Hi, good morning, everyone, and welcome to HCCI's Essential Elements of Home-Based Primary Care. I assume you're all in the right place, if that's the workshop you've intended to participate in today. I'm Melissa Singleton, I'm Chief Learning Officer for HCCI, and I'm so glad you're here. We've got a little bit of housekeeping as everybody is joining. I do have a request that on your screen, you make sure you change your name to include your first and last name, please. We will be calling on folks throughout the two days, and it would be helpful if we are calling you by your full name, your first name at least, so we can identify you correctly. Our goal right now is to make sure that everybody's got a good connection and you can hear me. You may be on mute right now, what we're going to do is unmute everybody, and then you will be in control of your mute button. And we're hoping this will all work out fine, so I'm going to have Danielle unmute you. All right, so now you should be in control of your mute button. Can everybody hear me okay? Yes. Yeah. Yep. And can everyone see me? Yes. Ma'am. Yes. Yes. All right. Okay. Well, very good. We may not need, you know, we built in some time for people to check their connections, and we do have a full enrollment in today's workshop. We've had 40 learners sign up, so I know people are still on mute. I'm going to go on mute for a few minutes and just let some other people continue to join, and we'll be right back with you. Thank you. Thank you. So hi, everybody. I know we've got a few more people that may still be joining us, but, and I will be looking forward to introducing our faculty here very soon. But in the meantime, I want to, I want to introduce some of the key staff members that will be helping to facilitate the workshop over the next two days. The chat box is going to be your friend. So you may want to specifically look for for these folks in your chat box. If you need any kind of technical support or, or are submitting a question to the faculty, we can help manage that too. So Danielle Feinberg, who is HCCI's education and research coordinator. Danielle, would you just say hi? You don't have to turn your video on if you don't want, but you just say hi. Hello. All right. So Danielle is running our Zoom over the next two days. She's advancing our slides. She's helping with all the technical stuff, and she may have even helped you get registered for this workshop. So please feel free to reach out to her with any support assistance that you need. Additionally, Michelle Adams, can you say hi? Hello. And Michelle is identified here as M Adams there. That's Michelle. And she's been helping to coordinate things as well. I introduced myself earlier, but I'm Melissa Singleton. I'm chief learning officer for HCCI. And if you are just coming in now, if you would please make sure that you have your first and last names entered on your screen, it will help us as we're trying to facilitate as interactive of a meeting as possible, given our virtual delivery. I know we're going to keep watching the waiting room to make sure we're admitting everybody else. But in the meantime, why don't we just kind of go ahead and get started with a few housekeeping announcements. The first is that the session will be recorded. And I know that that's important because sometimes, especially in the home environment, you can, you know, our home or office, you can be pulled away for a little bit of time and you may want to go back and revisit a session or some content. We will be recording at minimum the main sessions, the main presentations, and those will be available for you later. Certainly by early next week in the HCCI learning hub. And we'll be talking to you more about that as we go through. And I guess why don't we just go ahead and dive in and move into the next slide, Danielle. So welcome. I hope you feel welcomed. Again, we're trying to do as much interaction as we can. Can you go to the next slide, Danielle? So the objectives of this workshop. And let me just back up and say a big thank you to all of you for taking time to join us over these next two days. I think if anything, if we've learned anything in the last several months with COVID, you know, it's how essential it is to be caring for especially frail older patients in the environment where they need to be cared for and where they're safest. And that's in the home. And so at HCCI, our singular mission is to expand patients' access to high quality home-based primary care. Can you put yourself on mute, everybody? We can go back to the workshop objectives. Thank you. So our singular objective is to expand patients' access to high quality home-based primary care. And the biggest obstacle in being able to fulfill that mission is an insufficient workforce. And so it is so heartening to see folks here who are looking to begin a home-based primary care services in their practice, who are looking to expand and grow and serve more patients. And so I thank you on behalf of our faculty and Home Centered Care Institute for being here. You can see the objectives here on the screen, and we aim to meet all of these over the next two days. In particular, you know, this concept of applying the four M's in the care of older adults to this model of care of home-limited patients with multiple comorbidities. I mean, that's a framework that was developed as part of age-friendly health systems. And so we've adapted that into our curriculum. But we also will talk to you about how to do this high quality care in a way that's sustainable and can help you make sure that you are, you know, able to keep the lights on and have the staff be able to pay your staff and everything else that you need. So we talk about the business model and economic drivers and so forth so that you can understand that as well. So if we move into the next slide. And Danielle, would you go ahead and play that video? Hi, and thank you so much for joining us today. At HCCI, we talk a lot about transformation, how home-based primary care transforms the lives of the patients and family members, how this wonderful care transforms the people who provide it, and how this unique model of care has the potential to transform our healthcare system. You are a part of that transformation. You are at the forefront of a movement that will change the way we care for our most vulnerable patients, improve patient outcomes and experience, and do it in a fiscally sustainable manner. We are excited for you to begin your journey with HCCI. You are here with a few of our incredible partners, faculty from HCCI's Centers of Excellence, which have been established at leading institutions across the U.S. Your two days here are an important component in your home-based primary care learning experience. After this workshop, you will have numerous opportunities to continue your learning through HCCI's online courses covering both clinical and practice management topics, as well as our next workshop in the series, Advanced Applications of Home-Based Primary Care. You will also have the opportunity to register for the HCCI House Call Practicum and travel to one of the nation's leading house call programs to participate in a unique field experience. There you will shadow expert preceptors as they perform both clinical and practice management functions at their program, allowing you to observe up close how HCCI's practice excellent partner puts into practice the very concepts you will be learning at this workshop. Before you get started, I'd like to ask a favor of you. Please take a moment right now to write down two things you want to get out of the next two days. Maybe it's insight on staffing. Maybe you find end of life discussions challenging. Maybe you struggle to increase the number of visits you make each day. Write down those two critical takeaways and share them with the group. We will keep an eye on them over the next couple of days and make sure you walk out with answers. Thanks again for joining us. Enjoy the workshop. It's going to be amazing. Now let's get transforming. All right. So that was our founder, Dr. Thomas Cornwell. And so we're glad that we could share his message with all of you. Now we want to meet you. And what we're going to do here is we are going to ask you to open up your video and mics. We'll be calling on you to share with the group your name, your practice, and your practice name or health system, and what your level of experience is with home-based primary care. But as far as what you want to get out of this workshop, if you could go ahead and write that in the chat, that would be very helpful because then we can capture that in a document and be following it over the course of the next two days. And just in the interest of time, we want to just make sure that we're giving about 30 seconds to each person. So let us begin. And I'm going to start here with Caroline Garitano. Good morning. Good morning. I work with Unity Health High Risk Program in Akron, Ohio. I probably have 10 years plus with home care experience, but I've only been with this company since March of 2020. And I only got a chance to write down one thing. The biggest thing for me is I want to know how I can truly impact changes in my patients' lives as far as their health is concerned and how to truly get them engaged in the program. Thank you. Yes, I think that's going to be definitely something that we can accomplish here. Yeah, please feel free. We're going to share the contents of the chat with everybody, or you can be reading that as you go. So, yeah, you can just put your one or two things in the chat. And Amy Rosenbaum, can we just hear from you? Oh, yeah. Hi. Actually, this is Paul Wallace. I log on to my wife's computer, so. You might have to change your name on there. Yeah, yeah. I'll get confused. All right, Paul. Hi. You were one of our webinar faculty yesterday. Yes, I was. It's a busy couple of days. It is. Thank you. Please introduce yourself. Oh, my name is Paul Wallace. I used to be a hospitalist up until fairly recently when I decided to start a home-based primary care practice. So I'm in the startup phase of that and eager to learn more, especially about the business side of things and clinical. All right. Thank you. I'm going to have to call you Amy again. Okay. Jennifer Aery. Hello. Yes, my name is Jennifer Aery. I am a nurse practitioner here in Brevard County, Florida. I opened up my own practice back in March right at the beginning of COVID priority house calls. I've been doing house calls for about four years now, and I just really enjoy it. So that's pretty much why I decided to open up my own. And I just got my autonomous practice from the state of Florida, which was, you know, that law just went into effect. So I'm excited about that. The goals that I would like to achieve from this program. I want to really understand how the best way to expand awareness of home-based practice and also the confidence in home-based practice. You know, I think a lot of people are just a little uneasy about that. They don't quite understand what it entails or what our role is. They still think, you know, going to the doctor's office is a very physical thing. And even the idea of telehealth is so new to them that it's hard for people to grasp onto that. But, you know, it's kind of like once you get the foot in the door and you earn their trust, it's like a whole new world opens up for them. And I really I like that about about home-based care. And, of course, I would like to know some more of the business aspect of it and how to make my day more efficient billing claims. Obviously, my training's clinically. So doing billing and claims is all new to me and so much fun. I'm looking forward to this program. Thanks, Jennifer. Thank you. Luis Cortez. Luis, are you on? Good morning, everybody. My name is Dr. Luis Cortez. I'm the chief medical officer for Hope Health Care, a health care system located in the southwest Florida in the Fort Myers area, Fort Myers, Collier County. I've been in medical practice and on and off on home-based primary care from primary practice into administrative and in our organization for the last 16 years. We as an organization, obviously, we're looking to the trends in health care, especially when it comes to the changes in the last 10 years. We move from a value based system to sorry, from a volume based to now a value based and part of what that value based medical system, as we've seen, is the promotion and advancement of home-based primary care to address a component of a vulnerable patient population that are really the main contributors when it comes to lack of access and over expenditure of resources. So from our standpoint, we're looking to see how to expand our core product services to the community, which would be one of the providing home-based primary care. Thank you. Thank you very much. David Tapper. Good morning. My name is David Tapper and I'm a nurse practitioner with DCT Health Solution here in Tampa, Florida. I have been in the medical field for over 30 years and home health for, I guess, about 10, 15, 10, 15 years. I started my own business last year after one of the practices I was working with went out of business again. And so I've been doing this for a little over a year now. I am interested in learning how to hire staff and more efficiently and kind of, I guess, vet them more. So when I do hire them, they don't leave after two days when they find out what they're really into. And basically seeing patient more efficiently is kind of difficult when you're going to the home. And yes, you want to talk about all the kids and everything, but keep it focused without being rude and trying not to sound like you're rushing, but just to see them more efficient and have them feel, have everyone feel that the needs are being met without feeling like I've rushed them. Yeah. OK. Well, yes. Thank you. I think that's a that's a challenge. So we'll talk more about that. And what's great about this workshop is you'll you'll get to learn from our expert faculty, but you will likely also learn from your fellow learners here. So thank you. So next, Ederonke. You said that beautifully. The first time or the second time? I'm not sure. The first time. My name is Ederonke. I am a family nurse practitioner based in Anchorage, Alaska. I've been in Alaska for the last eight, nine years, and it's been a phenomenal scene. Health care here in some rural areas as well, too. I started my practice, my home based primary care practice in March at the beginning of COVID, like one of our other learners did. And it was a challenge. I think the biggest thing I wanted to learn from this course is how to recruit patients, how to talk to stakeholders and get patients and stakeholders to understand the importance of this program, as there are no home based primary care programs here except for the VA home based primary care program. So it's something that I'm really excited about trying to learn the nuts and bolts about home based care, how to bring in staff, how to increase revenue. But the most important when it comes to the administrative side would be the billing and the coding, which I found challenging. But just overall, I'm just great that this course is available and I'm looking forward to learning more. All right. Thank you. Anna Garanzi. Hi, everybody. Melissa, you got my name perfectly correct, too. You're rocking it. I'm so excited to be with you all today. So I am in Cincinnati, Ohio. I'm a physician, a family physician and geriatrician, and my practice is a little unique. It's grant funded and I've had I'm now in my sixth year of grant funding for it. So it's within our family medicine center and within our family medicine residency at the Cripes Hospital. So I'm a little bit unique, smaller. But the goal, especially with this latest round of grant funding, is to be able to have sustainability at the end of it. So that's one of my big goals this time is to and I've been grateful to have lots of interaction with the HCCI staff. And you guys are amazing. So this time around, I'm really thinking about how do I make a business plan for sustainability at the end of my grant time? I have about three more years of grant funding and also how to expand. We've been fortunately graduating a lot of residents that are interested in home visits, but our health systems here in Cincinnati are still very, very much fee for service. So my hope with that business plan is also can we expand that to other practices where our graduates are going so that we can expand home visits throughout Cincinnati, not just with my program. And then as nuts and bolts to think chronic care management is something our office is still really not got behind as far as coding. And I think we're missing out on some opportunities there. So I'd like to learn more about that as well. All right. Sounds great. Thank you. All right. Carl Russo. I am Carl. I'm coming from New York City. I'm currently with the Mount Sinai Hospital at Home program. I'm fresh out of fellowship, so I think maybe a little much fresher into my career than a lot of people who've shared so far. But I've been really interested in home base primary care as well as kind of home based care models as a whole. My main interest is to find out how they can be a little bit more sustainable as kind of individual identities. So I think a lot of the programs that I've been involved with have been either grant funded or funded by philanthropy efforts. I want to kind of see how to kind of make it a model that's more funded on its own. Yeah, absolutely. Yes. So you are in the right place both here today and and at Mount Sinai, which is a great leader in this field. So. All right. Chelsea Edwards. Good morning. I'm Chelsea. I am a nurse practitioner in Texas, and I started my practice similar to I think it was at Rokey right before COVID. So I have a telehealth practice right now. It's going well, but I would like more information about, like she said, you know, patient leads and the administrative side. And I want to have everything in order before I try to roll out house calls, because I know that's a whole nother. Another, you know, cup of tea, and I just want to be ready for that whenever I do that. All right. Well, thank you for being here. Dan Maher. My name is Dan Mayer. I'm a nurse practitioner at Rush University Senior Care at Rush University Medical Center in Chicago. And our system got a grant to start a home based program that went up a couple of years ago. I had one afternoon's experience seeing patients when someone called in sick. And the goal is for me to do more home visits. And I just want to learn a lot more about what to expect from those things and how to maximize visits. I know that during COVID, we've been having a lot of reluctance on the part of our patient population to actually have anyone come into the home at all. So we're slowly kind of breaking that down by phone calls and televisits and reassuring the patients that they are will be safe during this. Absolutely. Well, thank you and welcome. Deborah Clark. Hi, I'm Deborah. I'm a physician assistant at Wake Forest Baptist Medical Center with geriatrics. I've been doing this almost five years. Initially, it started out as transitional care visits post hospitalization. And I've kind of morphed into doing more home based primary care in the last two years. I feel like I've always been kind of thrown in. So, you know, sink or swim. And I want to make sure my footings are good. And I know everything. I don't ever know everything, but I know what all these other people know and will feel much better about my day. Also, end of life. I want to become more comfortable with end of life discussions. Absolutely. All right. Well, thank you. We have Dr. Shisha Kanitro. I didn't say that right. I know I didn't. Pretty good. Dr. Shisha Kanitro and I work for Hope Health Care. I graduated from medical school in 2004, did a family medicine residency in North Carolina and then came back to Florida, which I was kind of raised in the area I grew up in. So it's been kind of exciting time for the first four years. I worked at a health profession shortage area, kind of one of those federal qualified sites, then did two years in a hospital based primary care. And then I've worked for Hope since 2013. I did the PACE program, which is like a geriatric center based program. But we got to do home visits. And then the last couple of years I've been doing hospice, home hospice. So we have a big geographical area that we get to serve and go and do home visits. So just like Dr. Cortez said, learning more about how to kind of expand into primary care. I think one of the most useful things I've learned kind of going from traditional primary care to PACE and then to hospice is how important goals of care are. And once our patients are kind of homebound, you know, having those discussions and what is realistic and quality versus sometimes quantity of life and those kind of things. So I'm just here to learn. OK, thank you. So next we have an HBA Henny. How shall I address you? Hi, it's Amanda Henning. Amanda. OK. Would you care to introduce yourself? Sure. My name is Amanda Henning. I'm a nurse practitioner in Flemington, New Jersey. I work for Hunterdon Medical Center in a primary care setting for the last three years. I've been doing homebound for about 10 to 12 patients that I see in the home and I see them monthly. Then a geriatrician retired and they thought of me to take his role with home health and hospice. So I rolled that out in February right before COVID hit in New Jersey. I now have 60 home patients that I see and it's hospice, home care and palliative care. And they are hoping to roll out a whole program starting in the new year where I'll be the director. So I just I want to be here today to learn how to set everything up and make sure that what I'm doing already is the best way to do it. Oh, that's wonderful. I'm so glad you're here. And I'm sure you'll learn a lot and share with us, too. Harry Reese. Good morning, Harry Reese, vice president of home care with Ochsner Health in New Orleans, Louisiana. We've had some programs. We're doing some nurse practitioner visits in the home for chronic patients for transitions of care and for palliative care. Looking to start up a primary home based primary care program. Interested in seeing the different combinations of provider staffing models in the home, as well as the staffing for the complimentary services to help ensure success for your program. OK, thank you. Helen Phipps. Good morning. Yes. Having a little video problem. But good morning. My name is Helen Phipps. I'm a nurse practitioner, Cornerstone Services in Central Florida. Primarily, we have hospice and acute palliative care programs. I'm currently working in acute palliative care in Orlando, and we're looking to start a home based primary care program. I'm very excited to be on the beginning and, you know, helping get it set up. And I'm mostly looking just to learn everything I can to have a successful program and be a successful clinician in the field. All right, well, thank you, Hong, oh, sorry. Dr. Alan Shawi, that was supposed to be here also today, had a meeting and she was not able to come. She wanted me to let you know when she'll be here tomorrow. Okay, thank you very much. All right, so Jennifer Aarons. Hi, good morning. I am a registered nurse for Unity Health Network, which is a large physician practice in Northeast Ohio. And I work in the high risk care management department where we do some home visits with patients, but we're not officially doing any official home-based primary care. But that certainly could be something that we may want to move into. So I'm here along with Caroline Giratano and Jennifer Wainer who are also a part of the program today to just absorb and learn all that we can to see what we can incorporate into what we're already doing and maybe how we can transition into something like this in the future. Well, that's great, thank you. And yeah, Jennifer Wainer was the next on my list. Do you wanna just say hi, Jennifer? Sure, I apologize, my webcam isn't working so, but I'm happy to be here with you all. Yes, I'm a nurse practitioner with Unity Health. My colleague Jenny just spoke. As she mentioned, we're kind of in a hybrid situation where our patients do see their PCPs, but we're also incorporating home visits. So I have a lot to learn. I'm a second year nurse practitioner, so kind of dived into the deep end and seeing some pretty sick patients. I just would really like to learn how to make visits more efficient. One particular concern I have is when to, when patients should see my collaborating physician versus having mid-level care. That's one thing I'm interested in learning and kind of how to most effectively incorporate getting labs and getting data before or after the visit and just being really making the most of the home visits. Sometimes I feel they're really effective and at other times I feel like I might have done better and would like to learn how to do that more consistently. Okay, all right. Thank you. I also wanna thank everybody who's putting their notes in the chat of things they wanna learn. Keep doing that. Keri Pollack, are you here to introduce yourself? Hey, good morning. Thanks for having me. I really appreciate it. My name is Keri Pollack. I moved here from Tampa, Florida. I work at Wake Forest Baptist Medical Center. I am a DNP and I'm actually in a very unique situation that I'm excited about. I just joined the geriatric surgical team. It's a new research that we're doing. What we're doing is we're starting a surgical geriatric team, consult team and the research is to determine whether an advanced, whether a nurse practitioner consultation