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Essential Elements of Home-Based Primary Care-Virt ...
Recording: Day 2; Part 1
Recording: Day 2; Part 1
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Well, welcome back. I know as people are filtering in from the waiting room, we have a few housekeeping things we wanted to review with you. And so at this point with I think the majority of our participants joined, Michelle Adams is going to give you a little orientation to the PDF workbook that has been available for all of you in the HCCI Learning Hub. And she can help you navigate that to find things like your learning plan and other materials. So Michelle. Good morning. So I just wanted to give you a little, when you're using this online, sort of some little tips for you to quickly move around in your book. So if you open up your Adobe book, you're going to see it like this. You can go, these are all hot linked, anything with a blue line. You have a little arrow over here. If you click on this arrow, it will open up. You'll see thumbnails and bookmarks. You can click on your bookmarks. And if you, let's say that you're looking at something in quality and you're in there and you decide I want to go back to the table of contents. You can go ahead and click on that table of contents. It'll take you right back there. Let's say one of the speakers mentioned something in the appendix from the table of context. You can go down to the appendix, click on 141. This will take you to the appendix and you'll see that everything is hot linked in the appendix. This is all of the different forms that HCI has provided to you. So let's say somebody mentions the advanced coding opportunities. You want to take a quick peek at it. You can click on that. It'll take you right to that document. You can also go back to the appendix if you'd like. Oops, sorry. Sorry. I meant table of contents. Table of contents. Go back down to the appendix if you want to see another document and then go back up to the table of contents. If you are going back and forth to your learning plan, you'll see sometimes in the chat, we'll say go see page 11 or like for yesterday's learning plan, it was on page 13. If you're somewhere else in the book and they want you to go to page 13, the quickest way to do that is to go up to this little box right here that it shows the page numbers. You can put 13 in there and hit enter. It'll take you right to that page. And then we're going to take a little brief moment to look at the learning plan. This is the one from yesterday. Once you complete that, we would love for you to fill that out for us. There are a couple ways that you can do that. If you have an email default set up on your computer, you can hit submit. This is the default that is on my computer. It's on Microsoft Outlook. I can hit continue. And in a moment, you should see it'll pop up on my screen where it'll say the email will be right there with the workbook attached. That I just hit send, it'll go right to us. We have already received several of those. So thank you so much for sending those in. You can also do a save as. This will allow you to save it as a PDF somewhere on your computer. You could save it on your desktop is probably the easiest I would do. So you just say, choose a different folder, select desktop. You can save that there. And I'm not going to click that. It'll take me out. But you can save that there and email it to us. Or if you want, you can just hit print and it will set up to your printer. I don't have a printer, so it's going to send it to Adobe. But those are some ways that you can send in your HCCI learning plan. And again, a way to quickly get to anything is if someone puts in the chat, you can go to page 142. You can just one quick question. Sorry. Yes, I have a one quick question. I tried to send the learning plan twice and it got rejected from your server. Education at HCCI.org. Yeah, I'm realizing it's because it's created a PDF of the whole workbook, not just that one page. And the workbook is too large to get through email. So when you do a print and I just kind of got this. No, no. I am sending just one page. I just got it on my scanner, put it on my computer. I just said, I'll send it to you. And twice it got rejected. Only one page PDF. Well, I will work with you offline. Does that work for you? Okay. Okay, good. Thank you. Sorry. And yeah, that's one of the things that just as you're going through it, Michelle, I'm realizing it's saving the whole workbook. It's saving, you know, which is like 26 minutes. So yeah, but somehow if you can extract that page, the PDF, I'm sorry, the email address to which it would be sent. And we'll and I'll ask Danielle to put this into the chat right now. It's education at HCC institute.org. And we may even be able to send you just the send everybody just the learning plan outside of the workbook to make it make it easy. Easy for you to return to us. So stay tuned on that. Michelle, was there anything else on on the navigation of the workbook you wanted to cover? No, I think that's it. Does anyone have any question that's on? I don't have a question. I just have a comment. When I hit save as I just saved that one page. So I hit save as and I selected that one