Well, didn't quite work like I thought. And now we're repositioning to have wound care inside of a value-based care organization.  Well, the person we hired is fantastic and has never worked inside of a value-based care organization. And I said, so as we're having these discussions  and they're totally on board with transitioning into a value-based care kind of staffing model and resource and how we think about resources  and opportunities inside of our existing organization,  they expressed to me, but I've always done. That's how I know that I'm successful is I check off 10, 12 visits a day. And I was like, well, in value-based care,  there might even be a case where we ask you not to bill on a patient because you're just doing a consultation as a wound provider. You're not gonna be billing  or you have to tell a health into the situation  where just that is not gonna be billable or something. And so we kind of talked through that. And that's a mindset shift of how do we rethink that even for our team?  So again, another change management opportunity, not only do you have to change the business and how the business of staffing and productivity,  but you also have to change the mindset of I'm successful if I get this many patient visits. I'm successful if I had this many work RVUs. The totally different mindset  if your goal is to keep someone out of the hospital because they don't wanna be in the hospital. Well, then you might spend all morning with them,  but you won't spend every morning with them. You just might spend one day out of 365 days with them and you kept them from the hospital. And so how do you build those things in?  And then how do you think about those things in the proactive way? So I'll take questions.  Okay, I believe I'm going to turn it over to Ina for dementia. So I'm so excited. Thank you very much.  Thanks, Amanda. All right, so I think I only have 30 minutes to talk about dementia, which  just so you know, as a geriatrician, I can spend all day on this topic.  It's like, you know, it's like so much of what I do is dementia. So all right, so I'm going to  really speak through this and give you really big highlights about dementia care. Because again, like, you know, I did a whole fellowship, and a lot of it was dementia. All right,  so we're going to talk about treatment goals for dementia, really kind of focusing on behavior disturbances, and the pharmacological and non-pharmacological approaches for that.  And then recognize the prevalence of dementia and impact on patients, which is really quite, quite large. Okay, next slide. One second, I made notes on this, so I get that up too.  All right, so okay, well, I think, you know, the impact of dementia is just gigantic. I mean, you can look at the statistics on the slide deck. I just, you know, the thing that  really kind of sticks in my mind that's not on here, but basically, by the year 2050,  one in five people will have dementia. So it's just, you know, we're not going to be able to  escape it. Everyone, a lot of people are going to have dementia, and it's going to be something  that we really have to manage in our healthcare system. And I don't think we do a very good job  of it now, so there's a lot of room for it to improve care for our dementia patients. Okay, next slide. All right, so, you know, there's a lot of, a lot of care challenges, I side,  because there, people with dementia, it's just a fancy way of saying memory loss. I tell people,  like, it's not scary term, it's just memory loss is our medical term for it. And so people with  memory issues tend to have medication non-adherence, poor self-care, they have neglect, self-neglect, you know, we see that often. They often have other comorbidities,  and oftentimes, because they can't manage their resources well, they, you know, also, you know, just kind of put themselves in a state of neglect. Caregivers who take care of them,  it's very difficult, as you can imagine, taking care of somebody with memory issues. So there's a lot of fatigue and burnout. And I think the hardest thing for caregivers,  and everyone around them who's caring for them, is that sometimes patients with dementia have behavioral disturbances. Okay, next one. So, you know, it really impacts so much,  doesn't it? With dementia, it's, you know, it can affect your mood, they can, I mean,  everything, anxiety, mania, depression, apathy, their thinking, you know, delusions, hallucinations,  you know, the activity, the wandering that can happen. I have patients who forget that they've  eaten. And so they'll have a huge breakfast, one hour later, they'll tell their daughter, hey, I didn't eat yet. And the doctor's like, no, you just had a huge breakfast.  And then the patient gets agitated because he thinks he hasn't eaten and wants another big,  big breakfast and demands it and gets mad if the daughter doesn't give it to him. So, you know, so  just constant stuff that happens with dementia patients that, you know, they are, that they  forget, they just forget, like what has happened and, and kind of are in their own little bubble  and little old world. So next one. Okay, so there's a lot of treatment, like with patients with these,  these behavioral disorders. They will, I mean, look, 90% of people with memory impairment disorder will experience some type of behavior issues. Unfortunately, there are, they are  associated more with morbidity and more functional decline. And there's really no, like one medication  that's FDA approved for these. So, you know, so that's why everyone, there's like not one sure  fire pathway. I think that's the thing that's really difficult with treating patients with  dementia and behavior issues that there's not one pathway for us to treat. Like it's not like  congestive heart failure where I can tell you, yes, they should have an ACE inhibitor, a beta  blocker, and they should be on an aspirin maybe, or, or like a water pill. That's not for dementia.  It's kind of a hodgepodge of things we use and grab and, you know, to manage these behaviors.  So next slide. So, you know, the main thing I always tell people, the main, main thing is safety.  It's the second bullet, you know, patients with dementia really start losing their insight and  their judgment and, you know, just kind of overall kind of reality in some ways. So the  thing is, is that you have to make sure they're safe. You know, that, that's really paramount.  The other stuff, you know, that, you know, function, sure. We want to make sure they, they can still be mobile. They can still, you know, do as much function as they can,  but really it's safety because you'll have instances where patients wander out on the street. I had a lady the other day who left in the middle of night in a really bad neighborhood  and just wandered away. And, you know, the family basically scoped the whole, whole neighborhood at three o'clock in the morning trying to find her. So safety is,  is just really paramount with the dementia patients. Next slide. And, you know, it often takes a village really to take care of any elderly patient who's trying to age in place,  but especially with dementia patients who are aging in place you have your home-based primary  care providers, you know, but I often say my role as a doctor is pretty minimal when, you know,  you're really kind of caring for these dementia patients because oftentimes medically they're  really, there's not much to do, you know, with dementia. We don't have a cure and the treatment  options currently out there is not great. So it unfortunately is really a disease of time where  they slowly just deteriorate over time or we're just making sure they're safe and we're, you know,  kind of supporting the caregivers. So, and again, you know, hoping their function doesn't decline  rapidly, but often because of the dementia, they're, they're they will decline. You know, it's just unfortunately part of the disease process. So I often, often talk about like my  social workers are like my magical workers, my magicians, where they can bring in resources to  the family to help them really ease through all the transitions of dementia. So again, I tap into  all these people listed here, but my social worker, my nurses, I mean, everyone, I tap into  everyone, anything to kind of ease the transitions through the stages of dementia. Next one.  