during the perioperative period will reduce the length of stay, mortality rates and the poor postoperative outcomes. So I'm actually gonna be seeing patients telehealth prior to surgery and then I'll follow them along their course in the hospital. And then I'll do a recap with them after 30 days of discharge. We're trying to decrease delirium in the ICUs and in the hospital, because they have a high rate of mortality rate with this patient population. So my whole background is critical care, cardiothoracic. Actually, all of my background is ICU. So I feel like I'm a fish out of water here and I think I'm gonna learn a lot from everybody here. So I really appreciate it. Thank you. Thank you. We're glad you're here. Thank you. Kim Vasquez. Hi there, I'm Kim Vasquez. I'm the medical services administrator with Senior Resources of West Michigan. We are actually an area agency on aging first and foremost, but we received a rather nice grant to begin in-home medical services to serve our participants really trying again to reduce unnecessary ER visits, reduce hospitalizations amongst our population. So we were able to get going in the midst of COVID, hire a couple of providers who are also here today with us. Corinne, Gavin and Laura Macklin and begin actually doing home visits in late July. So this is a whole new world for me. I'm really looking to learn a lot about policy and procedure development because of course I'm administration. So that's my realm and really how to leverage the billing, the coding and the claims. All right, fantastic. Yeah, Corinne, do you wanna say hi too? Yeah, hi, good morning, sorry. So yeah, I'm excited here too. A lot of my background is also in critical care. So I've been a nurse practitioner for about two years and I've been with Senior Resources now for just about a month. So I'm excited to kind of get up to speed on home visits and home care. It's kind of a new world for me too. And yeah, I think just trying to figure out how our organization is going to fit in to the bigger healthcare picture with other providers that might also be involved with patients is kind of what I'm hoping to learn more about. All right, well, thank you. And Laura, you're also from Senior Resources of West Michigan, right? That's correct. Good morning, thank you for hosting us today. My name is Laura Macklin, also a nurse practitioner with Senior Resources. Corinne and Kim are colleagues in leadership. I have been a nurse practitioner also about two years, started with geriatrics, subacute rehab, staff and assisted living. And I have been with Senior Resources since May. I'm starting this and working towards developing this program. A background is very paramedical long time, ER, ICU, flight nurse, kind of the typical background that goes along with some of the home-based primary care. It sounds like listening to everyone introduce themselves. So I look forward to learning sort of all the things everyone's mentioned so far. All right, thank you. All right, so who is LD? Hi, Melissa, this is last call. I'm gonna skip it. I'm sorry. Laszlo's our IT guy. Laszlo, okay, I didn't realize that was you. Thank you for being here, Laszlo. Mary Hammersmith. Good morning, I'm glad to be here. My name is Mary Hammersmith. I work for Providence House Calls, which is based out of Greenville, South Carolina. We service most of the upstate and also some of the Rock Hill area. My background has been in home health for about 28 years. I've just recently joined the home-based primary care team at Providence for six months. So it has been a lot of learning. And thankfully, my home health background has brought a lot of experience as far as understanding the challenges of providing care in a patient's homes and also the benefits. But one of the challenges with the home-based primary care is reimbursement. So my main goal is to capture staff and models, productivity, operational efficiencies, as well as coding to ensure we're billing appropriately and capturing the right HCC scores, the risk adjustment factor. So just hearing everybody previously, I look forward to being a part of this meeting and just taking in as much knowledge as possible. So thank you for having me here today. Well, thank you for being here. Let's see, Madetric Wood? Yes, good morning. I'm sorry. Can you please, I guess, where I'm supposed to answer the questions on the screen? I just logged in, my apologies. No, that's okay. Hi, welcome. Just if you would briefly introduce yourself, the first three bullets there that you see on the screen, and then what you wanna learn from the workshop, we're just typing in the chat so we can move things quickly. Okay, I'm Madetric Wood. I'm a CEO and owner of Geriatric Solutions. It is a, I deliver care in several settings, a home, office, skilled nursing facility, and ALF. My level of experience in home-based practice care, I have been doing, rendering care in the homes for the past 10 years now, I guess. So the two things I'm hoping to get out of the, this workshop, I have to type in the chat. Am I correct? Yeah, go ahead and type that in the chat because that'll give us a chance, it can share with everybody. So thanks, Madetric. Okay. Thank you for being here. All right, you're welcome. And Melissa Markford? Good morning, everyone. My name is Melissa Markford, and I am with Genevieve. We are based out of Minneapolis, Minnesota, and we are a mobile practice with primary care, a number of, it's around 4,500 patients, split between the skilled nursing side, assisted living, which is essentially home-based, and then a very, very small home visit program. I'm in operations with Genevieve, so that means I get to be a Jill of all trades, but I'm specifically hoping to really share best practices as they relate to billing and staffing and innovation going on in healthcare, but really how everybody's adapted to this COVID landscape change and really everything that's been thrown in our direction since the inception of COVID. And it sounds like it's on trend. A lot of people have spoken about starting their practice right before COVID hit or right after, and we just went through a merger with two other primary groups, March 1st, and everything kind of ensued shortly thereafter. So just looking to see what everybody's got to share. So thanks. All right, thank you. Moses? Yes, my name is Moses Lourganis. I am based in Miami, Florida. I am a nurse practitioner for Florida- You're still on mute. Yeah, can you hear me? Oh, I can hear you. Okay, from Florida International University. I am president of Dobar Medical. We have been in home care business, medical since 2015, and nursing back from the year 2000. Has been in patients' homes for many, many years. And right now we are expanding the practice to the whole East Coast of Florida, from Jacksonville to Miami. And we are in the middle of the expansion. And right now we are three nurse practitioners in Miami and two based in Flagler County, which is St. John's and Palm Coast, which I am right now. And right now we have a great opportunity with the upcoming changes that the healthcare system is going to have in the next few years to expand the home care business, the house calls, and to bring that advantage to everybody. Has been doing that for many years, straight home visits. We only do that on Medicaid and Medicaid. Few HMO patients. We want to bring the benefit to the HMOs, to the hospital discharge planners and expand. Our three nurse practitioners, we got the autonomous practice designation just few weeks ago, which is something new in the state of Florida. And we want to use that to get leverage and HMOs and start doing ALF visits, assisted living facilities. Because we avoid that before because of the doctor protocol physician involvement and liabilities and all those things in between. We have been also for everybody to know billing on Medicare as a nurse practitioners, which we are penalized 15%. And we have built our practices for many years just on that. That's the main income coming to the practice. And what I want to learn from you guys, which I see very interesting, the program that you have at CCI, is how to increase the patient census to expand the practice, which is the main goal that we have right now at the World Medical. And also clarifying the billing system that we have, how we code, how we bill to maximize what we are doing. That's a very important issue. Actually, one of the most important issues right now. And of course, increase the patient census, which is the main goal. And we started with the Latin population. All of my nurse practitioners are bilingual. I'm going to have to stop you Moises there. I'm sorry. We're going to hear a lot more, I'm sure from you. Yeah, I know. I got my five minute warning like two minutes ago. Yeah, go ahead. Thank you for being here. Okay. You're welcome. And so we've got Nicole Evers-Lee Hall. Can you say hi? Hello, Nicole Evers-Lee Hall in Tamarack, Florida. Excited to be here. I already put my information in the chat and I'm from N Hall Medical Services. Thank you. Thank you so much. And Nicole Scott. Good morning. I'm Nicole Scott. I'm a nurse practitioner. I've been a nurse practitioner for 18 years. I had my own independent internal medicine primary care practice, but joined with Christiana Care here in Delaware, home-based primary care. And I have been doing that now a little over a year. And I am just interested in learning how to better manage my time in the home. And just as excited to learn from all of you. It seems like a really interesting panel of people and I'm happy to be here. Look forward to this. Thank you. Rita Laracuente. Hi, I'm Rita Laracuente and I'm here in Orlando, Florida. And I've been doing this since 1998. So it's been, it's going to be next month, 22 years doing home care visiting. I actually started the business as just a side thing. And right now it's my main job and it's very fulfilling. And I love to see my patients at home. And during COVID, everybody would think that they wouldn't want me to go visit them. And after the second time I did a telehealth visit, they were asking me, when are you going to come and see us? And I said, it's because of the coronavirus. They have us on quarantine. So it was very, very mind opening. And it made me understand that this is probably going to end up being the most type of care we're going to provide to the elderly population and not going to the doctor's office. And probably the specialist might have to shift a little bit from being in their offices. So I'm glad to be here and I can't wait to find out a few things. And right now I was wondering when the nurse practitioners here were going to be able to get the ability to work on their own. And I realized that when I got a fax from one of my nurse practitioners with her name on it and it was a 485 form. And so I'm just wondering how will that work out for me? Because they're kind of like employees or subcontracted. So that's one of the questions. And the other thing is, how am I going to get more nurse practitioners? Because I keep on getting more and more referrals and I'm maxed out right now. Okay, all right, well, those are great questions and we will work on responding to those. And Susan Nelson, I think you might be the last person for me to call on. Sent you a note, said, I'm okay to wave. I'm the Medical Director for Post-Acute Network, work with Harry Reese, who's already been introduced and we're working to expand our home-based programs. All right, well, thank you. And thank you for being here. Danielle, can you take us to the next slide? I was not able to introduce, actually I wanted to learn a little bit. I'm sorry, who is that? This is Hong Chen Chang. I have been working in the conventional primary care for about 15 years, did street medicine three years. And just after COVID, with the project of like physical outreach, we wanted to reach out to not only the elderly population. I'm here to learn, but also like to see if there's any perspective about bridging conventional care. Like we're still seeing our conventional patients, but how can we complement and get better data for better care for the population that cannot reach out visually? Okay. Thank you. Thank you very much, Hong Chen. I'm sorry if I missed you. Thank you for introducing yourself. Danielle, can we go to the next slide, please? So I wanna just get you introduced to our faculty and then they're gonna take it from here. So we can go to the next slide. Okay, so, oops, I wanted to pull this up. So Dr. Paul Chang is gonna be our first speaker and second there. So in addition to his role at HCCI, where he is senior medical and practice advisor, Dr. Chang is medical director for Home Care Physicians, which is a suburban Chicago practice focused on delivering care to medically complex patients in their homes. Home Center Care, I'm sorry, Home Care Physicians has made more than 117,000 house calls to home limited patients since its founding in 1997. And Dr. Chang has personally made over 34,000 house calls in his career to more than 3,000 patients. And he received the House Call Doctor of the Year Award from the American Academy of Home Care Medicine in 2019. So we welcome Dr. Chang. And we also have Dr. Konstantinos Deleginidis and he goes by Kosta, which is much easier for me to say. But in addition to his role as director of education and director of quality at Northwell House Calls, Kosta is an assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra Northwell. And his primary interests are performing home visits, shared decision-making and patient and caregiver engagement. And so I know you'll welcome him to our faculty. Brianna Plensner is practice improvement manager at Home Centered Care Institute. Brianna is a certified professional coder and medical auditor. And all of you people who were saying you wanted to know about coding and billing and staffing models, stay tuned because you're in for a treat tomorrow morning with a couple of our sessions that Brianna will be participating in. I think you're gonna learn a lot. Dr. Ethel Smith, if we can go to the next slide. Dr. Ethel Smith is a returning faculty for us from Cleveland Clinic. She's medical director and geriatric medicine specialist at Cleveland Clinic Medical Care at Home where she's been since 2010. She's certified in both geriatrics and hospice and palliative medicine. And we are so glad to have her on our faculty panel. Amanda Tufano is chief executive officer of Genevieve where she leads a team of over 115 people including physicians, MPs, nurses, and social workers who are deployed throughout the Minneapolis, St. Paul and greater Minnesota regions. And Genevieve delivers transitional care and primary care services in long-term care facilities. And I know you're gonna be hearing a lot more from Genevieve and Amanda's a wealth of knowledge about demonstrating value for this model of care. And then finally, Megan Verdoni is a physician assistant from the University of Florida. And she has 18 years of experience in emergency medicine and over two years experience in internal medicine. And she is chief executive officer of ER liaison and assistant clinical education director at Florida State University of Physician Assistant Practice. And we welcome Megan to our faculty. So if we can queue up the next slide. All right, at this point, it's my pleasure to turn it over to Dr. Paul Chang. If you are not already on mute, if you would please go on mute until we open it up for discussions throughout the day. Thank you. Dr. Chang. Melissa, thank you for that introduction. And can I have the next slide, please? Before I get into the session objectives, I must take a minute and pause and just reflect. I'm just so excited to see so many learners here today and to hear the great questions that we haven't even started the session. And these questions are fantastic. And over the next two days, we're gonna try to get to as many questions as possible and make it really productive for you. Something you can take back next week and really implement in your practice, no matter what stage of home-based medical care practice you are in. So engage with us, send messages or questions through the chat box. We'll try to get to them as many as possible. And again, just to remind you, this is an ongoing learning partnership and relationship. Obviously, we will not be able to address all of the questions, but we invite you to come back and visit with us and learn from us and with each other about home-based primary care. All right. So session one objectives today, we wanna assess the perception of home-based primary care and dispel any myths about the field that you or others may have. I wanna go over some of the fundamentals of home-based primary care and discuss the various characteristics and competency required to be a successful house call provider. I'm gonna talk more about the 4M in the care of the older adult framework that Melissa referenced earlier, and give you an introduction into the ACCI learning plan. There was comments about COVID and so on. Just a brief plug here. We do have a COVID learning hub about home-based primary care in the COVID era. There's been a lot of engagement on that topic, as you can imagine. So that's just something for you to look up when you have a spare moment. I hope at the end of this talk, and certainly at the end of two days, you have a better understanding of the various types of home-based medical primary care when it comes to structure or support, so that not only you can better understand your own practice but also as you engage and talk with other practices across your area or across the country to appreciate some of the challenges and the opportunities that they may have. And I also have kind of a selfish goal here. At the end of this session, or at the end of two days, I hope you can better appreciate, after 20 years of doing this, doing house calls full-time, I am more convinced than ever that House Call Medicine is a truly unique and amazing place to deliver medical care unparalleled anywhere in medicine. And I hope that at the end, like I said, at the end of this session, at the end of two days, you get a sense of like, yeah, I think I can see where Paul is coming from. And as I talk with learners, I talk about a power, two points. I talk about the power of your presence because of our proximity to the pain and suffering of our patients. And I'm gonna illustrate that with a story at the end of two days. So I'm gonna have you pause, hold on to that idea, and hopefully to kind of give you a summary of what we can do in terms of taking care of complex older patients at home. Next slide, please. So I want you to take a moment and go to your worksheet and take a look at, I've always thought worksheet in section one of your workbook. And I'm gonna give you a couple of minutes and to reflect on some of these three questions. I've always thought, what comes to mind first when you think of home-based primary care? Okay, what do you think are the greatest opportunities and joys in home-based primary care? And finally, what do you think are the greatest challenges or the barriers in home-based primary care? Again, go to your worksheet and let's take a couple of minutes and we can open the mic and it's on page 12. Melissa is sending me a message, page 12 of your learner's workbook in your workbook. So yeah, I'm open to hearing some comments from the audience. You can raise your hand and we'll try to get to you. Anybody want to share what comes to mind first when you think of home-based primary care? I see that Hong Chun shared in the chat, patient-centeredness, comprehensive data gathering, improved shared decision-making for chronic disease management. Thank you for that comment. Jennifer also raised her hand. Can we get to Jennifer? Well, I think that one of the benefits that we get from there is the relationship that we develop with our patients and getting to know them on a much deeper level than you would get in a 15-minute or a 30-minute visit that you get in the office. And I just think that that helps shed light on a lot of issues that may never be brought to surface in an office setting. I'm trying to raise my hand. I don't know where to go to do that. I can't find the button. But I'm just echoing what Jennifer said. Just the personalized care, the trust, and the development, you know, that you develop between the patient, I think is amazing. And I think it's just a personalized care. And where is the raise your hand button? Yeah, so if you go down to the bottom of your screen under where the slides are appearing, it's a reactions button. And there's one that looks like you might be clapping or raising your hand. But it says clap if you put that up. Oh, got it. Thank you. Or you can just unmute yourself and say, hey, I want to say something. We're gonna be pretty informal. We have several people raising their hands, too, Melissa. You can see in the participants chat box, I think, is how they're doing it. Yep, we've got some comments about seeing patients in their home setting and the challenges and practice like the olden days. Hopefully will be the new days. I see Ada Tapper has raised her hand if we want to unmute her. Well, I was also thinking, you know, when I first think about, like, a home case, home-based practice, I think of that old TV program with the doctor going to the home and getting paid with produce or, you know, food, bakery stuff. But now when I think about it, I think about it as more of a holistic relationship, one-on-one relationship in the patient setting, that you can not only take care of them medically, but physically taking in their whole environment, thus, of course, providing a holistic care. What about challenges? I think I'm trying to convince people who are not used to it that they are not missing out on anything, that they are not missing out on things that are available in the office. In fact, for some people, it relieves stress, commute, the, you know, the whole process. So trying to convince people who've never heard of it or who've never experienced it, that it is a great thing and doable. Hi, this is Ada Ronke. I find a challenge for me in Alaska is the inability to have that integrative care. Sometimes I find that there's a lot of care fragmentation, especially when I'm trying to get a patient on my service. They've been to so many different places and it's hard to know what's been done already. I think that's probably the most challenging. You're kind of like in a silo almost. So I think that's something hopefully, you know, integrative medicine, everything coming together electronically, etc., to get patients the care that they need. I think one that's shown itself during COVID is that where we're kind of not in that we're kind of on our own sometimes as far as guidelines. So for instance, I work in the hospital and the nursing home also. And while guidelines were slow at first, we at least have guidance now. But I feel like I'm making decisions about when to do home visits, when to not in person, all on my own or reaching out to like this organization, Academy of Home Care Medicine. But I feel like we are kind of forgotten in some of that decision making process. I think a challenge is actually identifying what the patient's challenges are and their barriers are and coming up with something to do about it. When you when you're in the home, you know more. Are they having food insecurity? Are they having problems with getting transportation for groceries to get to other appointments, grandmothers or grandparents taking care of grandchildren. And so then you're not only taking care of your own patient, but you're trying to take care of the family or at least find resources to support them. Absolutely. Hi. Oh, go ahead. I'm sorry. This is my deep regret. I've been talking and I thought you all have been hearing me. But apparently I've been hearing other people talk. So can you hear me? Well, now? Yes, we can hear you. Okay. One of the greatest challenges that I've faced is the fact of trying to find other providers that go into the home such as the the cardiologist, the pulmonologist or even psych. So it's the the fact that I may need to have this person evaluated by psychiatrists or psychologists or even a psych nurse practitioner. And it is just very difficult to find other providers who are willing to come into the home to provide those services. Yep. A great comments, everybody. You know, as I reflect that reflect back on on on all the comments and just my my personal experiences, I think relationship is a huge opportunity and huge win and joy for me as I do this work. Somebody mentioned in the chat box about being part of the family. Absolutely. Absolutely. Getting paid and what have I gotten paid in sacks of potatoes, homemade soup, garden vegetables, chicken eggs, you becomes an important part of the family structure, which is so critical when you're talking about serious things and of life issues, and so forth. So that relationship is huge and getting the full picture, whether it is as you as you do what I call the walk around in the house, as you look at religious artifacts, as you look at family pictures, as we call it the refrigerator biopsy. Right. You know what I'm talking about when you look in the fridge to get a better sense of their social determinants of health. Is there a food insecurity or is it just all frozen dinners? I just saw a patient yesterday eating frozen dinners. I say, you know, ma'am, you know, each package of this, it's about nine hundred milligrams of sodium. And that's really not good for your blood pressure and heart failure and so forth. So relationship being at the home is huge. And then the challenges of being being a solo provider, taking care