page and it was able to save that way as well. Just any just in case anyone. Thank you. Perfect. So hopefully this will help you quickly navigate and keep track with us and and use the workbook afterwards. So thank you very much. All right. Thank you very much. So I wanted to call on I know we did introductions at the beginning of yesterday. And there were a couple people that we missed because they weren't on yet. So Fran, are you on? Oh, and here I'll unmute you. Sorry. Yes, I'm on. Hi, everybody. Hi, Fran. So would you mind just introducing yourself? How long you've been working in home based primary care and what you're hoping to get out of the workshop? Yes, my name is Francisca. And I've been in primary home based primary care for about six months. And I'm trying to learn more about what it's all about and how to navigate through. Actually, I have like a house call that I just started. So I'm trying to learn more on how to get it started on how to run it. All right, great. Well, we're glad you're here. Thank you. All right. Thank you. Is there anybody else that I missed that did not introduce themselves previously? Yeah, hi. My name is Marwa Minchawi. I'm a geriatrician. And I work with Cornerstone Health Services in Orlando, Florida. And I unfortunately wasn't able to join yesterday. I'll be I'll be on today. Well, wonderful. Thank you for being here. Thank you. Anybody else? All right. So we've got another full day. We may actually get started now so we can we can get moving. I do want to let you know that we have a q&a panel that's set for the last session of today. We are you know, please continue to send your questions through the chat. Our faculty are answering some of those questions right there in the chat. So keep an eye on that as we go through the day. But any questions that have not been answered will we're saving for session 11 later today. So at this point, I'm going to go ahead and turn it over to Dr. Ethel Smith. Okay, good morning, everybody. And so I want to take a few minutes and answer any questions that came up over overnight or any aha moments that anyone had. I know it's early. But maybe somebody you can either raise your hand unmute yourself or put it in the chat. Along with that, did everybody get a chance to see the Brene Brown video? It's about five minutes on boundaries. What I did yesterday about boundaries, I have a person who religiously asked me to set into some zoom on a Saturday. And it's only 30 minutes, it is only 40 minutes and she sent one yesterday and I and I sent her a nice little text saying, you know, thank you for the invitation. However, my weekend are now reserved for my family and friends to catch up because I am unable to do so during the weekend, I will continue to support you. However, I will not be able to answer your during the weekend, I will continue to support you. However, my chance and jumping on a zoom for at this time on the weekend will not happen. That's excellent. And that goes to her point, putting the line between what is okay and what is not okay. Yes, you're very clear on that. So that's, that's great. Any other thoughts on on Brene Brown's video? Hi, this is Adiranke. Same similar situation here. When I first started in early March, I found that I was making myself more available than I needed to, including getting my cell phone numbers for after hours and things like that. And you know, I have an EMR where I can, um, patients can send me messages through the patient portal. So I started using that for patients to basically communicate with me instead of calling me about minor issues after hours. And that's that has helped. And just reflecting on that video really made sense that that can actually make you burn out if you don't, you know, watch those boundaries. Yes, it goes along with what she was saying about the, to be truly generous and to sustain it, you need to have that boundary. That generosity, as she put it, cannot exist without the boundaries. And I think we all start out giving our all and then learning where our boundaries are as we go through time. I'd like to make a comment. One thing I think would be important, which I haven't really incorporated myself, but I've thought about it is, you know, a welcome packet. And then being able to, on that first visit, go through that welcome packet and include in that your times and days of availability. And, you know, just explaining to them that, you know, I'm not of availability. And, you know, just explaining to them that, you know, I'm, you know, I'm independent, I'm a house call practice, you know, or whatever your reasonings are behind your boundaries, but trying to have that conversation from the get-go and just making sure that they're comfortable with that because it's not a traditional type of setting. Mm-hmm. Right. That's, yeah. And since you're solo, you're it. You know, they're, they're disturbing your dinner or your time with family or whatever. Right. Yeah. And I like the idea of putting it out there up front. Be aware that even though you say it in the beginning, you're going to be saying it again because there's only so much a person can take in on that first visit. Jennifer, I did that too. I'm sorry. Go ahead, Megan. I was just going to say, and I