Okay. So so the evaluation steps, you know, how to kind of manage them, dementia, medical history,  of course, is important to just, you know, see what other factors that could be affecting their  health medications. Absolutely. Some medications, you know, in geriatrics, we always say less is  more. So certain medications could have drug side effects. If they don't need it, decrease it. Laboratory testing, somewhat, somewhat important. I mean, if they have other  comorbid illnesses, sure, you know, like diabetes, chronic kidney disease, of course, you want to  make sure they're, they're stable. So again, managing all the other medical conditions is  important to, you know, make sure just overall health, they're okay. The other thing is really  assessing the environment. And I always tell people, like, the main thing about the environment  is, do they have caregiver support? Because dementia is a, you know, unfortunately, it's  just a slow decline, their memory will get worse, their functioning will get worse. And so they  need people around them to, to aid and support them. And if they don't have that,  then, you know, unfortunately, they're not going to age in place very well. And there's got to be contingencies made to think about moving them into a nursing home. Okay, next one.  Okay, so non-pharmacologic interventions is always first and foremost, always try this.  I really, so the five bullets here, the one that I really tell people to, to really kind of do is  provide structure. They're not good patients with dementia, especially in the moderate to end stages  of dementia, they get confused easily, you know, it's just, unfortunately, it's just a matter of  their brain unable to receive input, a lot of stimulation, process it and understand what  they're supposed to do with all the stimulation. So you'll see that families will say, like,  it's really hard to get mom out and not for her to kind of freak out. Or, you know, going to my  brother's house now is like a complete disaster, you know, so it's because little changes that you  and I can obviously manage on a day to day, they cannot manage it, it's just too much stimulation  for them. And so I tell people, it's like structure, structure, structure is very good,  have a very set schedule with them. And they tend to calm down and do well with structure. So at  this time is breakfast, you know, then we have a little like activity. And then we do this, you  know, basically provide structure for them. And they tend to be able to maintain the sensory input,  and then they tend to calm down. So I always tell people were like, they're kind of like,  you know, freaking out. I'm like, I need you to give them structure in a day. Okay, next slide.  So all right, I'm going to run through a lot of I'm going to run through these, these things that we tend to turn to, when the non pharmacologic interventions don't really  work, or they're not working, or the family's calling, because mom and dad, or anyone is not  sleeping, and I can't, I need them to sleep, because I have to work, I'm burnout. And I'm,  I'm like, gonna, like, just lose my lose my mind, if they don't sleep, or they're agitated,  they're hitting the providers, I'm sorry, the family members, or they're just they're yelling  out, or they're hallucinating. So, you know, various things I get, you know, called about from  family members, and, and we do reach for these pharmacologic interventions to kind of try and  manage that behavior. So I'll go through them. Now, none of them is magic, I just want to tell  you that right off the bat, none of them are magic. But we, you know, I'll go through kind of some of the pros and cons for each one. Okay. All right. So I think the first one,  if you can advance the slide. Oh, I'm sorry, I do want to say that I really want to thank Dr.  Ellison, who actually works with me here at Christiana Care in Delaware, for, and he's a  geriatric psychiatrist to that put together these slides. So yes, I actually talked to Dr. Ellison  right before I came to about these slides. All right, first is Haldol. This is, I think,  the favorite for hospitals to use when a patient shows up and they're agitated and give them Haldol.  Unfortunately, my beef with hospital systems is that they basically give them too large of a dose,  and they snow a patient, and then I can't wake them up for another two days. So, you know,  taken point is, is that, first of all, it is very effective, but you don't need a lot to just take  the edge off. I tell people, I was like, I'm not going to give them a big amount to sedate them for  two days. I just want to give them a little bit just to take the edge off. Right. And that's,  that's really all you need. You know, on the outpatient world, we don't really tend to use  Haldol very much. It has a lot of anticholinergic properties. So constipation, dry mouth, those  things are just, you know, like just a beast to deal with. So we just really don't promote this  on the outpatient side. So, you know, if you're on the outpatient side, we really tend not to,  you know, go to Haldol first. Okay. Next slide.  All right. The atypicals probably are one of the most used class of medications for agitation.  You know, so look, I use them, I'm not going to lie. I definitely use it, but I think, you know, again, they're, they are anticholinergic, some anticholinergic better than Haldol,  so a little bit safer than Haldol. And they really only have modest, modest benefit for  agitation psychosis. And, you know, Dr. Ellison has given this talk to like the geriatricians in  our system. He really actually says like most of the studies are, you know, a big question mark,  whether they really help or not. So, you know, he's like probably the best evidence for these  is probably, you know, I can't say the generic, the Ariprazole is like Abilify or Risperdal.  And so he's like probably the best for those. So, you know, if he usually reaches for one,  he reaches for those. So if Dr. Ellison does that, then I do that because he's like a geriatric  psychiatrist and he's really, really smart. Okay, next slide. So the atypical antipsychotics  really remember there is a black box warning on it. There was seven clinical trials of this,  and there was deaths that were highly, they were associated with these class of medication. Most were heart-related or infections. And it really was with, you know, all of these  antipsychotics. And so, again, when I do start these medications, I do tell families that there  is a black box warning on them. Okay, next one. Okay, so basically the American Psychiatric  Association really feel with, you know, with treatment of dementia with behavioral disturbances  is really, again, try the non-pharmacologic interventions first. Antipsychotics only when it's really severe and dangerous and causing significant distress to the patient. And I  would say, and or caregiver. Okay, Haldol's never, first line choice, never. And modest support with  Risperdal for psychosis agitation and Elanzapine and Ariprazole for agitation. So, so those are,  I mean, I usually kind of reach for Risperdal if, you know, because that's what Dr. Ellison does too. So that's what I do. And you can actually monitor treatment response with the  MPI, the neuropsychiatric inventory. And you, and I actually do recommend, and so does Dr.  