of complex patients on your own with various medical and social issues can be can be challenging. Great comments. Next slide, please. So what is home based primary care? It's a model of care that brings providers and modern technology to patients in the comfort of their own homes. It is an effort to improve the quality of life for medically complex, complex patients and their caregivers. We want to provide I'm sorry, we want to prevent avoidable hospitalizations and nursing home placements and visits. And we want to dramatically reduce healthier health care cost. Next slide, please. Now, home based primary care, you know, we have been effective in achieving the quadruple aim in health care and just to review better clinical outcomes. There's been a number of studies showing that as well as improved patient experience. Lower overall cost of care. And greater job satisfaction for provider and staff. Next slide, please. Now, home based primary care is not a kind of a monolithic structure. One sides one practice fits all across the United States. Some practices are part of an academic medical center where there's education and research integrated into home based primary care and learners are include residents of fellows that come out and participate in the care of our patients. Or you can be part of a large health care system where the home based primary care practice supports the overall strategy of health care health system, including ACO involvement, managed care, Medicare spending per beneficiary, avoidance of readmission penalties, which can be part of a community hospital, which is similar to the large health care system, but just on a smaller scale. Home based primary care could also be independent or group practice, they tend to reflect the culture and the passion of the entrepreneurial spirit or founder that started the practice. Somebody brought up the Veterans Administration Services, the VA, they are really pioneers in home based primary care. They're among the first to demonstrate value and cost saving in this model of care. HPPC could be part of a community based hospice and palliative care organization, where they add home based primary care as a service line in order to close the gap of care among the seriously ill patient population. And more recently, home based primary care could be part of a value based managed care organization system, again, to better care for our complex patients with lower cost. Next slide, please. Now, there are also different clinical care models in HPPC. One model is the transitional care model, where you involve short term support targeted at patients with particular diagnoses, or those with high readmission risk, as well as assist the office based PCP during the high risk period, often immediately post hospitalization. The other model is the longitudinal care, where we provide ongoing medical management on a long term basis. And these patients are often older, and they utilize the hospital and the emergency room frequently. They may not have any PCP, or they may have a PCP, but they have great difficulty in getting into the PCP's office, because of their multi complex medical condition. Next slide, please. HPPC can also differ in structure and administration, a practice can reside within an academic department, be a part of a hospital affiliated medical group, they could form an independent PC or an LLC. And the operations of a practice can be supported by the health system or the health system or academic department or medical group. You can have staff or directly employed, as well as contracted staff or outsourcing your services, or some combination of all of the above. Next slide, please. You know, as I look at my own practice, and I hear and learn from other practices across the country, to be successful in the HPPC practice, you know, a practice must have solid clinical leadership. Right? We need to provide excellent medical care. That is, you know, one of the cornerstones of what we do. We need to have efficient scheduling. You know, for our practice, we schedule our visits in a geographic fashion, in order to minimize travel time, and maximize visit numbers and visit time, because we are currently under my practice is under a fee for service arrangement. So we are still out trying to see as many patients as possible. So geographic scheduling is really an important part of our, of our, of our day to day operation. A practice needs to have timely triage of calls and messages. You know, what is your practice looks like, you know, who fields the call? What are the protocols? When a calls for a condition comes in, or for refill that comes in, there needs to be a timely response to these calls. So the patient doesn't end up in the emergency room unnecessarily. There needs to be good care coordination and social services, offering additional support for our complex patient and family. We must clearly communicate, you know, visit follow up orders, to family members to home health agencies, so that everybody is aware of the care plan that you have developed for for a patient. Good office management, whether you're talking about the front office, or the clinical back office is really important in HPPC. Some practices have MAs in addition to nurses in the back office, taking care of clinical questions. Other practices like my practice, we have medical assistant going out with the physician provider to increase efficiency, increase the number of visits that can be made in a day. Timely revenue cycle, self explanatory, you know, we have to maintain a good steady revenue and income. And education is really important. Patient, family, caregiver, they're complex and challenging, we need to make the instructions and how to reach us after hours, or you know, what symptoms to look for after we starting a particular medication and so forth, educate, educate, so that the patients that have a plan, in case there's an urgent need that comes up, and they don't panic and end up in the emergency room. And finally, data management and reporting, a really, really important part of HPPC, not only to improve the quality of care to drive down cost, but it also helps you tell your story. You know, what is your story? What we call the elevator speech, right? The value of HPPC that you and your practice bring to the health system, or the community. Next slide, please. Now, depending on a practice's clinical model, there may be a slight variation in patient and marketing demographics. Under transitional care model, patient are high utilizers of the ER, the hospital, patient may be non-adherent, patients of any age, whereas the longitudinal care model, again, as we said, you tend to be seniors with advanced multi, a multiple chronic condition. Although it could be younger people with chronic condition, they have a great difficulty getting to the PCP's office. And it could be, these patients may be disruptive or, you know, we'll call high demands to a PCP office. And home-based primary care can really help take some of the burdens away from the PCP's office, and provide, you know, outstanding care at the home. Next slide, please. As you can see here, there are common revenue and expenses category that HPPC practice should consider to track your performance on a revenue side, understand, you know, who are your payers, Medicare, commercial, Medicare Advantage, Medicaid, are you getting any additional money from philanthropic support? Are you entitled to additional dollars through a different payer contract, for example? And also understand your expenses, your direct expenses in terms of staff salary and benefits, your medications, your vaccines, and your supplies, billing and collection, administrative services, including marketing and human resources, what equipment is needed for your practice, and travel expenses for your providers. There's the provider expense, where physician and APP salaries and benefits are included here, as well as malpractice insurance. And then you also need to consider indirect expenses, such as your overhead and taxes. Next slide, please. There are also different compensation models for HPPC. Some compensation model is based on salary with a bonus, dependent on your quality, meeting quality metrics, patient satisfaction, volume, and so forth. There are the compensation model that's based on per visit completed, or tied to an RVU system, or tied to a percentage of collections, or some hybrid model of any of the above. Remember, compensation for provider is the single largest expense in HPPC practice. Next slide, please. Again, you know, I talk about having a three-minute elevator speech and so forth. These are important outcomes for you to keep in mind as you talk, as you not only manage your practice, looking on, you know, the impact that you're making, but also as a way to show the return on investment to your payers, to financial sponsors, to your grant supporters. You know, what have you done in terms of reducing 30-day readmission penalties? Also, looking at the competitive cost profile for your patients. Have you reduced utilizations of the emergency room or hospitalization? What is your patient satisfaction score or likelihood to recommend? A high quality of care that you're providing that is consistent with the goals of care of your patients. It's also a good chance to have a community and market relationship with those in your immediate area. Again, these are good metrics to keep in mind as you talk with people who might be willing to give you some philanthropic support for the work that you're doing. Next slide, please. Now, fueling the growth of HBPC. This is a white paper written by Dr. Cornwell. As we look at, you know, what's causing this growth in our field, there are four basic engines that's driving this. One is the aging population with chronic illnesses. The second is the evolution of technology. The third is payment reform. And the fourth is data demonstrating the value and the cost savings of house calls. Next slide, please. You know, as I look at and I talk with other practices, these are what I call the eight C's or eight characteristics that I think is needed to be a successful HPPC provider. First, I think the provider needs to be competent with complexity. We should be comfortable caring with patients with chronic, complex medical conditions, extensive medication lists, multiple abnormal labs, ordering different diagnostic testing, as well as be able to navigate psychosocial complications and challenging family dynamics. So, competence with complexity is the first pair of the two C's. Next is communicate comprehensively. You know, caring for our patients in their homes not only involve caring for patients with multiple medical problems, but caring for the needs of caregivers. We talk about it's always a dyad. We take care of the patient, we take care of the caregiver. We need to meet their needs, both of them. It also includes a strong focus on conversational skills that's needed to talk about end of life goals of care. We need to be good communicators, being able to guide discussions with not only the patient and the caregiver, but also other professionals that are involved in the care of their patient. The next two C's are character and composure. HPPC providers often work alone, and we deliver care in the patient's home setting. And we need to have the highest personal, professional integrity in order to ensure the safe and quality care of our patients, and also to improve the public image for our field. Providers' composure is also essential, as the scenario that we encounter at home may be challenging both medically and socially. You know, I think of working with PPEs over the summer, and it gets really hot. You need to have some degree of composure as you deliver care under a full PPE. And we need to be able to provide the PPE equipment, or you can walk into a home that has a strong odor, or a home that is extremely cluttered. So you need to maintain that a certain degree of composure as you conduct your work in a professional manner. The last two C's are providers should be considerate and compassionate. HPPC providers are in a unique position where the patient is not in a provider's office, or hospital, or the emergency room. We are in the patient's home. We're in their homes. We are, we are a guest. It is a privilege and an honor to be invited into the patient's home, and to take care of them. The provider needs to have compassion. And I would also add a charisma that can provide reassurance to the family and patient doing really difficult times, as well as inspire others to consider the value of this model of care. So those are the eight C's of what I think are qualities that are necessary to be an excellent house call provider. Next slide, please. Oh, sorry. HPPC providers are, you know, we're often mission oriented. When I talk with others, it is a calling for us to care for older adults and other vulnerable patients with chronic and serious illness. These patients are often disenfranchised. They have limited access to traditional medical care. And the care they're getting often is fragmented and disconnected. This is a chance for us to really integrate, pull together medical social complexity within the social determinants of health, and provide really exquisite care to these patients. Next slide, please. Next slide, please. Oh, sorry. The key competency for HPPC providers. We need to have advanced clinical knowledge and reasoning skills. We, somebody mentioned about, you know, cardiologists and pulmonologists. Yes, it is really difficult to get a subspecialist, if not impossible for them to come and do house calls. So we need to have really good clinical knowledge on how to manage advanced CKD, CHF, COPD, and so forth. Because that's, the patients really depend on us to deliver high quality care and take care of their chronic illness. We need to be competent in assessment, clinically at the bedside, and diagnosis, interpreting blood tests or x-rays, and also be competent in various procedures. Now, the procedures we do at home can be something as simple as phlebotomy. You know, I've been drawing blood since I was a resident, so I'm comfortable doing blood tests at home. Your practice may be different. You might be outsourcing your blood test. Other procedures, just this past two weeks, you know, in terms of joint injection, we did that on an older patient that really saved her a trip to the doctor's office, which is difficult, and really provided an immediate relief of her pain. Yesterday, I was out changing a tracheostomy tube on a patient who's on a ventilator. Again, saving the challenges and the difficulty related to, you know, getting him out of the home. And then there was a G-tube emergency several days ago where we had to go and take care of the G-tube that was leaking. Again, saving time and effort and money for our patients and our caregivers. Wound care and debridement, you're going to hear more about that. I'm sorry, wound care and debridement is also a skill that a provider should have, as well as hospice and palliative care ideas and concepts and management strategies, because many of our patients are sick and chronically ill, and many of our patients end up with hospice care at home. Commitment to integrity in order to provide safe and quality care for our patients, we talked about that. Able to work independently, but also skilled in relationship building, interpersonal communication, and collaborative teamwork. Again, yeah, you have to be independent, we are, as we're taking care of the patients alone, but we also have to network, network well with family members, with other care providers from the community. Keen attention to time management. Somebody mentioned earlier about efficiency. It is really important for our providers to manage your time well, to maximize your visit, whether it's geographic scheduling, whether it's pre-charting or chart review, having the ability to review what was done in the past or in the hospital, pre-charting, getting the documentation done so that your visit can be as efficient as possible, and also have that connection with our patients so that we're not looking down on a computer screen all the time. You can also pre-order the blood test that you think you're going to need for the visit. Again, all of that organizational skill, time management, efficiency, and ability to handle multiple priorities. And finally, good communication skills, both written and verbal. Again, this involves not only with the family members, but also with other providers who are involved in the care. Next slide, please. Now, Melissa mentioned the four Ms in the care of older patients. Again, this is from the Age Friendly Health System with a collaboration with the John A. Hartford Foundation and the Institute of Healthcare Improvement. And I'm going to walk through really quickly the four Ms that are listed here, as well as the final, there's a fifth M that we've added for home-based medical care, primary care. The first, if you can pull up the other bullets point, there we go. There we go. And you're right. Going from left to right, what matters most, mind and mentation, mobility, medication, and the one on the bottom is multi-complexity. Let's start with the first M. Next slide, please. What matters most? That is about understanding the health goals and preferences of our patient. It is about applying prognostication in medical decision-making with the understanding of the risk and the burden and the benefits and any impact on a functional status and a quality of life of intervention and making sure that the patient's goals and care preferences are reflected in the treatment plan and they're being honored. Coordinating advanced care planning and communicating this clearly with the family, other family members who may be out of state, as well as other providers who might be involved in the care. That might be the previous PCP, the emergency room, or the hospitalist, or the home healthcare provider. And adjusting and updating the goals of preference as their health changes. Next is mind and mentation. We encourage our patients to maintain mental activities, mental activity, I'm sorry, and identifying, addressing social isolation and stressors. And this has been especially important during the time of COVID. And working on ways to engage with them when they have limited ability to use technology. Even with my parents, getting them to understand a simple technology like a flip phone has been difficult. How to use an iPad. The idea of touchscreen and the motion on the iPad to slide when you have vision problems, when you have tremors, when you have arthritis. How can we engage our patients and keep their mind sharp during COVID isolation has been challenging for many of our patients in our practice. We monitor mental and cognitive well-being. We identify and address cognitive impairment. Consider medications in the light of their goals of care. And then change my goals of care and recommendation to support their needs over time as their medical condition change. Don't forget the caregiver's well-being. Remember I said it's a pair, it's a dyad. We need to take care of both of them. If one of them stumbles, the other one will likely not do well also. We help prevent, identify, treat patients from delirium and that includes exquisite medication management, taking away medication that may be a causative agent for their mental status change. And also treat, diagnose and treat any mood disorder such as depression or anxiety. Next slide, please. Mobility. We want to help our patients to maintain their ability to walk or to improve their ability in terms of improving their mobility overall in the home. Because many of our patients want to be independent in their ADLs and IADLs and we can make a dramatic impact being at the home, seeing their surroundings, going over the medication and helping them achieve or maximize their independence. Minimize the risk of falls by addressing risk factors related to falls and optimizing the home environment, whether you're talking about nightlight, whether you're talking about a grab bar or other assist devices and allow creative solutions from interdisciplinary team members to improve home environment that facilitates mobility and safety. A couple of days ago, I was at several patients' home. And again, one of my routine is, I think I said it before, is to walk through. I walk around the house from where they are, from to the kitchen, to the bathroom, to the front steps necessary to get to street level or through the garage and so forth. Again, that gives me the opportunity that really no other doctors can see in terms of appropriately recommending, say, a ramp that's necessary, or maybe we need to call in a volunteer handyman service as we did for this other patient to build a particular ramp for his garage so he can get down into the vehicle and have the ability to go out of the home, which was really good for his overall sense of wellbeing. Again, we are in the patient's home. We get to see the challenges and we can offer advice that's practical and feasible. Again, that's an advantage that no other docs or other providers have in the health system. Next. The next M is medication, and you're gonna hear more about medication management later on today. There are a couple of goals as we take care of our complex patients at home. One is reducing polypharmacy when it's appropriate. We did a study with my practice with a pharmacy team. The average number of medications that my patients are taking, average number, is 18. That's really a high number of medication in terms of costs and side effects that we have to deal with. So polypharmacy reduction is an important part of what we do. We also realign medication use and dosing with a person's individualized need and their overall goals of care. Deprescribing medication, whether it's a duplicate medication or the side effect chain of medication, if you're able to deprescribe, we take great pride in trying to get our patients off as many medication as possible, not only from the polypharmacy side, but also just reducing any duplication in medication or inappropriate use of medication where there's no indication for it. I think there was a paper published recently about this prescribing cascade. The example is you got a patient with arthritis, you prescribe an NSAID, and the NSAID led to hypertension. Hypertension led to the use of amlodipine, and amlodipine led to leg swelling and led to the prescribing of a diuretic, which led to gout, which led to colchicine for gout, and allopurinol, and so forth. You get the idea that from one medical intervention, and now you have led to one, two, three, four potential additional medication that perhaps was not necessary. Next is optimizing medication at a geriatric-friendly dosing. Again, when we bring learners with us, I had a resident with me this past week from Northwestern. We talk about the importance of, for example, renally dosing medication for our patients, whether it's based on creatinine clearance or on an EGFR. Dosing, don't forget adjusting your medications for your patient clientele. We have the opportunity to review the patient's medications at home, right? It's the brown bag. It's no longer just a sheet of paper that you bring into the doctor's office. You just say, show me the brown bag. You go through every medication one by one. You can get a much better sense of what they're actually taking when you're at the patient's home. And you have the opportunity to really work with a caregiver and the patient on the benefits. What are you trying to achieve with your medication as well as the side effect of the medication, things that you need to be on the lookout for when a particular medication is used. Next slide. And finally, it's the multi-complexity. HBPC takes the previous four M's into the home, right? And in the home, we help older patients manage their multiple medical conditions. We get to assess their living condition that's impacted by their age and decline and other social drivers of health, whether it's a language or a barrier or food insecurity or we may have an internet problem or broadband connection in the era of COVID if you're trying to do a tele-visit, right? And being on guard to look for elder abuse or neglect. We have an opportunity to take everything that we see and optimize therapy and care plans and choose therapy that optimizes benefit, minimizes harm, minimizes harm, enhance function and a quality of life. Okay, and I would also add, and that can be feasibly delivered at home. We need to involve other care partners to support the wellbeing of, again, not only our patients, but also their caregivers. And we need to understand and incorporate into our care plan different philosophy of care appropriately. Again, being at the home, we understand better the social, cultural, religious context, and we're gonna talk about that later on this morning about cultural engagement for a home-based primary care provider with a case demonstration. And we can coordinate and integrate the recommendation of specialists weighing in the risk and benefits as well. So what does that look like? Next slide, please. So the delivery model looks something like this. It's a continuous PDCA, or plan, perform, monitor, improve cycle, right? We come up with a plan for our patient, we execute, we do. And once we do, we check or monitor for any side effects, upside, downside, improvement, or decline. And then we adjust our plan accordingly. And then we go back and do it all over again. So this is the care model of continuous cycle of the kind of care delivery that we do at home for our patients. Next slide, please. Has anyone seen the movie, Sliding Doors with Gwyneth