think you guys are all making a really good point. And Jennifer, the key behind stating those boundaries up front is that it's a lot easier to put it out first than have to backtrack after the patient has already crossed those boundaries, and then it becomes more confrontational. But if you put it out there and you say, here's my boundaries, here are my expectations, I'm going to be there for you as much as possible. But, you know, I've even seen where some providers have said, but we are not friends. We will not meet after work. We will not go out for drinks. So that way it was very clear that there was a kind of that line in that relationship. Ada, were you going to say something? No, I was telling Jennifer and with Megan, both happened to me when I first started. And again, I've only been in a little over a year, but I did not set boundaries. And one particular individual would text me just to tell me anything at three, four o'clock in the morning, she would text me. And then I started, I put up a thing saying hello, everything. And in the initial package, when I do the first visit, I tell them, I love hearing from you, but if it's not anything urgently, if you call me 501, I will respond on Monday. So if by all means, I want to take care of you, but I won't, but let's leave after hours for urgent matter only. And that works well. And, you know, and if it's emergency, let me know from the emergency room. Not, I need to be the second person if you have two calls, but not the first. And I'll just jump in here too. Anna wrote here too, about a colleague also ask for stuff and how do you, how do you kind of set those boundaries? And I, I've always said employers and it will go to patients. They'll ask and ask and ask. And you're the only one who can say, no, people just keep taking. So, you know, it, it, you can kind of see in the chat, two people are, are starting to set those boundaries, but especially when you're first getting up here, you have this, or starting up a practice, you have this fear of, if I say no, I won't get more work. Or if I say no, I won't have a colleague or a friend who will refer me this work or will continue to work with me. So just to add to all the pieces of boundaries. Right. And that goes to the next question about setting and sustaining boundaries. What keeps us from being able to do that? Guilt, which is what looks like Anna put, put there as well as some fear of not getting future business. What else, anything else keep us from setting and sustaining those boundaries? Some of what was mentioned yesterday, sorry, some of what was mentioned yesterday us feeling that we just have to work and grind all the time and not need rest and time for family, like that same thought process and understanding that rest is just as important. And that personal time is just as important for a healthy you. Right. I'm from the islands and you grind till you die. It's like you just, that's, that just makes you who you are. And that's not true. And that's the thing that we have these inner voices telling us that you're not sufficient if you can't work and you have to do go above and beyond what you actually can. And then when you do it, the patients think that that's the way it's supposed to be. And I, I remember I got a call at I remember I got a call at 7 30 PM for a refill on a medication on a Saturday. And I'm saying, why are you calling me today on a Saturday at this time? I don't mighty, but and so that's the thing that they just don't think that, Oh, by the way, they think that a refill is an emergency. That's what I've been told on various occasions, which is ridiculous. Might depend on the medicine, but a little planning goes a long way. Yep. And in his case, it was Levothyracetam. It's for seizures. And I know if he's off of it, he'll have a seizure. And I told her I'll give it to him, but don't do that again. Right. And this is the second time you've done this to me. See, that was the thing that say she did the same thing before, but I don't know. So good pharmacy will give them 15, seven, seven or 15 days refill. If it's one of those necessity medication. And if you love that to happen once, because they still have to pay the full co-pay for that. If you allow that to happen once it doesn't happen again. It certainly could be something to go in your, your welcome packet, you know, please keep on top of your medications. Give me a week to refill that sort of thing. I forgot about that, that they, the pharmacy will honor a refill for two or three days. Like if it was on a Saturday, they would give her until Monday or Tuesday. Oh, that's yeah. I forgot about that. Next time I tell her I'm not giving you the refill because you're not following instructions. So call the pharmacy. They'll help you. So there's the, our fix it mentality. Why are we even in healthcare? Because we want to fix it. We want to take care of other people. We want to be compassionate and empathetic. But in order to do that, we do need to take care of ourselves and we want to do it in a generous way without distancing our patients from us, but at the same time, letting them know where our boundaries are. Anything else on the Brene Brown video? I just want to sum up what she said when she summed it up. I just