Ellison, we do try to recommend a taper after four months. So once you stabilize the patient and they're pretty stable, you know, it's, you should just try to get them off of it,  like taper them off of it and see what happens. Because sometimes it's just like a temporary thing. Whatever they were responding to is, was temporary and doesn't need to continue,  continue for years and years. And I often see that on patients' medication profile, right?  You'll see Risperdal on a patient and I'm like, why are you on this? And the family has no idea  why they're on Risperdal. And I'm like, were they agitated? And they were like, oh yeah,  he probably was agitated in the hospital or the nursing home. I'm like, but he's cute, you know,  completely calm in the home. I'm like, well, I don't think he needs it. So let's just try  him off of it. And usually they do totally fine off of it. So just remember to think about doing  a trial of tapering them off. Okay. Next one. Okay. So I think we talked about some of this,  I mean, document, you know, that we can really kind of follow the process, you know, education,  consent. Remember there is a black box warning. And again, just reassessing, assessing how, how are they doing? We started atypical antipsychotic, how are they doing with it?  Are they still agitated? Well, can we do, you know, non-pharmacologically to kind of calm them  down? Can we give more structure? You know, is there certain people that agitate them? Are there  shows that agitate them? Can you do other things like soothing music? I had a son who was just all  about non-pharmacological stuff. He didn't want to give mom any medications. So when you walk  into the room, it was like this really peaceful Zen room. It was like, you know, dim lighting.  It was aromatherapy. He had beautiful, like soft music going on in the background. I mean,  it was like very chill. Even I was kind of like, this is awesome. I'm feeling very calm and  de-stressed, you know, being in this room with your mom. So, but he was just all about like,  I'm just going to make things really like easy and, and everything smells good. It was wonderful. It was a wonderful environment that he put forth. So really kind of, you know,  think about doing some of that kind of stuff. Okay. Next one. All right. The next big class  of medication that I think we all turn to next is the benzos, benzodiazepines. And I'm going to  tell you, I don't love it. All right. I don't love this class of medication. It's been, you know,  very much associated with high falls risk for the elderly patient. So this is never something I  reach for first. So I, you know, I do tend to probably use the antipsychotics and the next  class of medication, the antidepressants that we're going to talk about first, before I even  ever entertain this, just because of it causes sedation and it makes people fall and fracture.  And, and I just don't think it's a wonderful medication at all. So so the other one I do sometimes use is buspar though. Buspar is pretty mild, very mild side effects. So I,  I do use that one for as an anxiolytic. Okay. Next slide.  So antidepressants is probably what Dr. Ellison says we should, we should basically  use first in a trial looking at selexa and the antipsychotics or citalopram. Sorry.  It, you know, citalopram actually was shown to be more effective, believe it or not more effective  than antipsychotics for reducing anxiety in dementia patients with behavior issues. So I  tend to use the citalopram especially if they don't have any cardiac risk factors, because the  worry about citalopram is that it can give you EKG disturbances and prolong the QTC interval.  So, you know, if they have a heart issue, I tend not to, you know, reach for the citalopram. I  might go, I will use a cousin of it, which is the escitalopram, which is Lexapro. Okay. So, um, I actually, when people say, oh,  my mom's, you know, anxious and agitated and, you know, they have dementia, my first medication and  Dr. Elson's first line of medication is to use escitalopram and escitalopram. Um, and then maybe  add on antipsychotic, if that's not, you know, the escitalopram is not working. Um, so that's what I do just because the study shows escitalopram is actually more effective, the  antipsychotics and yay, that's much better side effect profile than the antipsychotics. So, you know, why not use that? So, okay. Next one. Okay. So now we're going to get into, um,  medications that are less utilized to be quite honest. And I, I have to say, when I start  thinking about these medications, I usually do try to run it by Dr. Elson, um, to see whether  we should use it. Um, so the, there are ones that, um, you know, you might also want to think about  using is, uh, carbamazepine. It, there is some modest benefit. So, you know, people, psychiatrists  use it for like a mood stabilizer. Um, so, you know, carbamazepine actually kind of, you know,  falls in that category. Um, I have seen people use Depakote, but Dr. Elson actually really does  not like Depakote. Uh, he doesn't feel like there's ever really any good evidence for it, except for maybe in, in like some mania cases. So if you're going to use like a, like a  anticonvulsant for like a mood stabilizer, use carbamazepine. Um, only thing is, is that, you know, they can affect the LFTs and you do have to get, um, blood levels on them to get  them to the right target range. So there's a little bit, you know, cumbersome to use. Okay.  Next one. Okay. Clenidine dextromethorphan, sorry, is, um, this is the, uh, the brand name for this  is called Nudexta and people, um, some people use it. Um, I've never used it, but Dr. Ellison has,  is really for people with like a lot of emotional incontinence, like quote unquote, emotional  incontinence, where they have just sudden outbursts of uncontrollable inappropriate behavior, like  laughing, they're crying and is related to their neurological disease. And you not only see  inpatient dementia, but you also see it with people with like stroke or MS. MS tends to have  some of this, like, you know, emotional lability that happens. Um, and Parkinson's, you know, uh,  people with traumatic brain injury. So this medication actually, um, has shown in one randomized control trial to show, uh, to reduce agitation and aggression. So again, you know,  something to think about, uh, for, um, people with really a lot of emotional ability. Okay. Next one.  Okay. Uh, okay. Drinabinol, um, is, you know, something we use, uh, some evidence of this. I  think medical marijuana is one of the things that really is being touted out there there. So one of the things I just want to really highlight here is that there's really no,  no clinical trials that shows that medical marijuana actually helps with agitation in Alzheimer's. I know in Delaware for it, when we do the medical marijuana application,  like dementia, it's actually one of the check boxes you can check off on to say, yes, they  have dementia and you can get medical marijuana, but there's really no trials, which is I think  fascinating, um, only anecdotal evidence that it works. So, you know, got it. So just, just know  that do what you want with it. Um, but you know, for some of my patients, uh, I have used it in  I'll tell you, it's been hit or miss, uh, you know, some people have said it works and some  people said it did nothing for their parent, um, except maybe make them more, uh, um, tired,  but it's like a sedating effect. I'm like, all right. So, um, so just kind of take this class  with like a little bit, like, you know, just, you know, kind of think about