Paltrow? Yep, I got a yes here. Yep, that's great. For those of you who may not have seen it or forgotten the plot, it explains that Gwyneth Paltrow's character missed a subway train by a second when she dropped something on the stairs and she bends down to pick it up. And in that period of time, she misses the train and the door closes and the train, the subway is gone. And then the film rewinds to show her not dropping the item and she actually got onto the plane, not the plane, the train that she intended to get. And as the story unfolds, showing the impact of a split second decision that really changed, that gave her like two lives that happened to her. So how does Gwyneth Paltrow, how does she get involved with HBPC? It is example of experiences that our patients can have when a split second decision needs to be made. Okay, the two different paths our patients may face depending on the decision that is made at the time. Now you're about to watch a video that will explore this option. It's about Fred. Next slide, please. It's the two treatment pathway, right? Think about, you know, before we play the video, think about the four Ms as you apply to Fred's story. And I want you to capture in your notes and some of the observation in your workbook as you listen and watch this video, all right? So we will regroup after we have a chance to watch this video. All right. Just like the movie, Sliding Doors, elderly patients can have two vastly different experiences as a result of small decisions, small care decisions, such as caregivers calling 911, resulting in ER, visit, hospitalization, getting lost in a medical system, or wonderful care at home, which is what we're trying to advocate here. So session one takeaways, the perception of HBPC can vary significantly among clinical providers and care managers and administrators, as well as general public. HBPC is not a one size fits all, one size fits all program. The decision you make will impact your ability to achieve your desired clinical and operational outcomes. The four Ms in the care of older adults is a framework that focuses on four key areas of caring for the elderly. And the fifth M involves the additional dimension of multi-complexity. And finally, as shown in a tale of two treatment pathways, elderly patients can have two very different experiences as a result of seemingly minor care decisions. Next slide. I want to remind everybody that this workshop is just one component of a comprehensive educational program for HBPC from HCCI. We have a advanced application seminar coming up in about two weeks, where we get into even deeper aspects of home-based primary care, including things like tracheostomy to change and joint injection and G-tube change. We have a great course library that's online that is on demand, web-based education on a variety of topics. There's a house call practicum. It's a very unique two to three day field experience at one of the HCCI practice excellent partner site where you actually get to be there and shadow and be mentored in a one-on-one way by a seasoned provider. And also our monthly HCC intelligence and webinar and virtual office hours. Yesterday, Dr. Paul Wallace, along with his colleague, was able to present to us a POCUS, a point of care ultrasound, as it relate to elderly taking care of patients who are older and complex and its applications in the home. So that was, I invite you to join us next time for a webinar and HCC intelligence and virtual office hours. And finally, next slide. I wanna direct your attention to the HCCI learning plan. It is intended to help guide your continued development. I want you to think about the session's objectives, review the sessions with your group. Again, thinking about the perceptions of home-based primary care, review the fundamentals, the characteristics and the competencies that are needed to be a successful house call provider. Review the four Ms. All right, and then I want you to consider, what concepts do you need to learn more about their additional topics in which this session stimulated your interest in and perhaps revealed like, you know, this is the area that I want to do even more learning on. And add these concepts or topics to your HCCI learning plan using your fillable PDF that's provided to you. Now, before we move on to the next session, I know we're over by a couple of minutes. We're gonna talk, next session's gonna be about clinical care. We're gonna take a 10 minute break. Thank you, everybody. Thank you so much, Dr. Chang. That was wonderful. I wanna just say a couple of things. We are gonna resume at 10 minutes past the hour. You do not need to disconnect from your Zoom. Just please put yourself on mute and you can close your camera and we'll resume at 10 minutes after the hour. I wanna make sure everybody knows that if you've been typing questions in the chat, I know some of our faculty have been responding to those questions there, but any questions that we are not getting to in the chat, we are saving and we will bring back to our faculty as we have time later today. And then finally, you all should have been able to find your learner's workbook, which has the companion materials to what you're seeing here in the presentation. And so Danielle's gonna be posting some instructions for that. And you can also reach out to her directly if you're having trouble locating that in the HCCI Learning Hub. So we will see you in 10 minutes. Thank you all so much. To reconvene. And I know our recording started again. Welcome back, everybody. Dr. Smith, are you ready to go? Yes. Can you hear me okay? I can. All right, well, very good. So welcome back, everybody. We're about to start our next session. It's clinical care. And I have the privilege of turning this over now to Dr. Ethel Smith. Okay. Hi, everybody. I just wanna echo Paul's enthusiasm about the number of participants, but also the range and depth of experience and the different questions that everybody had. I think this is awesome to have so much going on with this group. So right now, we're gonna look at the clinical care of HBPC or Home-Based Primary Care. If you could go to the next slide. So we're gonna review the essential elements of the Home-Based Primary Care Assessment and Care Plan. And then we're gonna view a simulated house call with actors. This was pre-COVID, so keep that in mind when you're watching it. And describe recommended approaches to various aspects of clinical care for the homebound patient, including medication management, prognostication, and acute and urgent care. Also, we're gonna look at how the 4Ms apply to the care of the older adults in three different patient cases that we're gonna have. So if you could go to the next slide. So first off, if you could turn to your pages 15 and 16, in your workbooks. On 15, you'll see the demographic intake form. And it has much of the same information that you would have on any intake form. However, you'll see also more about the living situation. Are they living alone? Do they have somebody who can look in on them? And responsible financial party information. I guess that would come up on any one of them. But also, you'll see equipment and supplier name. And at your first visit, you may not think that's a big deal to know who's giving them their oxygen until they call you on a Saturday and tell you that your oxygen's not working anymore. So then it's really handy to have that type of information. Also, depending on your community, you may wanna ask preferred pronouns. It's not on this form, but you take this form and you tailor it to what you need and what your community needs. And then if we go to then the next page, which is the Home-Based Primary Care Assessment form. And it includes a lot of what you normally see, chief complaint, history of present illness, then the past family and social histories, review of systems, medication management, and given this era of EMRs, you're not gonna have just five or six lines like you do here for the medication management. It would be great if you could put all of them on there, but we all know that in this population, we're working towards that. We also have included a number of screenings here. You're not gonna hit every screen every time. You'd be in their house for eight hours if you were gonna do that. But when something kind of triggers the red flag, you might wanna go to one of these screenings. It's nice to have them in your, if you do have an EMR, it's good to have them flagged in such a way that you can easily pull them into your note. I'm gonna let you look up most of them on the web if you need to. For alcohol abuse, Audit C includes how often they drink and the usual amount. And then you could, of course, use the cage. Ever cut back, felt annoyed by somebody telling them to cut back, feel guilty about drinking or an eye opener. One thing that I find very helpful on my first visit is a tug or a timed up and go. And that is that they start from a sitting position in a chair without arms, and they stand up, walk three meters, turn around and go back. If they can do that in less than 10 seconds, that is normal. And then as they progressively get higher up on the amount of time it takes them, their increased risk of falls or whether they need assistance or not really gives you some indication of their frailty and their risk for falls. And then you can take a look at some of these others. Some will be really handy and you know them already. Mini COG is a very quick cognitive assessment that can give you a lot of information very quickly. It's much less time than a MoCA or a Folstein. Here, if you're looking at caregiver burden, there's the Zaret burden interview, which can, again, be very helpful. So I'll go on to your physical exam. And like I said, I always include mobility on that physical exam, at least on the first visit. And then using a problem-based assessment and plan in these very complex patients can be incredibly helpful to just help you organize your thinking as you're going through that. It can be very, very helpful. Let's see. I think, oh, I've kind of breezed over. It's in there, but the goals of care, very important for this population. Are they in the category of, I never ever wanna go back to the hospital? Do they need palliative care? Is hospice gonna play a role here very soon? What about their nutrition? Again, although you probably do a brief look at nutrition, just kind of how they look when they come into the office, in the home, you have the opportunity to look at them. Are they obese? Are they cachectic? What's in their cupboard? What's in the fridge? How are they getting any food? Are they getting meals on wheels? Which, although it provides food, it may not be low salt or may not be diabetic friendly. So just different things to look at while you're in the home that you can't see in an office setting. Or that if, as you're expanding your home-based primary care maybe you're not adding that sort of thing in, but that's one layer you can really add in. And it's very, adds a lot of value to your visits and to your care of your patients in the home. It's also that first visit or farther down as you get to know them, really talking about advanced care planning. Do they have a power of attorney? And trying to help them understand why that's needed. Do they have a living will? Or at least if they don't have a living will, what are their preferences? Not that it's legally binding once you put it in the preference list, but it easily, I believe it's the same thing. But it easily, at least then you have it written down what their preference is. Okay, let's move on to the house call simulation. Like I said, it's pre-COVID and these are actors so we can't judge their medical expertise too much. But Danielle, are you able to, that's it, thanks. ♪♪♪ ♪♪♪ Home-based primary care is often delivered in a highly unstructured environment. A successful house call practice must have a high level of efficiency to maximize patient-centered care, manage costs, and optimize professional and personal satisfaction. As you're preparing for your day of house calls, be sure to do the following. Call ahead to confirm your appointments. Prepare your paperwork and review patient charts. Anticipate any non-standard equipment you might need. Prepare your equipment. Review and maximize your travel route. Okay, Rebecca, I just went through Brianna's morning email and there are a few changes to our schedule. Cancellations aren't ideal, but in this case, it's a good thing. It's Betty Connolly and she's going with her sister to visit her new great niece. Remember when we first started seeing her? The only time she ever left the house was when she was being transported to the ER. Oh, and we're seeing John this afternoon. His mom says that he's really congested, so I grabbed a Lukens 2. So our first appointment for the day is a new patient visit, which is always nice. Her name is Sharon May. Her chart says she's a 72-year-old widowed white female with congestive heart failure, hypertension, and arthritis. I'm gonna finish reviewing the chart and the rest of today's patients. Let me know as soon as you're finished restocking the bag and mapping our route, and we'll head out for the day. When you arrive at the house call, it's important to keep your own safety in mind. Always carry a charged cell phone, have accurate directions, and always make sure someone knows your exact schedule and the addresses of where you will be going. While you're out, periodically check in with your office, and if you're delayed, let someone know. When you arrive at your call, survey the surrounding area for any dangers, unsecured pets, or conditions that may impact your patient's quality of life. Ah, right on time. Great, I am Dr. Hoffman, and this is Rebecca. Hi. Come on in. Thank you so much. Sharon, is it okay if we set our stuff down over here? That would be fine. Okay, great. So it was fun reading about you. Thank you for submitting your information. I understand that you've got some grandchildren? I do, eight of them. Eight of them, oh my gosh, that's a blessing. I'm just gonna have a seat next to you, okay? Okay. So Sharon, how are you feeling today? Not much better, really, about the same. Okay, I'm sorry to hear that. I've got all of your information in front of me, but I'm gonna go ahead and ask you some questions just so I make sure that it's all the right information. Okay. Okay, and then while you're talking, is it okay if Rebecca takes some of your vitals? She'll just check your temperature and take your blood pressure. It's fine. Okay, great. I can see here that it says you were diagnosed with congestive heart failure in 2015. That's correct. That's correct, okay, and you've been taking medication for that? Yes. Okay. You've also got arthritis in your knees. And I see that you've got your walker. You weren't using it when you answered the door. Why is that? When I'm in the living room like this, I can kind of hang on to the furniture and it's awkward to try to get the walker in between the sofas, but when I'm walking down the hall or in an area with more space, I do use the walker. Okay. Do you have somebody who checks in on you? My sister's daughter, Isabella, comes by maybe every other week or so. Oh, that's a beautiful name. Do you guys ever get a chance to go out of the house and do things? We can't really because my wheelchair is so heavy and so bulky, and to get it in the trunk, it's just really difficult. I see that you are taking amlodipine for your blood pressure. That's correct. Okay. And you talked a little bit about being unsteady and feeling a little dizzy. Right. When I stand up, especially from a sitting down position, I get a vertigo type of sensation. Okay. And when you're standing? Lightheaded. Okay, lightheaded. Do you feel like you might pass out? At times, they do, right. Okay. The arthritis in your knees, are you taking anything for the arthritis? I do take some medication for the arthritis. Do you feel like that's helping? It does. Okay, we'll take a look at that when we go through your med reviews as well. There's also some exercises that we can show you to do with your walker that just might help with some strength as you're moving around. Okay, so why don't I take a look at you? Okay. Before you finish the call, there are several important things that you must do. The first is to discuss advanced care planning with your patient. This can occur at any time during the visit, especially if the opportunity presents itself naturally. If not, it is important that before you leave, you discuss the importance of your patient's safety. So, if you have a patient that is in a critical condition, and you have a patient that is in a critical condition, and you have a patient that is in a critical condition, it is important that before you leave, you discuss and document next steps with the patient and any family who may be present. You may need to revisit these steps on a return visit. Second, be sure to schedule a follow-up visit. Third, answer any questions the patient may have. Fourth, remind them how and when to call your office if they need anything. And last, thank them for their time. So, your heart's pumping your blood down, right? And what we wanna do, and that puts all of the liquid and the fluid down around your legs and your ankles, which is where you're experiencing your swelling. So, what we wanna do is we wanna increase your circulation. So, one of the things that you can do really easily is just walk in place. And you don't have to do it for very long. Absolutely do it while you're in your walker. And you can do that while you're watching TV. Okay, so what we're gonna do is we are going to drop your amlodipine from 10 milligrams to five milligrams. And we'll see if that helps with the dizziness. We talked about switching you from the Advil to Tylenol, because the Advil is something that we think is probably blocking your water pill, which is kind of making the swelling a little worse. And then things that you can do, right? So, we'll move your pillows to this side of the couch before we go. If you are gonna sit on the couch, maybe have a pillow under your legs. Keep them elevated, that should help. Some of the exercises that we showed you, where you can start moving your feet while you're watching TV. Maybe five minutes as you're watching your favorite show. Okay? Yeah, and that'll just help with your circulation. So, there's some other things on here. We talked about walking in place. And then your medication changes is right up here. And then we're gonna move your furniture. If you could, if you could maybe talk to your family over the Fourth of July weekend and see if they could help you get a smaller coffee table. And that way you can get your walker around, so it's more accessible for you. So, I'm gonna leave this here with you. Okay. If you have any questions, Sharon, call us, okay? It is never a bother. It bothers us when we don't hear from you, okay? We wanna know, we wanna be able to answer your questions. Is there anything else that I can do for you before we go? I think this is great. Okay. Thank you. You're welcome. If you think of anything, you'll give us a call. I will. Okay, great. It was so nice to talk with you today. The home visit isn't finished until all charting has been completed and any calls to family, power of attorney, and other caregivers have been made. Properly dispose of all medical waste, restock standard supplies, sterilize all equipment, and recharge your electronics so you can be ready for the next day's visits. Remember, a successful house call begins outside the home. Okay. One thing that Michelle put up in the chat that I forgot to tell you about is the worksheet in the workbook. So I'm gonna give you a couple of minutes to look at that. And then we'll open it up and talk about the house call. Okay, is anyone ready to share? Either we unmute or you can type it into the chat. Let's start with the first question. What did you observe about how the care team prepared for the visit? Is this how you currently prepare? Is this different? One thing that I think is different is there was a huddle. They talked on the phone about the visit beforehand, who they were going to see, what they needed. They got their equipment together. I have to say, when I was in an office setting, I wasn't preparing like that. I do now, but when you're in the office, there's a lot there. Now, everyone does their team huddles a little differently. We do ours once a week and then more on an individual basis if need be. We also don't travel with an MA. How about what at the start of the visit, anything you notice there? One aspect that was nice was the rapport building in that she mentioned the patient's grandchildren. And I certainly think that's kind of an easy way to try to build some rapport, talking about something the patient likes can be helpful. Right. Yeah. Right off the bat, she's starting on a social note rather than making it all medical. One thing I always notice is how they show the ID as they walk in the door. I always liked that piece. Someone else was going to say something? She took notice of the patient's surrounding and noted that she wasn't using her walker when she entered the door. So looking at her mobility right away. It was also constant assessment as she go along and as she addressed it. So even before she got down to asking direct questions, she was assessing and discussing with patients the different aspects of what's going on. And for instance, how to stand up and, you know, increase the flow to her life and stuff. So as she was assessing, she was giving her things to do. Okay. Okay. Hong Chen wrote, I wonder if there'd be another simulation video that shows how to do the home walkthrough. We don't have a video like that, but definitely it's a, it's a good suggestion. What did you notice about the physical exam that was different from a typical office visit? And we invite everyone, please don't hesitate to unmute yourself to answer. And if you'd like to turn your video on when answering too, it's always nice to put faces with our names and our learners. It was much more relaxed, I would say, rather than, you know, sitting on an exam table. I think patients are more comfortable with the I think patients are more comfortable and they're themselves. So some things that you would have to look for that you could easily see it when you're in a patient's home. I really liked how she was able to assess how a patient just simple as answering the door that she didn't have her came with her. So I think that's something you definitely wouldn't know in a hospital or I mean, in a clinic. Mm-hmm. I would say the assessment also began as they've been saying from the time she hit the door. So the date was assessed, the environment, risk for falls, like everything was, it didn't appear to take a long period of time to get all those key points assessed and even having the MA, which is something likely I won't have in the beginning. She was allowed, she was able to start the process of the physical assessment, even while, of the vitals and different things like while she was communicating with her. And you're also assessing the whole environment, the cleanliness, ease of accessibility. And are you going up a very steep, dark hallway? You know, there's lots of things that you're taking in all at once. You're in their space. So your patient has more control, rather than in the office setting where you have all the control. She also asked about mobility outside of the home, like if she gets to go out and then also who she has for help. And when she described her niece and help a little bit. Yeah. Excellent. She did. She asked about how does she get out? Does she get out? Who's, who's nearby? Yeah, that's great. I have a question more about like a physical exam also, like nowadays patients usually have more, their own like glucometer or blood pressure cuff. Like should we just use them, especially now in the area of COVID that we try to not contaminate any or like bring any contamination to the patient? Should we just use their vitals or like, should we always do our own vitals? I, I, I think this is individual. I tend to get my own vitals at a visit if they want me to use their equipment. I'm happy to do that. And, you know, certainly will, I want to respect what the, what the patient is needs. I know if they don't want me to use it, I also will wash my equipment in their presence. Unlike she did with the stethoscope, I usually do it at the end of the visit. You could do it at both times. And, one thing I'm, I don't usually sit on upholstered furniture. I usually sit on like a, a hard chair that doesn't have a cushion on it or anything, but that's again, a preference. How do other people handle it? A lot of you have experience in the home. I haven't done this, but I've heard someone say that they walk with a step stool, that they walk with a portable stool. And even it's like a quick portable table that they have their own setup. And the patients don't seem to be offended by it because sometimes they're able to move into areas that they wouldn't normally be able to go into because they have that device. I saw one for like $10. One of our NPs carries one. I typically carry the pads, the disposable pads with me. And I sit them down on the table and on the chair. I sit on one and I put one on the, on the surface that I'm going to be putting my equipment down. And I take a big container of sanitizer wipes with me. And I wiped down the equipment in front of them before I leave. And I explained to them that I do that with everybody so that they wouldn't feel like I'm doing it because I feel, you know, I don't feel like the area is clean and the feedback that I get just from doing