want to repeat that is that empathy without boundaries is not empathy. Compassion without boundaries is not generous or genuine, excuse me. Vulnerability without boundaries is not true vulnerability and boundaries are all about respect for ourselves and our patients and not about division. So I think it's a process. It's much easier to say that a boundary is the difference between what is okay and what is not okay. And then through our practice in our own lives, we learn where those boundaries truly need to be. And they may change through time. When you're single, you may call me up until 10, I don't care. And then you get a spouse, you have children, however it works out. And you may change your boundaries through time or a parent becomes ill and you're paying more attention to your parent now. So I think our boundaries do change through time. What about challenges from yesterday's session? It's all good. No problem. This sounds terrible, but I've been doing this for such a long time, long, long time that I am not conscientious about wiping down my instruments and my back. That's something I have to incorporate. And that's one of the challenges I have right now. You know, I have to say every time I help with this program through HCCI, I am reminded of something that I need to reincorporate in. So it's good for reminders even after 20 plus years. I'm very new to the home-based care. I've always been inpatient. And I mean, I'm so new. I'm actually have been following another physician to home care appointments. And I, however, I would say one of my challenges, I have a feeling and even watching them is to walk away. I mean, you, at some point, you have to be able to, to walk away and say, I, you know, I've got other patients I have to do, you know, she, she stayed so much past her time, which is probably what I would end up doing, but, and doing so much more and buying stuff out of her pocket for them. And, you know, and doing that for every patient at some point, you have to be able to say, I have to take care of myself. I know that sounds really selfish, but she was spread so, so thin. So I think that would be a huge challenge for myself. Yeah. It's not selfish because if you don't have that, that boundary, you can't keep giving and then you burn out and then you're not available to anybody. So it's not selfish to say that at all. I do find, you know, at times when I'm, in the patient's home that I often do, you know, much more than what I'm supposed to be doing from a medical standpoint, you know, I'm helping them get their breakfast. I'm, you know, straightening up whatever mess that they've made. I'm doing a wound, you know, dressing. So the visits are, tend to be long and, you know, I would love some advice on how to streamline and be more efficient, but when you're in that home environment and you see all these needs, how do you, I always find it so hard to how to walk away, you know, it's just frustrating at times. I have my answers. Anybody else want to jump in first before I, one of the things that I do, some of those needs are so upfront that you need to do, you need to take care of them. And how I have tried to deal with it is deal with that in that instant, because it is an urgent situation. For example, I had a quadriplegic who she had an aid from nine to 10, and then went from four to six. And I came closer in the morning, closer to her 10 o'clock, and she was completely soiled. There's no way I could leave her in that until four. So I went ahead and changed her and then worked with our social worker who, to get her an aid in the middle of the day, so that that wasn't an urgent situation. Our social worker who, to get her an aid in the middle of the day, so that that wasn't going to be such a long period of time. And if you don't have a social worker, most, many of our patients, not most, many have care managers who you can work with, or at least work with some other resources in the community. And there are some days that you do have that little bit of time. I've taken out trash. Obviously that wasn't an urgent situation, but she needed it. So, and I was kind of on my way out, so I just grabbed it. So sometimes you can do those things. And those should be the extras and not be the routine. If they're becoming your routine, look into other resources to help out the patients, because you can't, you will burn out if that's what you're doing. Plus, if you're spending two hours in a home, there's no way to be sustainable financially, because you need to have more visits than that. Anyone else on that subject? I just have a question closer to the subject. My question is, I have, well, there's now several patients that lived in less than desirable environment, and they do not want to leave. For instance, they moved from a temporary hotel into this mobile home, but the floors are unsteady. The first time I said, okay, you know, they just moved. But then when I came back the second time, it got worse. Meaning there's dirt, there's dog, you can't tell who it is, the bathroom is horrible. I got social work in there. And we help with transportation issue, but he does not want to leave the situation. And he says, basically, the uneven floor make him more, more focused and keeping his balance