it before you would do  it, whether there's really good evidence and starting it. Okay. Next one. Okay. Stimulants,  um, you know, some stimulants are really for the people with apathy. Like, you know, like you'll  see patients or families would say, oh, they're just sitting there all day. Can't get them to do  anything. Can't get them to get up and like do engage in anything I want to do. Everything is  like an effort. Um, you know, some of this might be depression, but sometimes it's even, you know,  you've treated the depression. You think you've treated the depression pretty well, and they're still kind of like blah. Um, so then you might want to think about adding like a  stimulant, like methylphenidate, which is like Ritalin to really kind of try to give them a  little bit boost. So some, so, so you can use it in that situation. Um, bupropion, Welbutrin also can benefit, um, apathy, um, usually is, you know, can use oftentimes with  citalopram. Citalopram is like SSRI. Bupropram is more, more epinephrine and dopamine. So  combination of the two can sometimes really kind of, you know, boost that patient up even further, um, as an anti, uh, as like a dual effect antidepressant effect. Okay. Next one.  Oh, next slide. Sorry. Okay. Here we go. Um, so here are just kind of other things to look at.  Um, you know, paracetamol is just Tylenol. It's just acetaminophen. Uh, I think actually the  paracetamol in opioids is really interesting because I'm thinking people probably have pain  and they're agitated because of the pain. And if you treat the pain better, they are not as  agitated. So, so just kind of think about that also is that, you know, sometimes people with  dementia can't tell you what's wrong with them. Like, is it, are they just constipated? You know,  and they can't tell you they're constipated. So, you know, ask about constipation, like, are they constipated? You know, do they have a UTI? Right. So ask about UTI symptoms. Um,  sometimes it's a medication effect. Um, sometimes it's because they're not sleeping well, and that's why they're agitated. Or again, sometimes there's some environmental stimuli  that they, they hate, you know, but they can't tell you that they hate it. So they're agitated.  So you really kind of have to be like a detective, like, you know, what, what is triggering them?  Like, what are things given standing tunnel, you know, I give people like with known arthritis, so you can see their knees. So like you have arthritis, you know, give them standing  tunnel orders of like, you know, tunnel, like a thousand milligrams, three times a day,  or a thousand milligrams twice a day, or maybe just a night. So they get a better night's sleep.  And those are things to kind of really help with, um, you know, again, calming that agitation down.  Okay. Um, next one. Okay. So insomnia. So we talked to him about like, you know, sleep, sleep is important for everyone in the family. Um, not only for the caregivers who really,  you know, at night they need to go to bed, uh, but they can't go to bed if the patient's up because the patient's not safe. If they're up in a row, roaming around in the house,  who knows what they're doing. And, um, or they might just wander out of the house, like I said earlier, and just leave. And that's really unsafe. So everyone will like the patient  to sleep so they can sleep. The one I probably tend to use most is, uh, either Ritazapine or Trazodone. Uh, I don't like to use Zolpidem just because Zolpidem actually has been, uh,  has a carryover effect can make people drowsy, drowsy. It also has been associated with high falls risk. So I tend not to use Zolpidem or Ampions of the world, uh, but I would use  Trazodone. Um, so some evidence shows that helps with insomnia, agitation, and, um, and Ritazapine.  I definitely use Ritazapine for not only sleep, but if you feel like they have depression,  um, or they're losing weight, then I, it's like a triple effect and I give Ritazapine very low  dose at 7.5 milligrams. Okay. Next one. Oh, I want to go back one slide. The, um, I do want to just  say that Diphenhydramine, which is Benadryl is not to be used, uh, anti-cholinergic. So Benadryl,  so Tonal PM. So everything that has PM or makes you sleep like over the counter, usually has some  type of Diphenhydramine compound into it. And it's not great to use in the elderly because again,  it's anti-cholinergic, urinary retention, constipation, and it can also cause delusions  and actually should have been shown to, uh, give you worse sleep than if you didn't take it. So  definitely, um, do not take it. Um, and then, you know, people use Melatonin. Um, I'm not sure  why I actually was going to, uh, forgot to tell Dr. Allison that he has to maybe change this,  but we do use Melatonin for older people who don't sleep well. So I actually do use Melatonin,  um, and, uh, and, and see if that works is pretty mild and some people get good effects from it. So  I, I do use Melatonin for sleep. Okay. And next one. Um, okay. Oh, and then this, uh, also  generated some, um, press when it came out, the Pimavanserin and, but it's only really associated  for, it's only really approved for people with Parkinson's disease and psychosis. So there was  one randomized controlled trial that actually showed that decreased hallucinations and delusions,  um, for patients with Parkinson's disease. Um, and it actually in Alzheimer's, they also had a  recent randomized, randomized controlled trial that showed acute benefit for treating psychotic  symptoms. The problem with this is that it's very, very expensive. Um, so, you know, you probably  have to fail everything else up top for the insurance plan to approve this medication. So,  you know, so it's not something you reach for like right away. Okay. And let's see anything  after this. I don't think so. Right. Okay. So, you know, basically, you know, dementia care  is very multifaceted. Um, you really have to look at, gosh, there's just so much to look at,  right. You have the disease itself where you lose a lot of function, um, and then how it affects  the caregivers around them. And again, safety is a paramount treatment goal for patients with  dementia, uh, safety and function. And really I tell people you have to support the caregivers.  Absolutely. They're the unsung heroes of our country, uh, to care for these people because  24 seven care with no vacation is exhausting. So I always tell people, like, if you get a moment,  just remember the caregiver is doing superhero work and just ask them how they're doing. Um,  it really makes them feel seen. And sometimes they, no one sees them. No one gives them a  pat on the back, certainly not the person who's who they're caring for. So give them a pat on  back. You're like, you're doing a really great job. You know, I really try to boost the patients,  the caregivers up because they really are. It's, it's just unsung heroes, superhero work.  Um, non-pharmacologic interventions should absolutely be tried first. Remember, look for triggers, look for triggers on what might be causing their agitation and really,  and try to remove it and then try to make the environment soothing. Make sure that it is a  structured environment, structured day plan, evening plan. Um, and patients usually tend to  calm down when things are simplified for them, you know, their structure. All right. And I won't go through all the pharmacological interventions, but there are many as I showed  you. And, uh, and again, I think the takeaway point, the pearl is to try the SSRIs, especially  the Celexa and the Lexapro first, the acetalpram first, and then the second line will probably be  the antipsychotics. Okay. All right. And those are, that's, that's dementia in a 30 minute  timeframe. So hopefully you got a lot out of it. Any questions about that? Okay. Thank you.  