that alone is very, it's welcoming and it assures the patient. And I just explained to them that I just don't want to contaminate anything. I don't want to bring anything with me. Don't want to take anything with me when I leave. Yes. And people do really appreciate it. They, they can get a little paranoid. You're right. So I always say, this is standard. I do this with everybody. And so that works. Okay. Anything else on that? All right. What about the safety issues? What would, what safety issues did the professional address? And were there other things that you would have asked about or looked for? I usually ask permission to check the fridge and the pantry. She talked about getting a smaller coffee table so she could actually manipulate the walker in the home with a, with more ease. That makes more sense. I think probably evaluating whether or not she could use a cane in the house, seeing as she was furniture surfing anyway, that might've been something that would have been helpful for both the patient and the provider being more confident that she was using a device. She also said that she didn't get out because the wheelchair was too heavy. And that was one thing that they didn't address was maybe getting her a lightweight instead of a transport wheelchair, instead of a, a big, heavy one that, so she could actually get out of the house. Right. And it also, those are the things that come up as you you're going along the visits, you know, okay. Right away, you're talking about needing a transport chair. So I always keep kind of a running log of things that I need to address at the end. So what about restroom facilities? We don't know if there were any on that floor, if she was needing to go upstairs, did she have a bedside commode? That definitely be something I would ask. What else? Anything else there? I didn't see her ask, unless I missed it about any sort of alert device, like a life alert, didn't see her wearing one. And with her being a fall risk, it wasn't something that I saw addressed unless I missed it. Great point. Great point. How was the care plan communicated? Is that how you would like to see it done? How would you do it differently? I didn't see she gave it to her in writing and their memories sometimes aren't that great. So maybe that was one of the things that she forgot about. And it's very difficult to ask them to elevate their legs. I don't know why, but it's like almost impossible with some of them. They actually refuse to elevate their legs because they have to reach the bathroom. And so I know she stressed it, but that's all I can think of right now. Right. But now in, you know, in this day and age, we go in, we get a printed out after visit summary. And that was, you know, unless you're carrying a portable printer, but it's not so easy. You have to write it out or have at least have her repeat back what she's heard in her own words. What about after the visit? What are some of the things that need to happen as a follow up? Nothing. Rita, are you are you saying something Rita, because you're on mute? Sorry. I didn't hear her mention anything about when her next visit was. And I always tell my patients, when I already gave them my card, the new ones, I tell them I'll be back. I or my nurse practitioner will be back in about four to six weeks. I can't tell you right now because the schedule can change on a daily basis. And so they understand. And I try and tell them that if they need me for anything, call the office and if I or Lisette is close by, we will come if not, I'll try and figure out what I can do for them on the phone. Excellent. Excellent. Anyone else? Sometimes it's good to follow up with family, especially if they don't have the mental capacity. Just sometimes there's a lot of coordination that goes on and the family needs to be aware of the plan too. I will often call the family at the end of the visit so that we kind of we have a plan all together. And then I'll call so the patient is actually hearing what I'm telling the family member and I'll keep them on speakerphone so they don't feel like we're talking about them. I have written down my instructions before and then taken a picture of it and put it in EPIC using the under HYCU and use that directly in my notes as part of my plan. So it's clearly clear what I have instructed the patient to do. And so when we review it next time, I can say, hey, remember, or do you have that paper? And so that goes into the photo section? You can in EPIC, if you have HYCU on your phone, where I don't know how many people here have EPIC, but you can take a picture that will go directly into media. That's a great idea. When I do my note, I can pull that in. That's great. That's possible in ECW also. I wish we had EPIC, but it can also be used in ECW, taking a photo, it's helpful. Any last comments? Okay, we're going to move on to prognostication with Dr. Della Giannidis. I think I just slaughtered your name. My apologies. No, that was perfect, thank you. So hi, good morning, everyone. So if we can go to the next slide, I'm going to talk about prognostication. And so before we begin, I'd like to review the objectives. Oh, sorry. Let me put on my video. There we go. All right. I'd like to review the objectives. So first of all, we're going to review the elements of prognostication, including its role in caring for complex patients and their families. In addition to talking about what it is, we'll also talk about what it isn't. And second, we're going to describe and discuss functional patterns of life-limiting illness. And then lastly, we're going to identify some barriers to accurate clinical prognostication and use some tools to effectively overcome those barriers. So next slide. All right. So Dr. Christian Sinclair stated that medical prognostication is a prediction of future medical outcomes of a treatment course or a disease course based on medical knowledge. So prognostication is not fortune telling. It's not playing God. It's the science of estimation. It's estimating the likelihood of an outcome due to a medical condition. Now traditionally, it's focused on remaining life expectancy. But it also should include outcomes that are important to patients and families. I'll talk a little bit about that at a future slide. And most patients with serious illness would want a discussion about this, but it often doesn't happen. And we'll talk about why that doesn't happen a little bit later as well. So next slide. So it's important to recognize patterns of functional decline. So there are patterns, right? Or if you want to call them clinical trajectories. And those patterns, those trajectories can help inform prognostication. There are four trajectories we'll talk about in the upcoming slides. But the thing that I wanted to mention that we were talking about at the previous slide is that it's important to recognize these patterns. And by recognizing these patterns, it not only helps with prognostication of life expectancy, but it also helps with prognostication of patient outcomes, like events in the disease process that patient and family members will want to know about. And it'll help them also anticipate family, help them, patients and families, anticipate resource needs. So one of the classic examples I give patients and I give everyone in terms of outcome, not necessarily life expectancy, but outcome patterns and prognostication is the entire thing about dementia and incontinence. So as dementia progresses, one of the steps in the progression of dementia is the development of incontinence. So by giving anticipatory guidance that that will happen, patients and family members will know, okay, this is what to expect. I'm going to need to look out for skincare. I'm going to need to look out, make sure I have the appropriate supplies, the appropriate things to address possible skincare issues. So that's just an example. So the four trajectories that we're going to go over in the next few slides are sudden death, cancer death, organ failure, and dementia slash frailty. And this is about life expectancy prognostication and functional status prognostication. So if we can go to the next slide. So we'll start off with an easy one, but a painful one for families, and this is sudden death. So in these upcoming slides, we're going to have functionality on the Y-axis and time on the X-axis. So, I mean, this is self-evident. Patients have a high level of functionality, and then they suddenly die, and this is the ultimate compression of morbidity. Now next slide. So now we have, in terms of cancer death, the onset of incurable cancer to death usually happens most often over a few years, but there's a rapid decline over the last four months or less. And this is usually the traditional hospice model. The trajectory is six months or less. Patients get referred to hospice, and the life expectancy is short at the end. But there's usually a high level of functionality and then a rapid decline. So next slide. So the next one is organ failure. So kind of like either a heart disease, lung disease, for example. The overall trajectory is a decline, but it might be slow, but then we have these dips. And functionality can take a dip and might recover, but when it recovers, it's never as good as it was before. And it continues until there's another dip at the end, and then there's a rapid decline. And because of that rapid decline, caregivers, family members, or providers even will say, you know, oh, that was sudden. But when people look back over time, they'll say, oh, actually, they were declining for a while, but it just felt sudden at the very end. Next slide. And then we have dementia or frailty, sometimes referred to as the dwindles. And this is like a slow and steady decline over time. Now, it's not like a, it's not a linear line. It's a, you have, you know, you have some areas of slow trajectory and then rapid, you know, rapid decline. Sometimes as you can see there, we have waves, right? So because there are waves, you know, there will be some times of some improvement. It's not all decline. But you know, this trajectory of life expectancy is about, you know, four to eight years or even more. So it's a long-term gradual decline. So next slide. So the thing that I wanted to talk about is even though their prognostication is a, you know, science of estimation, you know, it's, there are limitations, right? You know, there's, there are insufficient evidence-based guidelines. And people usually don't have just one medical condition, right? You know, there, our patient population has multiple comorbid conditions like frailty and organ failure. And it can result in, you know, different trajectories. You know, they might not necessarily fit in the pattern that we talked about. They might be even some hybrid of those, of those patterns. And the next point is particularly important now, you know, especially in COVID, you know, now that we're all experiencing COVID, is acute hospitalization is very important in the disabling process. It can cause a rapid decline, you know, than otherwise would have, would have been predicted. Even for those who leave the hospital and survive hospitalization, the decline afterwards might be much, might have, will have happened a lot faster than otherwise would have predicted, would have been predicted. And so prognostication is like a prognostic tool is effective in combination with clinical judgment and clinical experience. It's better than when either are used alone. So next slide. The other thing is, is that there are clinician barriers, right, to clinician barriers to prognostication. So there's the concern about removing hope. There's the concern about stressing or even damaging the therapeutic relationship. When there's, you know, when there's a decline that's happening, there's a concern about, you know, giving information about trajectory that the patient or the family members didn't ask for, right. But it's important to share in a sensitive matter. There are also cultural issues, and I think we'll talk about that in the future. There's also the concern about being wrong. Clinicians, because of that, clinicians consistently overestimate survival. Sometimes because of the concern about removing hope, sometimes clinicians are enthusiastic and sometimes overly enthusiastic about new treatments. And if there was a past negative experience, you know, there's a strong, you know, internal gut reaction to that past experience. And there's, you know, there's the, there's that kind of tendency to not want to prognosticate or give information based on that one experience in the past. And also there's limited formal training about this. So if we can go on to the next slide. Actually let's go to the next slide just for the purposes of time. Included in your worksheet is, there are these different resources. If we can go to the next slide, I want to call attention to the last three. So Calculate by QXMD is, I think it's available as an app on the smartphone. It has multiple calculators in there. MDCalc also, it's a desktop and a smartphone app. Really helpful, I'll explain, I'll show you a screenshot of that at a future slide. And E-prognosis from UCSF. So if we can go to the next slide. So this is E-prognosis and I find it really helpful for cancer screening and for communicating. There are these modules about communicating prognosis and they're like training modules. And so these are resources that you can use to help with communication skills in communicating prognosis. The cancer screening, I think it's specifically for, I want to say breast cancer and colorectal cancer. And after you put in some information in the calculator, it says what the number, it gives you like a snapshot, is cancer screening recommended? Is it more likely to give benefit or more likely to give harm? And it gives like out of 100 patients who would have benefit and who would have harm. It's a good visual tool to share with patients. Next slide. MDCalc is really helpful. I have it on my smartphone. I think I use it three times, three days a week with my patients every week. To say that, I use it very frequently. So one of the common things I hear is, okay, doc, in the hospital, they said, or my cardiologist said, you should be on anticoagulation for my atrial fibrillation. But I'm concerned about bleeding due to, if I fall. And so what's my risk of, what should I do? And by using MDCalc, there's a calculator for the CHADS-VASc score about the stroke risk with atrial fibrillation. And there's also the HASBLED calculator about bleeding risk. And so putting in information into those calculators helps patients make a more informed choice as to what they should do next. So that's a helpful resource. Next slide. So just a summarization, prognostication is an essential tool in caring for complex patients and in facilitating advanced care planning discussions. There are four major trajectories, like we talked about, and there are a lot of different tools available, and it's best to use them in conjunction with clinical judgment and clinical experience. If we can go to the next couple of slides. Here are some references and one more slide I wanted to call attention. So this book by Dr. Adler, I think is very similar to the UCSF website on cancer screening, but the prognosis website, but it goes into things beyond colorectal cancer and breast cancer screening. The other really neat part is the number needed to treat website. It's helpful for, for example, if patients are wondering whether or not they should be on Fosamax or bisphosphonates for osteoporosis. It gives the number needed to treat, number needed to harm. And again, it gives people information, helpful information as to the risks and benefits and makes patients and family members more informed. So that is it. Do you have any questions? Oh, thank you for putting the information on the chat. All right, well, thank you very much, Costa. That was great. We have one more mini lecture before lunch. And I just wanna remind folks, if your screen does not say your first and last name, could you please change that now? It's gonna help us when we go to move people into breakouts when we come back from lunch. But so for now, I'd like to go ahead and turn it over to Dr. Paul Chang to talk to us about our next mini lecture. Thank you, Melissa. Next slide, please. The next couple of minutes, I'm gonna talk about cross-cultural competence. But before I get there, there are a couple of comments I wanted to make about the previous couple of mini lectures. Regarding prognostication, there's one additional app that I use. It's called Fast Facts. It gives you a lot of tips in prognostication regarding traumatic brain injury, dementia, CHF, COPD, HIV, and so forth. And also give you some guidelines regarding how to conduct family meetings. So it's called Fast Facts. That's one app that I use. And there was a comment about a walkthrough. For me, I try to make it a natural part of my visit. And this is the way I typically, you don't have to do it this way. Obviously, you can do whatever way that works for you. I typically start, and I try to make it part of it, a natural part of my visit. I say, hey, can you show me how you go through your day? Let's start with, what do you sleep? And then how do you get out of bed? And after you get out, how do you get to the bathroom? And where do you eat your breakfast? And so on. And have the family take you through how they do each step. And you can better appreciate the struggles, whether it's a mobility issue, whether it's assist device that's really needed, or some remodeling that's potentially necessary, or, and then you go through food insecurity and so on. Make it kind of, not kind, make a natural part of your visit. I think they really appreciate that, that a doctor is taking an interest in how I live my life. And by doing that, using again, the power of your observation to see what's feasible, what's challenging. So you can craft a care plan that's appropriate for your patients and family. One final comment, it's about infection control. We do, ACCI does have a module on infection control. So I encourage you to visit that to get additional information on how to minimize contamination when you're at the patient's home, especially during the era of COVID. This, the objective for this section regarding cross-cultural competence, we're gonna define and discuss culture and shared decision-making process. We're gonna talk about culture and the biases and their impact on how we engage with health care delivery and recommendations. And we're gonna review the role of HBPC in enhancing cultural awareness and how to facilitate a patient and family in decision-making. I practice outside of Chicago. I practice in suburban DuPage County, and I was looking at some statistics from DuPage County. And there are 43 languages that are spoken here in DuPage County. And as a household provider, you are most likely, you're gonna encounter people from different background and ethnic group who may not share the same perspective on care and decision-making and truth-telling that you and I have. So just want you to be aware of that. Now regarding culture, one sociologist define culture as the effort to provide a coherent setup answer to existential question that confronts all human beings in the passage of our lives. Culture is that glue that holds our ideas together. You know, what is good? What is bad? What do we like? What we don't like? How do we live? You know, the death and dying process and decision-making. So all of that is important as we engage with patients and family from a culture that's outside of the U.S. Next slide, please. Most people have heard of the golden rule, do unto others as you would have them do unto you. But if you have not heard about the platinum rule, or if I can remind you about the platinum rule that treat others the way they want to be treated. Now, the difference is that the platinum rule demonstrate a greater sensitivity to cultural differences by focusing on treating others the way they want to be treated. We are acknowledging that they have different values and beliefs that's different from mine, okay? So what does this mean for HBPC? It can mean that the etiquette of a visit can vary differently depending on the culture of the patient and family that we're visiting. Certain culture, for example, I'm required to take off my shoes at the entrance or put on shoe covers, all right? Other culture wants a provider of the same sexual background. Say, for example, a female provider is preferred to take care of a female patient. A culture may request that the husband or the oldest son be present during the visit. Other patients or family may ask that you don't tell the patient the diagnosis or the truth regarding their condition. Time of day of the visit may depend on the culture of the patient and family regarding their work schedule, their sleep-wake schedule. Some patients only want afternoon visits. Elderly patient may make us wait in the entry hall until she gets a chance to put on her makeup. True story. This is a cultural norm for her from the era that she grew up in. Next slide, please. So how do we go about assessing patient and family preference in a culturally sensitive way? May I just highlight four areas that you can see here on the slide? First is explore. We explore the religious and spiritual beliefs that may impact the healthcare preferences of our patient and their families, okay? We seek to understand, that's the second step, the historical and political context of a patient's life and how that may impact decision and decision-making, thinking for our patient and family. Next, we address communication and any language barrier that may be present according to best practice guidelines, including the use of language translators when it is appropriate. And lastly, we involve, if needed, religious community leaders when it's desired by a patient and family, especially as we're talking about, say, end-of-life decisions. So a thorough assessment of HBPC patient is not just their medical conditions. It is how they make decisions about their care and who they may want to have involved in making the decisions, okay? Having these discussions early in a culturally appropriate fashion and review them regularly allows the HBPC professional to develop a care plan that's appropriate to our patient and family. Next slide. So these are steps in shared decision-making. They're not necessarily sequential steps as I see it, but I consider them bullet points as we think about how to engage in shared decision-making with our patients and families. One is assess cultural beliefs regarding truth-telling or withholding of information. Another consideration is try to elicit the patient's values and preferences. Pay attention to cultural and spiritual values. Again, you can see that when you walk into the home, right? You get a sense of that from how the family dynamic is flowing around you, or again, like religious artifacts that you may encounter in the home. Be aware of the clues that the family's providing for you. Next is be aware of preferences for family-centered decision-making in many cultures. In the States, we often think, patients write to self-determination, I did it my way, and so on, but that's not a shared belief with patients from other culture. And finally, assess the family's preference in decision-making. When I was talking about this with a learner this week, he asked, how do you do this? Do you have specific questions and so on? Yes, there could be some question that we can tailor trying to bring out these ideas, but I say, you know what? One general comment I wanna make is that we need to learn not to make statements as doctors who often just go around saying, sodium's low, you have cancer, and so on, making statement, you should be on hospice. But I think, and I told the learner, learn to ask questions, learn to ask questions, because by asking questions, you can better understand the patient's and the family's presuppositions, and you can also find an entry point for your discussion regarding what to do next step. For example, if you're thinking about hospice, instead of saying, mom needs hospice because she's dying, she's got cancer, you can learn to ask in a open fashion by saying something like, tell me what you know, have you heard of hospice? Tell me what you know about hospice, and then you can find either good or bad experience they may have had, and then find entry point for ongoing discussion. So all that is to say, learn to ask questions, so you can find better entry point for ongoing discussion with your patient and their families. Next slide, please. Next is a case, it's a real case that I had, Mrs. Chang. It's a cross-cultural patient case, and I want you to, and I want you to go to the case example that's in your workbook. I'm gonna give you a couple of minutes to read and review the case, and then we'll get back and we can discuss what the provider should say or should not say, what the provider should do or should not do in terms of engaging with this patient and family. So I'll give you a couple of minutes to read through this case. All right, I hope you all have had a chance to look through the case, and we can take a look at some of the questions that's listed below on Mrs. Chang's case. Okay. I'll open it up to the audience. Any general comments about the case? With my experience, I once had a Vietnamese lady that developed and staged Alzheimer's disease. And the problem was neither one of them, well, she couldn't talk because she couldn't comprehend. And then the husband, he couldn't understand English. And so the only person that I could communicate was with the son. And they had decided that they were just gonna keep her