and helping him. What do you do in a situation he doesn't want to leave? All of us know that is unhealthy for him. Home health, they, you know, when they call me, it's even worse. Right now in Florida, when you call, when you call on DPS, that's what it is, which we have done a couple other patients, they're so overwhelmed, they're not doing anything. So I mean, what do we do? Well, one is does the person have capacity and to formally test with our four pieces of that, the understanding, the communication, the appreciation and the reasoning. If he has capacity, you, he is making a choice that you don't believe is reasonable, but it is still his choice. So you can't do very much. If he does not have capacity, then a, well, I say, I say you shouldn't, you can't really do very much. You can recommend, you can help get them connected to resources that might be helpful to him. If he does not have capacity, then, then that's when protective services can jump in and with a surrogate decision maker. So these were, these were all great. And I, you know, I, even just as we introduced ourselves yesterday, I thought, you know, I could have coffee with every single one of you and chat for like two hours on the different issues of home care. It'd be, it'd be very fun, but we have to move on. And today we're going to see how everything comes together. So we, we need all the different team members in the office setting and the practice setting to pull it all together. So we're going to start with operations, technology, and staff safety. Megan, are you starting? My apologies. I had to take myself off mute. Thank you. Good morning, everybody. I'll get, I'll wake up here. So we're talking about operations, technology, and staff safety. And next slide. So we're really going to take a look at the different roles of the team members in your practice. And the interesting thing for some of you is that there's, might just be you in your practice. And for some people it's a large practice. So it's going to be different for everybody and what resources that you use. We'll take also a look at ways to find resources, different strategies to identify it. Also how some people work with the geographic scheduling. I know one of the questions in the chat was how do you determine how many visits a day? And this is where the geographic scheduling becomes a big factor in how many visits you can accomplish. We'll look at how to effectively manage DME and ordering. Also examine the options for improving patient care, making it more efficient, and how to also make sure to keep in mind staff safety. And that goes back to the boundaries that we were just talking about. Above all else, you need to make sure that you stay safe. If you're not safe, you can't keep doing this for long. And we'll work on our policies and procedures towards staff safety. Next slide. All right. We'll start first with team member functions. Next slide. Next slide. All right. So this pyramid goes over all the different people that you might find in a practice. Some of them are pretty obvious, you know, down from clinical where you're the provider and you're managing that direct care. And then it gets into practice management, which again, billing, coding, you know, a certain amount of marketing and scheduling and medical records. And then you've got social services. The thing that is key to look at this, is there anything here that you are surprised to see or you hadn't expected as you're trying to put your practice together? Anything that that you hadn't thought about? I know for myself, even the thought of having a pharmacist on staff that was mentioned yesterday, seems rather unusual, but it makes sense. And as I thought about it more, because that would have been something I would have been able to implement. You know, the thing is the patient already has a pharmacist and the work around as I can call Walgreens and ask to speak to the pharmacist of the store they go to, and that pharmacist will answer those questions. Not every pharmacist is agreeable to that, but a lot of them are. Nutritionist. That's another good one. Thank you, Anna. That would be nice. So there's, you know, ways of how do we determine or find workarounds in those situations where maybe we can't necessarily hire that person and bring them on staff. Dentists, optometrists, those would be great. Particularly here in Florida, dentists, very frequent problem is dental health. And what's been good to really see also, I agree, is the psych services, the telemedicine and counseling, that is becoming, I feel, more readily available, particularly with telehealth. Megan, I was just going to comment too, I think it's important too, especially for those providers who are just starting out. These don't all necessarily have to be on your team, you know, work with your community resources, find, you know, partners with home health agencies, senior services, local, there's lots of resources. So, you know, it takes a team to care for the patients, but that doesn't mean that that team has to be all employed in the practice either. There's a lot of opportunities to partner. And that is an excellent point, Brianna, because it's very easy to look at this and suddenly feel, oh my gosh, how would I ever get