Thanks, Ina. Appreciate it. Michael, we'll pass it on to you.  Yes. Thank you everybody. So, um, so yeah, we're going to talk a little bit just about, um, you know, hiring the right people. And once you hire those individuals,  um, how do you support them? And I think, you know, we've, we've all really learned, uh, you  know, through this pandemic that, you know, um, staff resources are, are, are valuable and, you  know, I think burnout is, is, is real. So, uh, so let's jump to the next slide here and we'll talk  a little bit about what we want to accomplish today. Um, and the first one is just going to  be that we want to really think about how do you create a, a really strong hiring practice as you  start bringing individuals in and really making sure that you, you are able to, to match the  right individuals to this type of work. Um, and then we're going to talk to just a little bit  about how, um, you're just going to recognize some of the common stressors that are, are faced by a lot of our, our home-based primary care practitioners. And, you know, how do we  identify these early on so that we can help out and support our, our staff doing this work every  day? And then how do we just implement operational administrative strategies to just really provide,  you know, patients with really good, high quality, compassionate healthcare and, and safe healthcare,  um, while also trying to avoid, you know, uh, our, our providers being burned out or, or not satisfied within their career. So next slide.  So, um, you know, a lot of times, you know, home-based primary care providers, you know,  there, there's many disciplines sometimes that they can lead to the right mix of people doing  this work. Um, you know, I think that, you know, depending on what your practice is, is trying to  accomplish or the population that they're trying to, to manage, um, really drives the skill mix of,  of, of what you're trying to do within your practice. So for instance, our practice is mostly,  uh, you know, patients 65 and older that are homebound, but we do have about 30 patients  that are under the age of 65 that have, you know, um, some, you know, severe chronic diseases,  they're disabled, um, or a variety of things that, you know, make them like a 65 year old patient.  But yet sometimes we have to realize that those individual patients don't always fall into the  traditional treatments that, that we would do for some of our, our older population. So we do have  to modify some of the, some of the stuff that, that, you know, or, or the treatment guidelines  that we, we are providing for those patients. But really, you know, a lot of times traditional  primary care or hospital medicine providers, internal medicine, I think for a lot of us, it's,  it's, it's a geriatrics driven, uh, program, but we did last year bring on an internal medicine  provider that, that was, uh, that was part of our hospital medicine group to really help us manage  some of these patients under the age of 65. And this year we're actually, uh, adding a couple of  pediatricians for some complex care pediatric that is going to run through our practice. Um,  and, and we're going to see how that program goes this year, which is in our pediatric population.  But when you're creating these job descriptions, we really want to be thoughtful, uh, about how  you post these jobs. Um, you know, making sure that we are, are scoping out the work and the  expectations of the individuals doing the job. And then, you know, are we going to target specific  disciplines? Um, and, and again, you know, I want people to think a little bit, you know,  outside of just thinking of physician and nurse practitioner, PA, but it's also about the nurses  you bring in, the social workers, the schedulers, and, and all of those individuals that, that we  have to really think about as you, as you grow this team. Um, you know, depending on the market,  um, you know, um, some, uh, you know, some may have to use, you know, agencies to help recruit  these individuals, but, um, you know, it is important to look at your market and, and really,  you know, be able to, you know, tie the costs of these positions. You know, we talked about finances  earlier in our, in our, in our panel discussions, making sure that the, you know, all our overheads  and everything that we need to factor in. So a lot of times the market itself, and I'll just,  you know, use the example in San Francisco, you know, my nurse practitioners are union nurse  practitioners and, you know, the average nurse practitioner in, in my practice, you know, they  are hourly, they're not exempt employees. So they are an hourly employee because they're under the  union and most of them start out at $130 an hour, which is, you know, not a whole, whole lot less  than what a lot of our providers are at. So you have to think about as you're, you know, as we  staff the model, what are the right pay skill mixes and, and, and, you know, you have to factor  that into your budget. Um, the other thing is, is, you know, um, you might have to, uh, adjust your  hiring methods if hiring is really difficult. And right now, I mean, we know that there's a shortage  of not only, you know, physicians and nurse practitioners and PAs across the country, but also nursing staff. So you may have to think about, you know, can you go with a medical  assistant model with your providers or are there other skill mixes such as healthcare navigators or  community workers that you could bring into the practice that, that would have a very meaningful,  um, way of being able to attribute to the, to, to the, to the, um, you know, to the patients that  we serve. And then I think the big thing is just making sure that you have some type of a policy  around equity and, and making sure that, you know, we, we, we value the fact that depending on the  types of patients we serve, we want to try to recruit, you know, uh, providers that speak the  same language as our patients, uh, providers that look like our patients. Um, and, and you might  want to, you know, do a really good, um, analysis of your demographics just to validate that,  you know, you do have the right, um, you know, groups of individuals that are, are, are caring  for our patients. Because, you know, again, I think, you know, through the pandemic, we started  to find a lot of disparities and, and, you know, we assumed a lot that, you know, we were managing our patients appropriately only to find that culturally,  we weren't managing them really well because we didn't have people that were like our patients or understood the culture and so forth.  So I think a couple of these that we put in here,  sometimes you have to simplify the hiring process. I think this really depends on if you're a private agency versus like a large academic center where I come from in the sense that,  I can't really adjust what counts as a Tardy or what we give for benefits for all of our individuals. But as a private practice, as you start setting your pay practices up,  your benefit practices, start to think about what kind of helps people manage their work-life balance and what type of leaves do they get in those types of things.  And then make sure that you review your benefit packages frequently.  I think a lot of newer employees are looking for more expensive coverage, not less. So as you offer out insurances and paid time off  and sick time and childcare benefits and things like that, just to make sure that you are reviewing that based off the needs of your employees. Next slide.  