comfortable and they didn't want her to go to the hospital. And so then I presented to him that it would be a good idea to put her on hospice. And I asked him, do you know what hospice is? And when he told me no, and I explained, he said, sure, that sounds really good because it helps him with the cost with the diapers and have a bath aid and all that. And she didn't have any of that. So she died under hospice. It was a sad story because there were one of those that escaped Vietnam on a raft. And out of all the children they had, I think there were six of them, only that son was the only one that survived the trip, which it just makes you feel sad about them and him losing his mom and the husband losing his wife. That's an interesting and great story. I think it serves to remind us that our patients are complex. We all have stories to our lives that shapes our decision, good and bad experiences in the past. Medicine tends to be very reductionistic. We reduce our patients to what COPD, CHF, we reduce them to electronic medical record or whatnot. Being at the home and listening to the story reminds us they are human beings. They have history, they have stories that shapes how they think about life and death and so on. We may not agree with what their decisions are, but there is a story behind that. So thank you for that reminder. In my palliative care role, I've often come across similar situations where families are a little bit more distressed about disclosing a diagnosis to a mother or grandmother and how that could potentially expedite their decline. And I've found that in many of those situations, just addressing the patient and just plainly asking them how they prefer to make decisions about their care. And that has not only alleviated a lot of the burden and concerns that the family has, and also that kind of meets our own kind of medical, legal navigation that we need to do. Yep, great, great, great comment. Now I'll just go down to the bottom bullet point here. And I would love to hear other people's reaction to this. I'm not looking, there's no right answer here. I want all of us to kind of wrestle through the case. In our Western view of autonomy, are we doing a disservice to the patient if we defer everything to the son? Dr. Chang, Ada Tapper, I know you were trying to say something before. Can you speak? Sorry, Ada, didn't mean to cut you off. No, we're not hearing you, Ada. Is there a microphone that's muted on your computer? No, now you're muted on Zoom. Okay, we can, why don't we come back at the break and we'll try to help you, but we're not hearing you, Ada. Okay, so who else? I'm sorry. Who else would like to make a comment? I mean, I believe there's a definite cultural component. And I think the important thing to do is see what her basic understanding and if she has capacity and then would she want to defer her, the details, I guess, to her son. And she might say, yes, yeah, just tell him or something like that. I think it gets sticky if they have capacity and where you're trying to keep something because they have a right to know as well. But I think it is a definite cultural component. And as we get older, I think our, we get more anxious in general, right, about our health. But like, if you're gonna bring in hospice, they have to, we have to know, like, is she capable of making her own decisions? And then she has to know why these people are coming in, at least a general understanding. Not necessarily because I've had patients that don't know why they're on hospice and the family members request not to tell anything to the patient because they will have, they'll go into a nervous breakdown and they don't want the patient to suffer like that. And you have to take into consideration their suffering of knowing the prognosis and that lady's gonna die of cancer. So I think the most appropriate thing is to ask her, who do you want to let, are you going to make your decisions or who do you want to make your decisions? And she's most probably going to say, I want my son to make the decisions. He knows what I want, that's it. And so you have to honor her. And I know it's very, very hard and I've had to go through that, but you have to honor them because I've seen hell break loose when you don't. I have just one question, like procedurally, would it be beneficial to have her sign a healthcare power of attorney or explain to her maybe through a translator that that's kind of just, you know, the expectation for documentation and then we can designate her son that he be her decision maker and certainly give all the information to him or is it sufficient just to chart that that's her preference? It just, you know, on an ongoing basis. Oh, great comments, everybody. If I remember the case correctly, this has been many years now. I remember her having some memory loss, but I did not, again, I don't know what her MINICOC score or anything like that was, but if I recall correctly, in my opinion, she did have decision-making capacities. So even if she did have a power of attorney paper signed over to her son or husband or whoever, the initial conversation regarding goals of care needs to be had with her. I think the tension for me was my duty to be truthful and providing a factual-based care to our patient and balancing, again, somebody mentioned about disrupting the culture, upsetting the visit and really taking a risk of ending any kind of relationship I may have with the patient and the family, especially during a time, you know, she's got a critical need, she's dying. Now, am I going to just say, well, for the sake of truth, I'm just going to hammer away and whatever happens, happens. So I think that was the tension that was in my heart when I was sitting in the living room trying to figure out a way that's culturally sensitive, that preserves my role as a clinician in the home in taking care of her who really needs ongoing care and is going to need more and more hands-on care in the days ahead. I just want to reiterate asking the patient who they, about, you know, do you want me to give your information to your son or who's, you know, I really have gotten some answers that kind of surprised me. You know, you say, well, who, do you want to know what's going on with you or should I be speaking to your son? And I've had people say, just talk to my son. He'll tell me what I need to know. So asking the question does help with rapport rather than just blurting out the prognosis and disease diagnosis. And the important thing is not what we think, it's what they think because they are the patient, not us. We're the healthcare provider. So we need to, we have to be, oh my God, why the word came out? We have to, that's their choice, not ours. Let's put it that way. Can you guys hear me now? Yes, now we can, Ada. Okay. Thank you. Well, thanks for the comments, everyone. I have a timer who's trying to keep me on time here. So if we can make, go to the next slide, please. So in summary, cross-cultural competence is really critical for HPPC providers because culture impacts the way people think, feel, behave, and it impacts healthcare decision-making. And obviously that'll lead to their overall health. And practicing culturally sensitive communication skills, it takes time, it takes practice. And by developing a series of questions, we might learn to ask open-ended questions, addressing these differences and having these difficult conversation will become easier and feel more natural for you. Next slide, please. And here are some references. And I think it's lunchtime. Hi, yes, it is. All right, thank you all so much. We are gonna go ahead and break for 45 minutes. Please stay connected to your Zoom and you can just mute and turn your camera off and we will rejoin at 15 minutes after the hour. That's 45 minutes from now. Thank you all so much and have a great lunch and we'll see you soon. Just coming back or you've logged, you logged out before lunch and are logging back in, please make sure that you have your first and last name on your screen. You can change it by changing the three dots in the, I guess it's the upper right-hand corner of your screen. Anyway, I wanna welcome back and we are gonna get started with the next part of our session. We're gonna be moving people into breakouts, but before that, I'm gonna invite our faculty member, Megan Verdoni to tee up the next activity. Hi, great, thank you, Melissa. As she mentioned, I got into, I'm a PA and I got into house calls about five years ago and my background is also emergency medicine. And so it provides a really unique viewpoint on this. And so as a result, we're gonna take everything that we've learned from this morning and we're gonna try to put it all together so you can formulate some care plans for three of our case studies here. And I want to make sure that when we go into the rooms, cause everybody's gonna get broken up into rooms, there'll be eight to 10 of you learners in a room. There'll be a faculty member with each of you. So that way you're able to ask questions, utilize the resources, and we'll put this all together as we develop these care plans. Make sure in your group that you designate a spokesperson. A spokesperson, then when we come back to the live session, we'll then present what your care plan was for each case study, okay? Again, if you have any questions, please reach out to us and make sure to ask the faculty member in your room in your chat session. And with that, we'll start off with the first case study, which is Ralph. We'll go into our rooms. I told you. Make sure that everybody gets back into the main session here, okay? And then we'll go over the different patients. Looks like all 40 of us are here. Okay, get my screen. All right, so we're going to do a debrief of the patient cases. And we'll go ahead and go to the next slide. We'll start with Ralph, and we're going to talk about with Ralph what matters. So we had different groups, and so we may have had some different answers as to what was considered important for Ralph. We'll try to go through each group and see if you can talk about what you found was important and what your solutions were to help out with Ralph. But again, what matters, what's important for the patient and family and their preferences for care, what are their short and long-term goals, and then what else do you need to know, and what was your sense of Ralph's prognosis to remain independent? So is there a way, Melissa, that we can look at, have the first group go for review? Yeah, so who is in Breanna and Matthew's group? So that was us. Terrible. Is there a spokesperson from there? If we could have, Breanna, if we could have our summary of Ralph come up, and then we can go through Ralph. Is that possible? Sure, yeah. I can just pull up my notes on him since I'm not the one sharing the screen, and we can talk about it. I know with Ralph, the CHF and his O2 level was one of the first things that came up. I think it cut out there on, yeah, Breanna's phrasing was from the hospital, does he understand them all, you know, talking about his COPD and functional status and mobility really digging deeper into the functional status and mobility, and his fluid intake was the other big point we talked about with Ralph. Again, Ralph is a pretty complex patient, and so those were the things that we identified in that group, and I know it kind of cut out a little bit with Breanna, but what about the next group? So we talked about what matters for Ralph is that he wants to be able to sit on the porch and hang out with his friends, but what keeps driving him back to the hospital is his shortness of breath. He's not really maximized on his Carvedilol for his heart failure. He was also started on Metoprolol in the hospital, so we definitely would want him to not start that. Getting him some physical therapy in the home would be very helpful, and then his med compliance is also one of those driving factors that keeps sending him back to the hospital, so tapping into his VA benefits so that he could get his meds not only in a 90-day supply and paid for, but also delivered to the home. I think that the physical exam pointed out that he was conversationally dyspneic until his machine was fixed, so actually walking him through how to use the equipment, when to use the equipment, and is he using his inhalers correctly to sort of prevent those exacerbations in the hospital. Getting that home health in there to really kind of also keep another eye on him, that would be a helpful thing, too. And then, did anybody have anything else on Ralph that they found that was different or that they felt also needed to be stressed? I mean, we talked about a lot of the same things. Obviously, he values living alone and how to make that happen at least short-term, as long as possible, and with him having Medicaid, maybe having home health up to 40 hours with that, seeing if his VA benefits, if he would qualify, and then polypharmacy was kind of a big issue, meds, that he had duplicates, like beta blockers, and why he wasn't able to, some of the noncompliance related to finances. There's also safety around his living situation around his home, worried about gangs and those kind of things. I think he was also on Motrin, those kind of things. Benzodiazepine. So, what's different about caring for him at home versus if he came into the more traditional setting or the office? Well, first of all, it talks about how he had extension cords running across walkways. It talked about how he was unable to use his equipment correctly, because once it was administered to him correctly, he was no longer conversationally dyspneic. So, you can't experience that in the office. You have to be in his home to see it. Exactly. Exactly. So, you're able to identify the problems that never would have come up, because he probably would have had portable oxygen in the office, and it never would have been something that was noted that he's not using it properly. Is it that or a very long extension cord? Yes. You have a lot of advantages by seeing him in action, whether or not he's using his oxygen properly and getting the right medications. Great. We also talked about possibly for his blood pressure, increasing the hydralazine. I mean, whether you increase the beta block or increase the hydralazine, the hydralazine was once a day. Once a day, yeah. And I believe someone already said discontinuing the NSAID, the ibuprofen. Yes. Yeah, absolutely, because that may be driving up his blood pressure as well. So, that would be helpful to try to reduce that. So, he's got a lot of- Also on warfarin, right? He was on warfarin, which risk versus benefit of that at this point, we think of all risk. Exactly. And so, Ralph's got so many different options that we could approach with him to try to help improve his overall status and his care and make him feel better. So, there's no one right answer for how to approach these patients. I mean, a lot of times, it's just trying to chip away at the iceberg and see if you can't try to make progress with each visit just to improve them and catching the problems where they're not taking their medications right, they're not using their oxygen the way they're supposed to, and whether there's dangers in the home. So, all right. So, that's Ralph. All right. Let's go down to the next slide. Danielle, can you move to Betty, please? Thanks. All right. So, let's talk about Betty. You know, Betty, just to kind of review, you know, she had the COPD exacerbation, she had control of blood sugar, depression, she had an abscess, and, you know, the physical weakness in deconditioning. You know, let's try it this way. I'm going to have one of the groups, if you could just kind of go over what was the biggest issue that you found for Betty that needed to be addressed. So, the most immediate issue was the abscess. I don't know if that's the biggest one. That's the most immediate one. It's certainly an easy way to make her feel better and kind of maybe improve her mood in a certain way by not having that abscess be an ongoing problem for her. Right. That kind of solves a couple of issues besides the fact of the infection keeping her out of the hospital with it. Right. All right. Any other suggestions as to what you found from other groups that was important to address right off the bat with her? Safety was a big issue because she had been living in the basement. And we talked about if, because the husband is truck driving in a way, and even if the daughter runs to the store, would she be able to get out of her basement if there was a fire? Right. That necessitates like further, you know, intervention now. What interventions did your group decide might be a way to improve that or try to get her on a better path? I mean, first, kind of have the discussion with the daughter in terms of being able if she's able to be left alone in that state. We don't know the situation if the basement is a different issue, you know, like if there's another place that she's safer could be. And then we talked about possibly getting family services involved in the future if we couldn't find a safe solution. Our big question was whether or not there was a bathroom in the basement. So how was she actually cleaning herself up? Is there a shower down there? Can she get in and out of it? She's usually doing sponge baths, but she's 5'6 and 465 pounds. She's missing a lot of surface area just because of the fact that she can't reach. So we wanted to make sure that that was somehow addressed. First things first, just getting in maybe like a home health aide that can help her with just wants a sponge bath, somebody that can actually get to all the crevices. And how is she even going to change the dressing for the access? Yeah, we talked about the same thing. Maybe having a home health aide, maybe having a RN evaluate for a couple of days along with addressing the polypharmacy that likewise could be contributing to the way that she was feeling. She was on multiple psychotropic meds or meds that also could affect the neuromental status. She was hallucinating. So in addition to trying to take care of the COPD exacerbation, possibly with steroids or just inhale steroids or whatever we were going to use, having that RN to come back to evaluate the site, the antibiotics, and home health aide for bathing, and then you would make a decision whether she needed to be hospitalized, she was getting better, something else was going on, bringing someone into the fold, or that she was getting better. And checking labs, of course, in the midst of all of this, because she had a lot of various things going on. She's got that chronic kidney disease, and that's an interesting thing when you go back and look at the medications, and if she's overprescribed, that polypharmacy, is that the cause for her over sedation, her depressed mood? Her hallucinations. Yeah, right, right. So really, sometimes you got to consider, is that one of the big issues? We can kind of start to deprescribe a little bit, maybe, and she might improve. So it's a good point to bring up getting some labs. What's her GFR? Are we causing more problems? She's definitely very complex. Depression was a big issue with her too, and obviously she's already on multiple medicines, and thinking about telemedicine, maybe therapy that way, would be a way, because even just having someone to talk to, and talk through things, might even be more effective than the medicines. Exactly. And that's becoming a lot more available for some of these psychiatrists and specialists, the ability to do the telehealth now, because they're more open-minded about it, versus saying, oh no, they've got to come into my office, because the reimbursement's there again. All right. Awesome. All right. So that's Betty. So let's go down to the next slide. All right. Christina. Christina, you know, is an interesting patient, in that she doesn't speak English. We've all run into this before, but she's got weakness, fatigue, she's got a rash, you know, shingles, ovarian cancer, hypertension, you know, her cholesterol's being treated with a tortosatin, you know, hypothyroidism, and then you've got her daughter, who essentially has to still work, although we had in our group a good suggestion that maybe her daughter could, since she's got Medicaid, maybe there might be a way to get paid for some of the caregiving that she does. There are some of those resources available, and that's where a social worker and really looking into resources could be helpful. And of course, advanced care planning, you know, does Christina really recognize the severity of her illness, and what are her goals and plans for end of life, and how she wants to approach those things? What were some of the things that you guys decided that were most important, or the two three things that you really wanted to address in your first visit with her? First things first, her constipation, because that's something that's really bothersome to her. She's on, as far as I'm concerned, no medication at all. Colace isn't worth the effort of taking the pill. So getting her on a bowel regimen with Miralax, maybe some Senocot, but get those bowels going because it's going to make her feel better. That was her big complaint. The other thing that we noticed was that the goals that are listed in there are all her daughters. None of them are hers. So finding, using InterpreTalk or something else like that to actually find out what her goals are, and this is a situation that's sort of rife for using those tools that we learned about prognosis and figuring out whether or not this is a situation where she needs to be in hospice. It doesn't sound like the daughter is ready for that because she wants her to start chemo again as soon as possible. So I don't know what information she's getting from her oncologist, but that would be certainly worth finding out. Now, in our group, we had mentioned when it comes to interpretation services that there is a national group, and Brianna helped me remember who suggested it, but there is access for interpretation on some of these bit more rare languages that you might run into. What was the name of the organization, Voices? Yeah, National Voices are the woman from senior services that was in our group. I'm sorry, could you share? It's Voices for Health. Voices for Health. Thank you. Kim, I was looking for your name. I'm like, hang on. We use specific interpreters. So always, yeah, make sure those are a couple options, but that way you've got one in a case like this. I know in our area, we run into Ukrainian a lot, Russian, you name it, Creole. We have a large Creole population as well. So sometimes it's really important to have those resources available to you. All right, so, oh, go ahead. We wanted to check some labs, especially she's on levothyroxine, we want to check the thyroid. Is the thyroid contributing to the fatigue and the constipation? Is it from the shingles that she currently has? Is it from the cancer? Is she anemic? Is something else going on? So checking out maybe a blood count, her electrolytes, and also her thyroid, just to make sure that with everything going on, the recent surgery and the fatigue and the constipation, was it severe or is it something mild occurring with her? If I recall, she has pain medication, she's got narcotics in her med list. Is that the problem with her constipation, you know, and it's going to be tough because she may need that for her abdominal discomfort. It's very complex in that regard. We saw her as very frail after this recent surgery and whether she needed a little bit more time to recover, discuss maybe doing home health first for a little bit of possible therapy, time to get her anemia a little bit up, obviously treat the shingles, and then see if she became more debilitated during that time and is like a hospice referral or kind of having that discussion versus if she was strong enough to maybe resume and kind of approaching it that way with the daughter. We also noticed the daughter has a lot of caregiver burden and kind of discussed ways to maybe provide some respite about that. We talked about her church, faith community, and maybe that would help as well. When do you guys like to bring up the hospice conversation or how do you like to bring it up earlier, you know, or do you prefer to wait? Well, I'd like to get some collateral information. It's stage three recurrent, so what is the prognosis according to the oncologist who's been following her? Has the oncologist brought this conversation up at all? Has there been any conversation with the patient or the daughter, especially in her language, about her prognosis? So first things first, I just need some more information. Absolutely, absolutely. To see what the oncologist has to say about it, you know, that way we've got a good direction. All right. Anybody else have any other thoughts on Christina and how to work with any of the 4Ms and treating her? Okay, good. Can I make a comment? Absolutely. I am a little bit hesitant asking the oncologist because I have noticed that there are patients in chemotherapy that should be just terminal and they don't tell them and same thing happens with neurologists too. I have a patient that's end-stage MS and he won't tell them to not come to the office anymore because he's not giving him any medication. So I find that that's often the case myself, however, they will tell me, oncologists will tell me that the patient, that there's not much to offer the patient and I'm perfectly willing to sit down and talk to the patient about that. Yes, but let's talk about this neurologist I spoke to and I asked him, you're not offering her anything. Can you please discharge her from your office? Well, if they want to come, you understand what I mean? So let's put