to this point? I just don't have that cash flow. I can't even figure out how to get patients. And you're wearing all of these hats yourself. So, and this is the other part where if you're the one person kind of managing all of this, because you're just getting started, which is a lot of you, really look at when it comes to credentialing, for example, to getting on insurance, you know, make sure to look in at and around your community for somebody who specializes in credentialing. Those are things that can take a lot of time. But if you find somebody that can help you with it, you may find that that allows you to spend more time on the scheduling or your marketing and talking to different companies. Make sure that you also reach out to other different home-based practices in your community. You're a team. And, you know, Florida Mobile Physicians, I'll give you a shout out here. There's many times where we would work back and forth trying to help solve the same problem for a patient and figure out how to get their best care. They're not your competition. They're your colleagues, and they can really provide sometimes a good resource for you. Okay. Going through the chat here. An efficient approach to connecting with local agencies. You just, you start calling and seeing what you can provide to help them. And as you work through what they need, and if you're able to help out in any way, a lot of times then they will recognize how you can help them and vice versa. And you find out they end up getting a lot of referrals that way, too. Next slide. So, as you combine some of those roles, and you may find, or that you're bringing in more people, one of the things is you want to make sure that you communicate with each other and make sure that that you all are on the same page about how you're going forward with patient care and the direction of your practice. So, make sure to come up with a time frame of how often you want to meet up with your team members, and or even those resources that you are frequently using, whether it's a pharmacist or your medical director. Particularly for those of you, if you're out there practicing solo and you've got a medical director, how, what problems can you solve together? Always have a set agenda. Always make sure that somebody's running the meeting. That will help you out quite a bit. And next slide, please. Sample things to talk about or make sure that you go over the metrics that you're trying to accomplish. Review hospitalizations on patients, those who've gone in the hospital, and those who have recently come out. See if there, you know, review if there's any ways that you could have improved their care. Talk about your complex cases, so everybody's on the same page. And make sure that you talk about what your plans are going forward for the entire team, what's coming up. If there's any chance of improving scheduling or identifying different waste, you know, those are other things to consider. And provide everybody an opportunity to make suggestions. Sometimes, you know, even outside your organization, again, your colleagues can really come up with suggestions, you know, as to how things can run more efficiently for you. And then looking in the chat, we just talk about you've got small teams and how they're, they, an MP with an RN and an MA. And you also get volunteers for every 100 to 150 patients. That's a good ratio. So, those are other suggestions too. So, that way, you're keeping a core group for a certain area. And next slide. And that goes back to using team huddles for those kind of groups. You want to make sure to touch base and make sure to communicate with everybody. Shorten, sometimes it's even just very short, you know, five minutes, whether it's by texting. And make sure that, again, stick with your agenda. So, that way, everybody realizes that their time, you know that their time is valuable. And Paul's asking about online resources for hiring virtual front or back office staff. Um, I, you know, there, it depends upon I think what it is that you're trying to accomplish with office staff, you know, what tasks you're looking for. And what those needs would be from a per diem standpoint, there are probably some different options out there, but it would depend upon what you're looking for as to what resources I think there's definitely some temporary services in this area, for example, that might be an option. Next slide. A huddle board, as the organization grows, this is another way to always make sure that you're providing a resource for your staff as they come in and out of an office. Next slide. And then as you can see, it gets even more complex as you continue to grow, but it's still the same format, whereas you're having one central area for people to refer back to and see kind of what's going on in us. This is a larger setting, but in a smaller setting if again if it is just you or maybe a couple other people. You may find that using your EMR software there's ways to communicate and make a board similarly in your EMR software and formulating tasks that everybody can see when they log in. So even if you don't necessarily have a large office space to work out of, that's another alternative is to utilize the resources you have. If you're using a