So the next one, we'll just talk a little bit about retention and your practice. And again, right now, many of us are having to figure out and create some type of an incentive  to want to keep our employees. Turnover is really, really expensive. If you think about it, to onboard a nurse practitioner or a PA or a physician,  specifically if they've never done home-based primary care  it almost takes that first year just to mentor and get people comfortable in doing this work. So I think it's really important that you start to really think about  how do we mitigate some of this turnover? How do we balance out, again, work-life balance?  And really start to think about how do we incentivize our teams a little bit more for the great work that they're doing? Because we know this is really hard work.  And again, you might want to think about benefit increases  when a lot of times, zero to five years, you get so much vacation and sick time and so forth and just building up what those would look like and that people earn more  as they're with your organization longer. And then for some, especially if you're in value-based, think about some type of a bonus structure to incentivize people when goals are met  or when you're meeting your quality metrics or you meet shared savings. And again, that bonus doesn't always have to be in the forms of dollars.  For instance, here at our organization, a lot of times what will happen is we, as an academic center, it's really hard to incentivize providers.  But what we've done is we put programs together for providers that are doing outstanding work with their HCC coding  when they're meeting all of their practices quality metrics that we've done things like brought in scribes and those providers will get scribes  to continue to help them be more efficient because they're meeting their goals, they're providing great high quality care. So it's sometimes an incentive in the form of an FTE  or something like that.  And then also have some type of a program  and determine how do you recognize your employees for doing really good work or when they deliver on these goals or outcomes. And again, it doesn't always have to be  in the form of money, but it can be buying lunch one day for us meeting a milestone or something at the end of the year around the holidays is having a nicer holiday party  or something like that. But really just thinking about how do your staff like to be recognized and what types of things can we do with that?  The next one is just using existing networks to attract high quality talent. And again, I think this is getting really hard to do  because everybody's recruiting high quality talent right now and I think people just have so many options to be able to go where they want to go. So you may have to get creative  on what makes your practice stand out from others.  Make sure that you have a very transparent and clear vision of what your practice is about when you can do that and how do all the employees fit into the goals?  Because again, when you hit these value-based contracts, we're all moving towards the same, we're all moving in the same direction. We're all trying to strive for the same goals.  So we wanna make sure that everybody else is on board with that. And then again, as we talked about, understand your stressors, grief in the workplace and continue just to try,  reduce or provide a lot of coping strategies, whether that's through an employee assistant program.  A lot of times now our insurances that we contract with insurance for our employees have behavioral health, counseling, family counseling,  a variety of things that people would have access to. And you also have to remember, sometimes it's not about what happens outside of work, but sometimes there's that counseling  and support that has to do with people at work. And you may need to think about,  what do you do in setting up a program around supporting our employees when there's deaths of patients? And I don't know about your practices,  but we have about a 40% turnover a year in our practice due to deaths because we do a lot of end of life care in our practice. And that takes the toll on our providers every year,  specifically when a lot of these patients we've had in our program for five, six, seven, eight years that we've managed them. Next slide.  So let's talk a little bit about some stressors and some of our top stressors here. And we threw a little list out here, but I also want people to throw in the chat,  what are some stressors that you identify within your practice? But it's a lot of work being the mediator  between family members when you're caring for a patient and now you have the children that don't all believe or are not all on the same page with the goals of care for the patient.  And a lot of times, as you know, when our providers go into the home, they get into the middle of this. And this is why it's really important to think about  what other individuals in your practice, such as LCSWs or MSWs, or again, those healthcare providers that can help our providers kind of help mediate  some of these families and some of these conflicts we have, because it can take a lot of time away from the providers being able to see other patients.  And a 30 minute visit sometimes can turn into a lot longer of a visit when you get into the middle of that.  And again, there's a lot of other things that go on in our practice. Again, there's a lot of other things that go on in households. I'm sure many of you have run into the situation  where Mrs. Smith lives in the house with her husband, and then there's five, six, seven, eight other family members that live in the house.  And all those family members have different dynamics. There's other behavioral health issues within the home and so forth.  I think for a lot of people, our own electronic health record and the paperwork is a really big stressor. We have lots of paperwork that we have to do  for our patients around home care, around DME.  We have all these charting requirements. We have our HCC coding requirements. So sometimes just building into a medical record system,  the way that you can make it a little bit simpler for your providers can be really challenging.  It's hard when you have to change out that system or when updates come to that system and so forth.  I think right now in today's world, we're all feeling financial pressure.  I think that a lot of times, we have very, very, very complex patients that the complexities outweigh some of the resources that we have. And a lot of times,  I think a lot of our home-based primary care programs are inadequately funded for the level of care that we are providing to patients.  And again, I always tell when our CEO or CFO comes  and says, what is different in your practice that's different in our other big internal medicine practices that are taking care of the same complexity of patients?  And my answer is, is number one, we're running around town to go meet these patients because they can't come out of their home. We're coordinating lab and x-rays with companies  that aren't internal to our organization. And on top of it, we have the dynamics of the family and the caregivers that are really burned out and we have to support them.  And we put really good goals of care together. And I reiterate that with showing them our outcomes to say, and this is the reason why every,  if a patient stays in our program for six months, we reduce their ED utilization by almost 45%. We reduce their hospital admissions by almost 35%.  And consistently we do that with every patient that we bring into our practice. And you don't see that within our internal medicine practices where patients come to inpatient  and they have much larger, are in-person and those doctors have a lot more,  a lot more expectations on how many patients they take into their panels because we're going to the patient.  