it that. I think, Rita, you make a good point. I mean, we do see there is some of that aspect. At what point is it generating revenue for that practice versus having a benefit for the patient? Exactly. That's what I see. I see, Dr. Cortez, I mean, if you can then teach us how you get oncologists to tell you too that they don't want to give any more chemo that patients are asking, even though that there's no place for it and patients that have PPSs of 30%, four out of six ADLs, I think that would be a nice educational session for all of us, because I've been doing this for 16 years as a hospice and palliative care doctor and engaging, as a matter of fact, that was one of the ways of why palliative medicine back in 15 years ago was actually born because of the necessity of having these conversations because oncologists are not having them and they won't have them with other providers either. When they have them, they say, this is what I do, if the patient is willing, then I will. So I mean, maybe it's a regional thing, but I work in a lot of areas and that's a humongous problem because what ended up happening in the last 10 years is that we developed or not developed, we have pretty much promote what we call in the industry drive-by hospice. They then release these patients when they cannot do anything at all because the patients are at deathbed. So that's an interesting observation that it will really tell you. So part of this is, I agree, I've had issues with oncologists in the past who are like I have no one oncologist who specializes in lung disease, who I swear calls the family up and says, gee, I know you died six weeks ago, but dig them up. We can give them more chemo. I know that, I understand that, but we also have the power and the knowledge to ask the questions that the patients can't ask. We can find out what will it do to them? What's it going to do for them? What kind of longevity will this treatment give them? And if they're going to tell you that it's not really going to give them much of anything in longevity, we can share that with the patients. If the oncologist is outright lying to you, I suppose it happens. That's not been my experience, but what I do is I pin them to the wall. I don't let them sort of slip away going, well, we can give them some Tarceva. We all know what Tarceva does, nothing. It buys you weeks, that's it. Sort of holding their feet to the fire can get you the information, but you have to actually seek it out because they will never offer it. That's been my experience. I think that- I'm sorry, go ahead, Dawn. Sorry, Amy. The goals of care conversation is the thing that we, I think, is just, we're failing in the country in general, and not just for cancer patients. It's like, what are our goals of care? And then offering, this is what, if you go on hospice, this is what we can offer you. And if you do palliative care, this is what, if you do traditional aggressive treatment, this is what, and kind of having that conversation. I think we're just, as a whole, our medical system is like, do, do, do, right? Of course you're sick, you have to go to the hospital. There's no other option. Well, there are other options, right? So, I mean, I think that's just having those conversations as soon as we're able to get home, I think is important. And they may not have an answer for you the first round, but at least it puts the thought in the patient's mind as to, when we discuss it the next time, maybe they'll have some more thoughts because they were never approached and nobody sat down and had the conversation with them. So, I'm talking about, you know, you're going to get weeks or is it months or is it years by continuing chemo? And if it's weeks, does that change your opinion as to whether or not you want to do this? For some people, they may say yes, but my experience is a lot of them are like, wait a minute. I feel miserable. I'm not into more weeks of this. If they were going to give me years, I'd be into it. But those are- And my experience is, is that oftentimes they're not allowed, they're not told that they're allowed to say no. I tell patients all the time, it's perfectly okay to say, uncle. Right. Well, this is a really good segue probably into our next mini lecture on medical decision-making capacity. And so, I'm going to, Dr. Smith, can you take us into that and thank you all for such great conversation over our cases today, look forward to more of that. Yes, that was a great, great conversation. So, we're going to move on to medical decision-making, which is relevant with older adults who may have limited cognitive abilities. And we're going to look at the difference between capacity and competence. We're going to discuss the clinical approach to assessing medical decision-making capacity and explore a few scenarios that illustrate complex situations. Next slide. So, decision-making capacity is a clinical term. It is the ability to understand and appreciate the nature and consequences of a decision regarding treatment or foregoing treatment and the ability to reach and communicate an informed decision. Next slide. Competence is a legal term and it is determined by a judge, whether somebody is competent or incompetent, and our input on whether somebody has capacity or not weighs heavily onto the judge's decision. Next slide. So, in order to give informed consent that we talk about all the time, the patient must be given adequate information, which includes the nature and the purpose of generally the procedure or the treatment, the risks and benefits, and any alternatives. And they have to be free from coercion and have medical decision-making capacity. This weighs heavily into our last discussion about oncology and chemotherapy, actually. So moving on, how you approach assessing capacity. We intrinsically assess capacity with every conversation we have, every encounter we have. And sometimes it's pretty obvious that somebody does not have capacity. Other times, well, I guess most of the time we assume that somebody has capacity until proven otherwise. And as clinicians, we tend to overestimate somebody's decision-making capacity. So there are a few things that are red flags that indicate to us that a formal assessment is needed. If there is a neurodegenerative or a psychiatric illness or substance abuse, we tend to be more likely to assess capacity. If the person is acutely medically ill and with a delirium in the hospital or if end-of-life care, we're more likely to look at capacity. Also, if someone comes from a diverse cultural background than our own, if they have limited education or limited language or communication barrier, then we're more likely to look at it, the capacity, formally. A couple of other red flags that we may not be conscious of. If someone has given consent too quickly, it's a very complicated, high-risk procedure or complex treatment, and they are just all in before you've even told them the pros and the cons of the treatment. Also, if the person has always said, you know, I don't, if I get cancer again, if my cancer comes back, I'm not getting any more chemo. And now they're saying, oh yeah, do everything, do everything. That's another time that it should be a red flag for you to assess capacity. Next slide. So there are four aspects to assessing capacity, understanding, communicating a choice, appreciation, and reasoning. And often, there are ranges of capacity, and we're going to talk a little bit more about that in a minute. But if somebody, a patient is septic and delirious from a foot wound, and they have osteomyelitis and they're refusing an amputation, which is a recommended treatment in that case, then, you know, that's a time that capacity would be assessed in the hospital. So what we see more in home-based primary care is the general capacity. In a more general context, can they be making their own decisions? Next slide, please. So understanding is the ability to state the fundamental meaning of relevant information. And this includes treatment risks and benefits. So you say to the person, what have I just told you about your condition? You don't have to make them, you don't want it verbatim, actually. You want it in their own words. And give them prompts. Okay, what did I recommend for your treatment? What are your, what are the risks and benefits of this treatment? What are any alternatives? And what do you think is likely to happen if you choose not to have this treatment? Next slide. Then there's being able to communicate the choice. So this is the ability to clearly and consistently state a decision or preferred treatment. So again, can you tell me in your own words what you've heard? What is your choice? And do you choose to have this treatment or not? What have you decided to do? Unfortunately, although we know people who seem to just kind of be locked in and they can't give us their choice and we feel like they totally understand it, but they just, if they can't speak to us, then we cannot grant them the capacity because they cannot communicate their choice. They need to be able to appreciate it. So that's the ability to acknowledge the medical condition and the consequences of the treatment and options on one's own life. So again, can you tell me in your own words, what do you think the treatment is likely to do for you? How do you think this treatment will help or hurt you? What do you believe will happen if you are not treated? And why do you think this treatment was recommended? Next slide. And that's, we then go into reasoning. This is the ability to reason about choices, to be consistent with your personal values and beliefs, and to demonstrate a logical thought process in determining the choice. It does not require a rational approach. The patient has the right to make an unreasonable decision. And how we would phrase that was, can you tell me in your own words, how did you come to your decision? And what do you think makes this choice better than the other options? Couple of examples. I was asked by Adult Protective Services to do a capacity evaluation on a man who was an alcoholic. He was living on the second floor of his niece's home. It was pretty, the home was dirty. His room was filthy. He was sleeping on a mattress on the floor, no sheets. And he was recommended that he go to the hospital. He did not want to. He could, he was oriented. He could tell me that he wanted to stay and drink, and he knew it was going to kill him one day, but he was not going to the hospital. Not my choice. To me, that's unreasonable. But for him, that was his choice. Another example, I was talking to a young man, bilateral above-the-knee amputations, and he also had a history of some drug abuse, and there was some question of his mental health, and he wanted to live independently and didn't want 24-7 aids. He seemed to be answering okay, but when I said, what about a fire? If there's a fire in your apartment at night, what are you going to do? And he said, well, I'm just going to get up and go. What else? I'm going to walk out the door. So there was no, that's unreasonable. He can't walk. He has two amputations of his lower legs. So in that case, I determined that he did not have capacity. Okay, next slide. We touched on this a little bit. Capacity can be a temporal and situational issue. If it's a delirium, it's temporary, hopefully. And also, there are different thresholds of capacity. So a low-risk but a high-benefit procedure, you may not be, you may not even be thinking about capacity if somebody agrees to it, whereas if it's a high-risk but less certain benefit to the procedure and somebody quickly agrees, you may, again, be prompted to do the capacity test. I have, in certain circumstances, determined that somebody does not have capacity to make their own medical decisions regarding complex issues, but in something more simple, like who they wish to have as their power of attorney, I have allowed. And you can do levels and thresholds of capacity. It just has to be clearly stated on the statement of expert evaluation. And it is also important to consider the capacity of the person who's going to be the guardian or the power of attorney. I have had patients who've wanted their spouse, who clearly has some cognitive impairment, to be their guardian or to their POA, in which case we need to choose another power of attorney. That does weigh into it. All right, next slide. So cognition and capacity are related, but they are not the same thing, although we do use cognition as a huge part of determining the capacity. For example, here we have the thresholds on the Fulstein-Mini-Mental below 16. There's a high correlation with incapacity, and above 24 is a high correlation with capacity. But it is not a surrogate. You need to ask other questions, and mainly those four that we talked about, understanding, communication, appreciation, and reasoning. Next slide. So what is the impact of dementia on capacity and assessment? And this varies from individual to individual, but on a general basis, understanding is maintained through mild to moderate dementia. Communication is generally preserved as well into advanced dementia, although if you start seeing frequent reversals, that's a red flag. Appreciation or lack of insight can fall off anywhere along the spectrum. Oftentimes, you do see it early on in the dementia when there's even just a denial that they have any kind of cognitive impairment or memory problem. And reasoning is frequently impaired in the mild to moderate stages of the dementia. Next slide. Psychiatric illnesses can really complicate the issues of capacity. And someone with schizophrenia, you know, it depends on the psychiatric illness. Somebody with schizophrenia is more likely to lack decision-making capacity than somebody who has depression. But it cycles. Is the person who has schizophrenia fairly well controlled on their medications, or are they currently off all medications in the middle of a psychotic break? So you need to weigh all that when you're making capacity decisions. Many people do not, with psychiatric illnesses, do not have insight into their disease. And that would be a strong predictor of decision-making capacity. Sometimes with psychiatric illnesses, I've asked the help of a psychiatrist or psychologist because it can be complicated to tease it out, especially in younger people. Okay. What to do when a patient lacks capacity. If you, one is, how long do you expect it to last? Is this a temporary delirium and you expect it to reverse? Or is this a more permanent situation? Is it mild to moderate? Or is it more severe? Do you need to appoint a guardian? Has the person been diagnosed with dementia? Do you need to appoint a guardian? Has the person named a power of attorney and you can go to that power of attorney and you can use that instead of actually appointing a guardian? If you have an urgent situation, you may need to appoint a substitute decision-maker. And sometimes you need to involve adult protective services and get a court-appointed guardian. Next slide. Oh, I kind of jumped a little bit because this is where the court-appointed guardian might come in. Also, the guardianship and surrogate laws vary from state to state. In the state of Ohio, a guardian cannot be outside the state, but I think that's different in some states. So, you have to really learn what the laws are in your state. Next slide. So, here are some tools to assess capacity. I don't know if anybody uses other tools. These are, you can find them all on the web. But in the end, what you're really looking at is understanding, communication, appreciation, and reasoning. And that's what you have to fall back on. The tools are, you know, that's what they're assessing all the way along. Okay, next slide. Okay, so, we generally assume that patients have decision-making capacity until something makes us question it. Sometimes it is hard to recognize when someone does not have capacity. Capacity is decision-specific. And although assessment of everyday function can be more complex, I have had issues when I've had to come back. I've met someone, they seem to be telling me all the right things. And for example, this one retired RN, she could tell me what all her medications were for. She knew she had to take them. She knew what would happen if she didn't. And I said, I did a pill count and said, great, I'll be back in two weeks. I came back in two weeks, maybe she'd taken two doses. And she had no insight into the fact that she was not able to take, that she had not taken them. And that's when I decided she did not have capacity. But sometimes it's harder to, when you're looking at a person's general function, it's a little bit more complex. Explicitly assessing capacity is best to use a tool. Use a structured approach. I have a template that I've created that I use when I'm called in to do a capacity test. And you have to remember the impact of specific clinical situations, sensory impairments, health literacy, language, communication barriers, culture, norms, and cognitive impairment. They all play a role in this. If somebody can't hear you, you can't assess their capacity. You need to make sure that you can get past that in order to assess it. And that doesn't, if they can't hear you, that doesn't mean they can't communicate. You've got to work with them and meet them at their level to really assess capacity because you are taking away their personhood. It's a very serious thing. And I don't take it lightly. So in our case, we had Christina, whose daughter was the med tech, and they were speaking primarily, Christina spoke Romanian, Veronica spoke English, and there was no formal advanced care planning or documentation. So it was through Veronica that this was being assessed as to whether or not she should have further chemotherapy. And so we had a substitute decision maker, but it was informal. It was the daughter. And we didn't really know what Christina wanted. And so we needed to assess Christina's decision-making capacity more thoroughly in order regarding the chemotherapy. Christina could choose to have her daughter make all those decisions. If she had capacity and wished to use it, she could state what she wanted herself through an interpreter. But if her capacity was impaired, in some situations, you might need another physician or advanced practice practitioner to verify that she was unable to make her own decisions and then have a substitute decision maker in place. Any questions on that? Okay, I think we'll move on to medication management then. And yes, I saw in the chat that we're going to be on page 46 for the case. So if we can go to the next slide. So just the objectives for this for this mini lecture are just to review and discuss the essential steps in medication management. That's one of the one of the big you know m's in the four m's five m's. And discuss you know mitigation strategies for challenges in in oh sorry can I adjust my mic? Oh yes it would make sense if I brought it closer to my to my mouth. Okay can you all hear me? Okay good. And discuss mitigation strategies for challenges in medication management for home-based primary care patients. And identify assessment tools to aid in medication management. So if we could go to the next slide that'd be great. So you know this when I first saw this slide this gave me pause and made me think of so many things about about our the population that we serve. So let's let's just take a moment and look at these stats. The challenge with our home-based primary care populations and our older adult populations is that our patients have multiple chronic you know complex illnesses. And they're taking multiple medications. And here we have nearly 20 percent of our community dwelling older adults take 10 or more medications. I think Dr. Cheng mentioned that his average was I think 18 medications for for his patient panel. And almost 40 percent of seniors are unable to read prescription labels. And two-thirds are unable to understand the information given to them. And it made me pause because I wanted to think of well what else is you know causing like we might be doing our you know our prescribing our diligence of prescribing for a certain disease process. But you know are there barriers? So you know can and this made me think of other barriers. So can patients you know physically get their medications? Can they financially get their medications? You know cost, insurance, poverty. I remember there was before I started doing home-based primary care in my family medicine clinic. There was a patient that told me that she had to decide whether or not she was going to take insulin you know pay for her insulin. Or pay for her heat. And I mean that's that's a barrier. Yes we were talking about vision. We're talking about vision and you know reading the medications. But you know the information it's not just the cognitive barriers. But is it you know there's literacy barriers. There's language barriers. And are we our own problem? You know do we explain clearly medications when you know patients come home? So another example is I had a patient who was discharged from the hospital. The wife had dutifully you know gotten the discharge instructions. She understood them. And then she put them in a folder. And then she continued taking the medications that they were taking before the hospital. And so you know how yes the instructions were given. But how well did the the caregiver or the patient understand them? So this all can overwhelm the you know the ability to self-manage. So just things to think about with you know medications for our patients. So let's go into this next slide. And I want people to just chime in whether it's in the chat or you know off mic. You know unmute yourselves and just go ahead and talk. What's wrong with this picture? Well setting that up for most patients would be difficult. Plus there's medications that are spilled all over the in between week two and week three. There's a bunch of medications that are sitting there. Yep. Yep pills not evenly distributed. I see that there. Yeah and spilled. Yeah. Plus it's difficult to identify what what medications they are. They're not in the original pill bottles. So we don't know what basically what the patient is taking. Right. And there's skipped places as if they're not taking the medications every day. And then what's this piece of tape is it? What is that? And what are we on? Are we on week three? Are we on week four? Who keeps track of what week we're on? Week three. There's a piece of tape. Maybe. It's on week one. Yeah. If I can just show some like the numbers the patient or I think it was the patient tried or his daughter to try to number the weeks week one week two week three. But as you guys are all discussing this you know the pill box is not the savior. Right. And you can see the pills in between the you can see it in the gutter there if you want to call it that. And they're missing you know one you know how come you skip days and you took some pills the other day. So the numbers are for the weeks supposedly that you should be taking. And I'm glad you bring that up because and I saw something in the chat you know what time of day a.m. or p.m. So my thought like when I first saw this picture was I was making an assumption that these are you know daily pills and these are one month. But could this be a week could like the yellow be the morning pills the red be the noontime you know etc. And you know they just happen to have the the monthly pill box and they conveniently took you know took that and this is one week's worth as opposed to one month's worth. There's a lot of questions here. So so if we can go into. So these are all you brought up all really great questions you know pieces of information that you know we need to we need to ask about. So let's go to the next slide. So medication management process should involve four core tenants. So first of all it's important to create an accurate list of all the medications a patient is taking including non-prescription meds and supplements herbals etc. It's important to list the name the dosage the frequency the route and also the time because you know just because someone's taking a medication it's prescribed twice a day are they taking it morning in that evening or are they taking it you know both in in like before one o'clock in in the afternoon. So the first part is reconciliation. So it's having an accurate list. Review the medication list with what is currently found in the home. Consider like I mentioned earlier consider all medications prescription non-prescription supplements herbals. Number two justification. Is there a documented medical condition that requires the medications. Also it's important to have to look at the risk benefit balance to review the risk benefit balance of each medication and is there sufficient evidence to support the ongoing use that this treatment has been effective. The third is optimization. Have proper dosing based on renal and hepatic functions and consider drug-drug interactions. I personally use Hippocrates to take a look at the drug-drug interactions. I know there are other websites and apps that you can use for I think there's Micrometics that you can look at drug-drug interactions. But it's also important to know renal and liver functions as well. So it's the fourth part is demonstration and we were talking about this especially with the nebulizer treatments. Sorry with the inhaler for I forget which patient it was but just to demonstrate the proper use of the medication especially inhalers and if there are spacers that are needed etc. So can we go to the next slide. So medication management just the thing I wanted to mention is that it's important to review medications in the home and doing so in the home