Google Business account, there's, you can make task boards that everybody can access at any time. Next slide. And so that's going on into community services. Is there any questions about, you know, operationally? I see that for some people it's just trying to find people. Is it more just the office staff or is it more providers that you find are the issue and trying to find? What's everybody's experience or concern in that regard? Hi, Megan. My concern would be for those starting off and don't necessarily have a large office space and you're working out of your house, for example, your office is at home and you're looking to get, you know, bring on administrative staff, you know, is it feasible to use technology to manage a lot of this? You know, all the, you know, primary care planning and all of that, but how would you manage, you know, supplies? You know, do you have any ideas how to, you know, how do providers pick up their gear to go into the homes, things like that? So it depends upon how much gear are you talking, but we would just use, everybody had a black bag, you know, and there were so many supplies in the bag. And then if they needed to sign out more supplies, then they would call and ask me and say, Hey, I need some more 4x4s, Curlex or, you know, Coban, whatever it is that they might need. The other thing too, we found is that the home health agency, a lot of time was doing a lot of the wound care. And so they were providing those supplies as it was. So it wasn't even on us. And it was kind of a waste for us to even try to carry a lot of that. So I would encourage you to try to keep your bag as light as possible, number one, so your back doesn't hurt. But number two is each provider has that set kind of base supply kit. So then when it's their responsibility, they tend to take care of it pretty, you know, a lot, a lot better than if it were shared. Mary's asking the question about billing for medical supplies, gauze, foam dressing, suture removal kits, safer removal kits and catheters. You know, we started out in the beginning and we thought that we were going to use a lot of those supplies, and quite frankly, a lot of them were to expire on us. Other practices may have different experiences, but I would be real cautious to some of you who are just starting out. Get what you know you'll need, meaning that you have an absolute need for it, before you start buying a lot of supplies. And future med students who take a year or two gap year, yes, they are medically interested in learning, just as they would try to be scribes. They may have another interest in what you're doing and going on visits, because it's a great way for them to add to their resume for medical school and PA schools and even for a practitioner. Any other kind of operational aspects that you find difficult or concerning before I go to community services? Yes, I'd like to share. First, starting out, it was very difficult, like many of you that have your own practices have experienced. When you're doing a lot on your own, it can become overwhelming to manage everything until you can save up enough money, start getting money coming in so that you can hire somebody. I really would recommend, if you can afford to put out the money, to at least get an administrative person, somebody to answer the phone, somebody to schedule, so that that's one less thing you have to worry about. Because the clinical aspect of the practice is you, especially if it's only you. If you can afford to have somebody do those things, I would really encourage you to just put out the money for that, if nothing else. That's a really good point. That goes back to also, I agree with you in regards to credentialing and getting help with billing and coding. Those are a couple of things that you spend a huge amount of time on, and you're trying to focus on patients, and you'll wear yourself into the ground real quick. Make sure you've got somebody who can help you with some of the basics of answering the phone and scheduling. Going back to the boundaries part, if you have a patient who is calling you a lot excessively, sometimes you have to fire patients. There's no way around it. If they are calling you and texting you and not abiding by those boundaries, there's a point where you have to say, look, I cannot continue to care for you, because they're costing you a lot of time, money, and stress. Don't be afraid to say, that's it. We have to terminate this relationship. That's completely reasonable. Megan, I think it's also important to add that sometimes it's not the patient, but sometimes it's a very complicated family. We've been in that situation a number of times in which we've had to really have the conversation to set those boundaries and see if it's going to work. Unfortunately, we've had to dismiss patients as a result. That's a good point. Yes. There's still some patients that come to my mind, and I think that when I finally said, that's it, I'm not going to feel guilty about this anymore, and we terminate the relationship, it was such a relief to not have to worry about when they were going to call, when they were going to bother me, what was the next guilt trip. They'll always tell you that there's nobody else, but yet they always seem to find