Again, just patient adherence with care recommendations. This can be really difficult. We have a policy in our practice that any patient  that's on any opioid or benzo is required to have drug screens for other drugs that are being performed. They sign a contract. They have one time where a drug screen  can come back positive.  And then we have built into our protocols with our risk management team on what the next steps are for those patients around us continuing to prescribe.  A lot of our patients now we've been working on actually weaning off all controlled substances. And we've been doing a lot of work around prescribing  Suboxone and things like that to patients that have been on these long-term medications and really trying to think about how do we get them off of them.  And again, there's contracts around that that we do but really we want to set up these goals of care for our patients. And we want to promote a lot of our patients to provide  good self-care for themselves and but realistic with their plans of care.  As we know scheduling and the logistics of getting people around to go do these home visits making sure that geographically we don't have providers running from this end of a county  to that end of a county or this part of the city to that part of the city. But it takes a lot of work and a lot of pressure on our scheduling and office teams to make sure  that we're sufficiently putting our providers  in areas each day where they can see their maximum number of patients and not be running around trying to find parking and so forth.  And then again, I think a lot of our providers feel unsupported in the field. I mean, a lot of you go out and do these home visits by yourself  and we're managing a lot of complex issues where if you were in a clinic you'd have a lot more resource staff to be able to help manage some of this. Next slide.  I guess before we go on, anybody, I didn't see anything else in the chat but anybody else have anything that they would want to add  to that list of things that could be top stressors  for your practice?  All right. So grounding is just really stress and it stresses the body's reaction to change that can really cause physical, mental or emotional strains or tension.  And you can hear a lot, people are trying to get away from the word burnout because it's very negative. But I think if you read a lot of literature  out there right now, a lot of people say, burnout is negative and it's real. And by not calling out what it really is,  it hides the fact that we're not addressing it. But I think there's many definitions of burnout. I won't go through all of them but these are just some quotes  from some reputable organizations. But again, I think we all know what that feels like. And I think the message is just we wanna make sure  that we have programs in place for our employees that we can help work through some of this so that we don't lose them.  Next slide.  So just again, with stress and burnout, we start to see our own staff start to have higher rates of disengagement. And a lot of that leads to just that feeling of depression,  being exhausted, being dissatisfied. I think a lot of us in healthcare feel lately that it's about a business and not about our patients.  And I think there's so many things happening right now in the US healthcare system around, is Medicare gonna exist? Does everybody go into value-based?  It does, it just adds a lot of extra pressures. I think we're starting to see really high rates of addiction within healthcare providers. You see people just quitting,  changing their careers altogether.  And unfortunately we've start to see, especially since the beginning of the pandemic, some increases in our suicide rates. So again, this is just why it's really important  that you wanna make sure that we have programs in place that we can allow employees to tap into when they need it.  But yet as the employer, we also should have ways that we can help them. As the employer, we also should have ways that we can identify this ahead of time.  Patient outcomes, when our staff are burned out, we start to see lower patient satisfaction scores. We start to see lower quality of care.  So we start to see infection rates going up, start to see higher hospitalizations and utilization. And all of that stuff just really comes in  at the risk of a potential malpractice claim. So we wanna be able to identify that really quick. And the reality of it is we don't prepare our providers  for what they're getting into. And I think it's really important that as we, I always use the term, we can't bring people in and just throw them out there  and say, now go do home-based primary care. We really have to have a system of mentoring and making sure that we make the system better  because it's not gonna naturally do it by itself. Next slide.  So just some grief and loss is really a part of working in healthcare. And I think for many of us throughout our healthcare careers, we've experienced many forms of trauma ourself  of loss and grief.  We process things in our own individual ways.  And again, I think back to the pandemic, when the pandemic started and thinking about myself and my colleagues that we're working 20 hour days  and we'd go home for four or five hours and we'd be back out there the next day doing the same thing. And we did this for days on end that it snuck up on a lot of us.  And all of a sudden you started to realize like, wow, I've worked 30 days in a row and been working 16 to 20 hour days and I don't feel so well. My body doesn't feel right.  My mind doesn't feel right. I've neglected my own family and things like that. So just really thinking about how do people process this? And we just talk here  about recognizing the five stages within yourself or others around grief and loss. And that's just denial, anger, your bargaining, your depression, and then your acceptance.  And how we all move through these stages, we do it very differently. Some of us may have short stints with one of these stages and others may last a lot longer.  But.  So finding meaning. So, you know, just as we talked, we all experience these things differently. And, you know, then, you know, not all of us will find the true meaning  of how we process this and go through it. So just recognizing again that everybody goes through this differently and, you know, again, having the universal support,  you know, a couple of things that we do in our practices, every other week at our care conferences, we have weekly care conferences. And every other week we honor those patients  that have passed away. And then at the end of the year, we have a big celebration of life and we invite the families of these patients that we've cared for in our practice.  And we do a great big celebration of life and just have a lot of great things that happen. It's about a two hour program and we have a wall that names go up on.  And that wall is always there for people to come back to our clinic and look at. So just, you know, finding ways for that. And then also just supporting, you know,  we do a lot every week. We have a gratitude little statue that we hand around  and people give that gratitude back to the staff and they pass it around at her meetings every month.  You know, making sure that we encourage people to lean into the community, whether that's their, you know, their faith or their family or their friends,  you know, create actions for people to have outlets and then just, you know, really display love and acceptance. And I think this is really important  because we're all in this together. And, you know, we always want to equally support everybody  that's in our practice. Next slide.  My screen didn't change. Did it advance?  Maybe it's on my end. Margaret, did it go to the next slide? If it is, I'll just keep going if you're seeing the next slide. Yes, I am.  