offers us as the clinicians going into the patient's homes it offers us a unique opportunity and an advantage to accurately assess medication adherence completeness and barriers. By deprescribing and reducing the medication burden we can help with adherence. We can help reduce stress not just for a patient but caregiver and actually clinician as well. It's important to review medications to determine if they are appropriate effective beneficial and in alignment with their goals of care and then and all of this will allow providers to determine which medications potentially should be discontinued. So let's go to the next slide. So we have a patient case and I think that's page 46 in your workbook. I think we're going to work on trying to try to put it onto the screen. Here we go. Okay so if you all can just take a few seconds and review the case. And I'm just going to give a brief summary. So Mrs. Smith is a 72-year-old male. She has COPD, diabetes, and hypertension. She's got macular degeneration. She's got hearing impairment as well. And, you know, she's still able to shop. She gets her meds delivered by her pharmacy. And, you know, the different med bottles are in like these small cookie cans. And after, and when you do the medication reconciliation, you notice that one of them doesn't match up with the hospital discharge instruction, hospital discharge paperwork. So the conversation goes below. So I guess let's talk about some of the barriers that you see here in this medication reconciliation visit. And anyone can chime in her visual impairment. What else? Her hearing loss. Yep. Confusion on the hospital discharge instructions. Right. Her never statement. That Pepto-Bismol is for kids. Right. Right. And there might be something like, oh, they might not, you know, they must not have said Pepto-Bismol. That's for kids. They must have said something else. Like, oh, yeah, Pantoprazole. So there might be a combination of things going on at the same time. Yeah. When I saw her in the kitchen, when I brought up the Pepto-Bismol, there was almost a look of disbelief. Yeah. There was a preconceived idea that she was going to have a hearing loss. Yeah. There was a preconceived idea that Pepto-Bismol is, in her mind, is for kids. It cannot be what the hospital doctor said. So I think there was a misconception in her mind in terms of a barrier that our patient think the medication is meant for this or this patient population. So they automatically exclude that as a legitimate therapy. So I just saw her face, which is like, you know, she was almost like, are you kidding me? Very good. So let's go to the next slide. I just wanted to go. Yes, and over-the-counter meds are a concern too. Yes. Agreed. So can we go to the slide before? Yeah, there we go. No, no. Sorry. Forward one. Okay. So medication management tools. Here are some resources. They're in the slides. You'll have access to them. The thing I wanted to mention is, let's see, number four, the bullet point number four, the University of Maryland pharmacy. So University of Maryland has several tools to assess someone's ability to self-administer medications. This one I think is called MediCog. And it's like a seven-minute tool to assess cognitive literacy and pillbox skill. Underneath that is the creatinine clearance for drug dosing. And you can find that calculator in MDCalc, like I mentioned earlier. Epocrates, Calculate by QXMD. So there are a lot of different resources to help with kidney and liver function. So next slide. So just in summary, just wanted to mention that providers should consider physiologic changes associated with aging and the risks associated with polypharmacy. And at a minimum, with every clinical change or change in care setting or even following a specialist visit, clinicians should do a thorough medication reconciliation and determine if there are any indications for continuation of meds. And then evidence-based tools are available to identify high-risk meds and consider de-escalation or discontinuation. So that's it for medication management. And now we're going to shift gears a little bit and we're going to take a look at what urgent scenarios can happen in the home care setting and how you'll respond. So Megan's up next. So thank you. All right. So we're going to talk about the things that give the patient chest pain as well as you, the provider, when you walk in the door. Next slide. All right. So really, this acute and urgent care, these visits, really, although they're very stressful, you can really break them down into three things. One, we're just going to go over what are considered to be an urgent medical issue. So we can all be on the same page as what we're talking about. How to approach the plan, how do you prepare for these urgent scenarios, what do you do to evaluate them, and how can you decide whether they need to stay at home or they're going to have to go to the emergency room. And lastly, let's talk about how those urgent and acute issues can really be a benefit to you, even though they are pretty stressful as that provider walking in the door. Next slide. All right. So when we talk about urgent calls, it's the chest pain, the shortness of breath, fever, you know, 100.5 or higher, delirium, mental status change, falls injury. It's the stuff that you're going to have to do something about it. This is not something that can wait. Next slide. All right. So there are really kind of two different types of visits. There's the one where the family calls and says, we need a visit today, but there's also the one where, surprise, you walked in the door for a regular visit, and they have abnormal vital signs, you're confused, they don't even recognize their own illness. Kind of like Ralph in our first case scenario, he had hypoxia, and he didn't even recognize it or have the ability to really reach out to you. So you have to, when you walk in the door, triage the severity. Is this something where I need to call 911 now? Can the family help? Is it something I can fix? I think it's really important to note that if you think you're dealing with somebody who's septic or they're having an MI, they're really complaining of chest pain or potentially a stroke, they've got a lot of weakness, these are things that are time protocols in the hospital. And they're done for a reason. If you're going to have a benefit for them, they need to go, and they need to go quickly. And it's amazing how often we can kind of lose sight of that, because there's that thought of let's try to keep them at home. But make sure you've had these conversations with the family before they get to this point. Make sure you've talked about what do you want to do if they get really sick, have a fever, they're having chest pain, is this something where they're okay with being in the hospital for a prolonged amount of time, having more tests done? Is that the direction you want to go in? And what are you going to do if the patient says, no, I'm not going, I refuse? All right, next slide. And what if it's not necessarily the patient, but what if it's the caregiver? You know, you've got a patient who's got a history of dementia, and the caregiver suddenly gets diverticulitis and goes in the hospital. You've got progressive illnesses where suddenly their function is just totally decreased. You know, the stressful nursing task, all the other psychosocial issues that can come into play. And next slide. And, you know, keep in mind, these urgent calls, when you're setting up your scheduling, these calls take a lot more time than a regular routine visit. And so you want to decide, how are you going to handle these visits? Are you going to have a certain number of open slots per day? Are you going to manage this kind of urgent visit by telehealth? Are you going to have an RN go out? Are you going to also look at it and realize that I can't do a urgent visit because I financially just can't keep these holes in my schedule? Do I need to fill my schedule and refer anything that's a last-minute add-on and tell them that they would have to go to the emergency room? And consider that when you're hiring providers, sometimes you just logistically can't go from one site to another without getting in the hole and missing out on the last two visits of the day. So always keep those things in mind. Next slide. When you walk in on that patient who suddenly is hypoxic or has a heart rate, you know, their rate is 110, 115, what kind of technology are you going to carry with you? Are you going to have the ability to do an EKG? Are you going to use just pulse ox? Are you going to order labs? X-ray? What's the availability of X-ray? Is it same-day service? But how fast does the radiologist read those reports for you? What's the turnaround for labs? Here in Florida, the problem with labs that we run into is it's so hot a big part of the year that you can't keep blood in the car and the supplies in the car. The heat just kind of degrades it, so you really have to keep all that temperature control in mind. And then are you going to be able to use telemedicine to try to make that easier? Does anybody else have any other point-of-care options that they use or have found successful in these cases? Sometimes it's pretty limiting because you can only carry so many things with you. You can only put so much stuff in your car before it just becomes prohibitive. You know, you make the best of what you can do. One of the things that I consider is trying to get a nurse. Again, I utilize the home health care services a lot, nursing agencies. And if the patient really needs to be seen, something that's non-emergent or even is requiring some blood draws, I see if the nurse can get out there that day. And then I'll go in the following day if that's possible. That's the other option is have the home health company. Some of them will draw blood. We have run into where they may not be able to get it out. They have to have 48 hours notice. So it does vary, but it's a good resource if they're available and they can do it for you. And it's a lot easier for the patient than having them go anywhere because that's why they're homebound, they can't. All right. Next slide. And this is something where you all in your office have to be on the same page. You know, what is the triage procedure? How does your office know or whoever's answering the phone? What is urgent or how to recognize when it's urgent? Because what we've also run into, and you will, is that a patient may call and they want to request a same-day visit, and they may downplay their situation because they don't want to go to the hospital. They don't want to go to the emergency room. But it's really important that you train whoever's answering your phone in your office to really get details about why are they calling and asking for that same-day visit. And Brianna's mentioning, you know, it's important, get that resource inventory. Who's your mobile phlebotomist in the area? Who are your mobile X-rays? What are their turnaround times for patients? We even have a mobile ultrasound where they'll come and do a venous doppler, which is nice because that's a real frustrating thing for a lot of patients to have to go to the emergency room for. And, you know, your scheduling strategies, like I mentioned before, are you going to leave a hole in your schedule, or how do you accommodate urgent visits? One thing I really want to stress is we do discuss a lot how we want to avoid these trips to the emergency room, and they can be unnecessary. And that is true. Like in the case of Ralph, you walk in and you recognize he's hypoxic. You can fix that by, you know, looking at and saying, hey, let's get your oxygen on you, maybe a neb treatment, you know, what can we do to fix the situation? But if they're not something that you can feel safe managing in that, you know, few hours or even 24 hours, it is all right to say, I think you need to go to the emergency room. We need to get all these tests done. If there is concern that the coordination of care may not be as successful as what you would like, sometimes that is just what you have to do. And that's okay. That goes back to making sure you have the conversation with family ahead of time so you know what their wishes are. Next slide. Another thing that can be helpful, particularly on some of these patients and when you're scheduling, is labeling them in your system as low acuity, medium acuity, or high acuity. If you know that Ms. Smith is somebody that requires a lot of time and is very complex, don't schedule her with four other high complex patients in addition to three medium. Really be mindful of that when you're scheduling these patients so that way it's realistic for everybody to be able to get through their day. Because there's nothing more disheartening than getting way behind early on in the day and not being able to catch up or feel like you're going to make it to the last two visits. And those might have been add-ons that really needed to see you. Next slide. So that goes back to, you know, anticipate. Make sure you review the charts in advance. Make sure you've got all the necessary equipment. That way you can assess for potential decline in their status. And also if your office, which it's a good idea, have somebody call ahead when they confirm the appointment. That, you know, is there any new issues or any problems? So that way if they are starting to decompensate, that you can get kind of a heads up on this. And make sure to at that point educate the patients and caregivers. We really want to know about any worrisome symptoms, you know, and signs before we get out there to that visit. In other words, don't wait until the visit. Let us know ahead so we can plan ahead and do the right thing. And again, go back over that contingency plan and ask them to practice it. What are you going to do today if I tell you that you do have a decline or you might need to go to the emergency room? How do you fix that oxygen tank? How do you make sure that if you lose power, what are you going to do? Next slide. And here's another thing that these urgent visits, even if in the beginning of your career doing house calls, if you're not comfortable managing them when they have these kind of issues, and that's okay. You learn from each experience. It's important to debrief, go back over it, go back out soon after they get back home so you can talk about what happened, what could we have done that might have improved this situation, what can we learn from it? And also keep track of it. If you go out and you find a gentleman like Ralph and you fix that without sending him to the emergency room, keep track of that. Because when you go and you're talking to other family physicians or internists or you're looking for funding, they're going to ask you, well, what is your value? What is your benefit? Well, here's all the times that we found that their medications, they were getting into medications that were three and four years old. And we told them when we compared it, do you eat moldy bread? Well, why are you taking medications that are from three years ago? Because we all know that we found just a plethora of pills in the cabinet. But those are all things that you can use to document how your practice is a benefit to the specialist and to your hospital systems. Next slide. And it's been asked, and one of the things that were asked in the chat, how do you get paid? How do you make this all worthwhile? These visits, when you are there for extended time, make sure to put in for the billing. Brianna, she can explain to you some of the documentation aspect, and I think that's on tomorrow's agenda. But it's so important to make sure that if you're there and you get involved in a case, bill for it. This is for extended time while you're on the visit, in addition to the base visit code. Next slide. Let's go to the next one I want to talk about. Yes. And don't forget, when you have a new patient, if you had to request all their medical records, or let's say you find out that they were hospitalized and you have to review those medical records, or the home health company has sent you over a bunch of et cetera, make sure to bill for that time before or after, that even though that is not part of your face-to-face, you can still bill for that, and that is another source of revenue for you. So don't forget to, on these urgent visits, bill for the time that you spent before and after or extended time on scene, because it does add up. And don't, unfortunately, it'll come back and cause you grief later when you realize all the opportunities that you had to justify it. Megan, just to tag on a little here. So from a documentation and coding perspective, what's going to be important is your time in and your time out for prolonged services. 99358 has to be a minimum of 31 minutes, so you're going to want to tell me that minimum of 31 minutes with your start and stop times, and then a brief description that's specific to the patient, not just I spent 31 minutes reviewing medical records. The key words with prolonged services is above and beyond the normal effort, so you need to give me at least just a couple sentences explaining why and the specific unique clinical characteristics to the patient. This can really help boost revenue, as well as the prolonged services face-to-face. I usually say 90 minutes is about that threshold when you should start thinking about billing on that prolonged services face-to-face code as well. So your time is valuable, and you want to be there to be sustainable and take care of your patients, so you just want to make sure you know how to be fairly reimbursed for that. Absolutely. When you're reviewing their congestive heart failure, that also makes you review their renal conditions and their renal disease. In addition to their COPD, and if they're on Coumadin or Warfarin, Ralph is a very complex patient. Make sure as you're going over each of those conditions that you're documenting all the different issues that you had to review to make sure you could make any changes in his medications or in his care. Good question. So, for instance, if a patient I saw yesterday, I got in there and he was wheezing and we gave him two naps. So in documentation for the extensive time before and after, no, that's not what I was actually talking about. For prolonged, would that just mean just document that patient had two naps, didn't do good with the first, give him a second? Would that be adequate documentation? So are you talking about the prolonged services face-to-face, right, Ada? Yes. Like that you spent with him? Yes. So that's going to come down to time. So to build a prolonged services face-to-face, you would have had to exceed that visit threshold. So I would need your total amount of minutes and then, you know, the description of why it was above and beyond, you know, how that time was spent and start and stop times for prolonged services in particular. When we say time-based services, sometimes they just need total minutes, but actually the Medicare claims processing manual for prolonged services requires start and stop times. As a general rule of thumb, I always say, so you don't have to remember which ones need total minutes versus start and stop times, we always recommend start and stop times with time-based services. But with the prolonged services, it's all about the minutes. It's all about the time. So I would just need to know, you know, I spent a total of 90 minutes face-to-face with the patient. We gave several nebulizer treatments and discussed goals of care or whatever the case may be, and then including the visit times for those services. Okay, so just to clarify, so is my documentation, I got the timing down, I think, but for the documentation purposes, I just need to say we were doing C. neps treatment. I mean, you're going to have your whole note, but at the end, so when we're billing a visit on time, you have to be able to validate that it was dominated by counseling and coordination of care, right? So I need your total amount of time. If you're billing on time, that greater than 50% of it was dominated by counseling and coordination of care, and that you spend an additional, you know, you're kind of breaking up. I spent this many minutes on this, this many minutes on this, here's all this extensive time I spent on the nebulizer, goals of care, whatever the case may be, to really validate how that full 90 minutes was spent or however long the visit was. Okay. And I'll just cut in here because we are going to have a lot of coding education tomorrow. So I know we'll be coming back to some of this code. Okay, so we can go on. Megan, do you want to advance? Go ahead. Next slide. So that really, Melissa, is a good segue because it just goes to show that you want to make sure that you bill for the time that you spent, especially if you're fee-for-service, but there are opportunities for you. And make sure that you realize, you know, there's a lot of times where there's sudden changes in your condition. Be prepared for it. Have a plan with your office, how to recognize if there's a change in the situation. Are you going to leave those slots in your schedule? What are you going to do? How do you assess it? Do you have the right tools? And then after you go through an episode like that, you need to include your whole team and talk about where did we go right, where did we go wrong, how could it be better? And it gets easier each time. And the first several times will be a little stressful because you'll think, oh, geez, what did I just walk into? But, you know, just do the best you can and just make sure that afterwards you go back over it with all your staff. And then that way next time it's better and easier and include, you know, even the patient's family and follow up with them and ask if they have any questions or how they feel about, you know, next time around because it will happen again for them, all these patients. All right. And it's always good to be able to go to the emergency room. Very good. All right. So, um, let's see, Dr. Smith, can you just give us the key takeaways and then we're going to go for a 10 minute break. Dr. Smith, you're muted. Sorry. Thank you. So in this session, we reviewed the three patient cases and we looked at the five M's. All of them were very complex and had multiple morbidities. We discussed how prognostication can be a very helpful tool when you're trying to focus on the patient centered care and discuss outcomes. We reviewed an example of how cross cultural needs can impact decision making, and also the providers approach in caring for a patient with decision making capacity as well as cross cultural needs. We explored issues and strategies around assessing for medical decision making capacity and medication management. And finally, we discussed approaches for handling some common emergencies that can happen in the home based primary care. So I would like you to take a look at next slide at your HCCI learning plan and go through the grid and answer the questions. I review the session objectives concerning the questions of which concepts do you still need to learn more about? And were there additional topics in which this session stimulated your interest or revealed new learning needs for you? All right, I'll give you a few minutes to do that, and then I guess we'll just roll into the break. That's right. Yeah, we'll return about 40 minutes after the hour. Thank you all for your patience. I know there's such great information being shared here this afternoon. And so thanks for your flexibility with the timing. We'll see you in about 10 minutes. So I just want to give you a little bit of a preview. We're going to have a session by Costa on quality. And we are then going to talk. Amanda's going to talk to us about self-care, which is so important, of course. And then Ethel will take us through a wrap up of today's of everything we've kind of learned today and preview a little bit for tomorrow. I do want to say today was a pretty heavy clinical day. And of course, I think we had some great conversations around that. So for those of you who are like, I want to know about staffing models and billing and coding and some operational efficiencies. Those are all coming tomorrow. So stay tuned on that. So at this point, I want to go ahead and turn it over to Costa. And we can advance the slide, Danielle. Thank you. Okay, great. Thank you. So, Yeah, the purpose of the objectives for this next Session is To describe the value of quality measurement and why it was determined that home based primary care home based medical care required unique metrics. As opposed, you know, compared to like internal medicine practices, you know, primary care practices, etc. We're going to discuss the evolution of the qualified clinical data registry for home based primary and palliative care. Also, we're going to illustrate the vision for the future with additional data streams and I want to add one of the Additional data streams is practice characteristics and this is a specific focus from the HCCI and we're going to will illustrate how a research data warehouse for the field. Can identify best practices and then lead to better outcomes for our patients. And then cite the benefits of learning collaboratives. So, next slide. So we're going to go into. We're going to be in a video here with Dr. Christine Ritchie formerly of UCSF now at Partners Boston and also Dr. Bruce left from Johns Hopkins. So, next slide.

home-based primary care

4M framework

expanding access

high-quality care

challenges

opportunities

house call simulation

care planning

patient case studies

personalizing care

quality measurement

qualified clinical data registry

QCDR

standardized data collection

learning collaboratives