Okay, great. So there's this really long word that I can never pronounce and I'm not gonna try to pronounce it, but the definition of it is it's just a Hawaiian practice  combining love, forgiveness, repentance, and gratitude. And when it's translated into English, it just means correction. And what it's been really used for  is just to regain personal strength by using self-love and just thinking about four components around the, I'm sorry, please forgive me, thank you, and I love you.  And it's just something that has started to become a cultural thing in a lot of our organizations,  just around people empowering themselves around how they gain their own personal strength  back with that.  Next slide.  So home-based medicine equals the solution. And I think for many of us, we know that we are really moving to care outside of the hospital.  Many of us, depending on if you're part of a larger organization, through the pandemic started a hospital at home, which is taking patients that normally would go into a hospital,  putting them back into their own home environment, but giving them the same level of acute care treatment that we would be giving them in the hospital,  just using virtual and staff that come into their home to do a lot of it.  But we know that there is a lot of successful outcomes in home-based medicine, and it really is gonna be the new way of taking care of patients.  And I think for many of us, it's very rewarding work, even though it can be very challenging. I think so many of us could tell so many stories  about so many individual patients that have gotten better just by coming into our programs and having the extra level of care, or you're thinking the polypharmacy that you have.  I mean, I can't remember the last time a patient got admitted into our practice that was only on three or four or five medications. It's usually 15 to 25 medications.  But when you do this work, it does require you to have a complex team and really good partnerships.  So you gotta make sure that your internal teams are staffed appropriately to support the providers, because the providers can't do all this work,  and making sure that you really have good community partnership, because we really need our community partners to help us with a lot of the resources  that are needed for these patients.  The reimbursement model that was talked about in our first section, it is very lagging.  So we gotta just make sure that we are making sure that as you build a model or you build a practice, that you have sustainability, and you have some way of building up  this compensation model. So when you have poor months or at the end of the year, if you don't make your benchmarks and you have to pay some of the payers back  with this value-based program, that you have a buffer, so that you have that continued income. And then again, just making sure that your entire team feels valued.  Home-based primary care, it's part of the larger healthcare system picture, and we need to have the ability for patients to thrive in their own home environment.  And then again, to the best of our abilities, sometimes this does allow for some personal flexibility,  again, depending on the type of organization  that you're working through, whether it's a health system versus a private practice.  Next slide.  So some operational strategies that just can help mitigate sometimes some of our burnouts is thinking about  coming up with a model for joint visits to manage tension and to have separate discussions with family members. I mean, we will frequently sometimes send  one of our physicians and nurse practitioners out together for a really complex patient that we may have the physician involved for the first month that we bring the patient  into the practice as we transition them full care over to the nurse practitioner. If we know there's a lot of family dynamics, we may bring a social worker out with us  to really have the opportunity for our providers to do a good assessment and intake of the patient while the social worker is talking to the family,  trying to determine what some of the psychosocial needs are for that patient or where there's barriers or where there's conflicts and so forth.  Documentation, we recognize the time involved in paperwork and we got to schedule some administrative hours  for our providers, which sometimes gets very difficult, especially if you're in an organization where they expect providers to be at panel sizes or to maintain work RVUs.  Sometimes that can get a little bit difficult but we really need to think about how do you build in some of that paperwork time that's not just having providers go home  and then they get home at five o'clock or six o'clock, they have dinner with their family and then they're charting for another three, four hours  just to get caught up on all the paperwork.  Financial modeling, if you try to lower your overhead,  sometimes it can allow for some flexibility in the number of patients that are seen. If you have a lot of overhead expenses  and you're having to meet those revenue targets every month, sometimes that gets a little difficult. So think about where there's areas  that you could lower some expenses in that non-labor area.  Try to keep a team approach to continuously educating patients and families and reinforce these care plans or goals of care.  Again, one provider can't manage all of this by themselves. So it really needs to be a multidisciplinary team approach. And then make sure we have administrative support  to manage scheduling and routing of stuff and orders and faxes and all that kind of stuff. Because again, when you pull your clinical teams away,  then that's less time that they have to be with their patients.  Next slide.  All right, and here's just some resources and research, some articles that address burnout and that you guys can look up and have some leisure reading on.  Next slide.  So our takeaways is, again, know your hiring market in your area. Make sure that you create meaningful practices that will recruit people into your program  and hopefully lead to long-term retention. Remember that our home-based primary care professionals face many of the same stressors as all of our other medical professionals.  But again, we're going into a home environment that's not always predictable, and it's not like our office settings. And sometimes just the reality of going  into a not-so-good neighborhood or going into a home where 20 family members are living, that leads to just increased stress and the intensity that people are feeling.  Be really proactive in developing our coping strategies to just make sure that we address any unique stressors that we could encounter and have plans for those.  And then again, just develop your operational and administrative strategies so that it feels and shows that we have a culture of support, because in the long run,  it's really gonna benefit the team, our patients, their caregivers, and your whole organization.  All right, any questions? All right, I'll turn it back over to Margaret.  Thank you, Michael and Ina. I know Amanda had to leave, but that would conclude the end of our three-part workshop series on value-based care.  I hope that it was a high-yield sessions for everyone.  And keep an eye out for the recording. You can also submit your HCCI Learning Plan to the Education Help Inbox at educationathccinstitute.org.  But we will be uploading the recordings for today's presentation and sending out an email  by tomorrow afternoon. So again, thank you for everyone who's attended. And thank you, Michael, Ina, and Amanda. Your expertise is invaluable. We really appreciate it.

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