somebody else. That's the nature of the beast. They do. Quick question. If you are running your office from home, how do you get extra help, like an administrative assistant? The administrative assistant doesn't have to be, they can be from their home, or that's the beauty of the electronic world now. For us, in my practice, we operated, I had the core business from home, but then I had three other providers, and they had their own supplies, and it was all electronic. We really didn't have to, you know, I coordinated with my medical director electronically, I coordinated with all the help electronically, and that's a big part of, again, setting boundaries and training people that when they give you referrals, that they start to learn how your system works. Don't be afraid to say this is kind of, you know, you call and you leave a message with a referral, I have to call you back and let you know that I received it and accept it. We'll call you within a certain amount of time. And if you set those boundaries and train them from the very beginning of what your expectations are, it can go a lot smoother for you. Okay. Can I add something? Sure. Yeah, there's ways, I believe it was Fran, with, as you said, electronically, there's a lot of different apps, or even EMRs, that you, people don't even know that you're working from home, and you can interact with, you know, and some of them are pretty reasonable So that you can communicate and interact and have an online assistant, where people don't even know that you're in your home, outside of that the kids are screaming as we spoke about before, but yeah. That's exactly right, Nicole. Yeah, I mean, it's, it just, it's utilizing the resources there that are available to you and it's definitely possible to do so. Well, I'll go to the next session, community services. Okay. So, all right, go ahead. Next slide. Why are community services so important? We're going to talk about that. And how do you identify and connect with them? And how do you make sure they're legitimate? That's always a key concern as well. Next slide. All right, well, one of the big sites that is mentioned here is the Eldercare Locator. This website, if you type that in, and you go to it, it will pull up different aspects of how to find services in your area. For example, when I put in my area, it gives you the phone number and contacts for the Agency on Aging, which of course then can lead you to other resources. And again, I really stress the home health companies because they have a need to generate more business for themselves, but at the same time, they have a lot of resources, they're used to solving problems as well, so they continue to function. So you can work together a lot of times with different agencies. Don't tie yourself into one. By all means, make sure you're a friend to everybody, but don't necessarily get yourself into an exclusivity situation. Next slide, please. And that'll take us into the all-important geographic scheduling by Brianna. Thank you, Megan. So, you know, the geographic scheduling has come up a lot. It's one of those unique considerations that as house call providers, we have to figure out. And if we go to the next slide, while I'm kind of framing up this conversation and talking about why it's important and the effects that it can have, I'd encourage you all, if you want to share in the chat, what your practice is currently doing. You know, are you using any map-based tools? What kind of process does it look like today or one that you found very helpful? We'll come to that. But it really does come down to your bottom line because it affects productivity and also provider satisfaction. I mean, if you want to be caring for patients and doing what you're doing best and being face-to-face with them, and if you're having to drive hours and hours in between visits or throughout your day, and, you know, number one, you're not able to meet those productivities, those productivity standards, and number two, you're going to find yourself, you know, kind of adding to that burnout that Amanda talked about yesterday, if you're spending all your time in your car or however you get to visits, rather than face-to-face with your patients. So we really need to focus on an efficient, thoughtful process that minimizes travel time. It's not very intuitive. It's very easy as you're starting out to think, well, I know the area. I know my patients. I will tell you, you know, there's going to be zip codes that are different that are actually backdoor to each other. So, I mean, you really do have to think about that, and it's easier to do it from the start than to wait until you build up your practice and try and kind of categorize all your patients that way. Next slide, please. So what are some strategies for this? And, you know, thinking about it from grassroots efforts, from the very start, you need to start with territory zones for you guys as the providers as well. And if you're on your own and you're just starting out, you have to fight that balance of you can't see everyone. You have to give yourself a assigned zone. Yes, you want to allow flexibility so you're not kind of not being able to grow and not take patients. But you do have to have a realistic expectation of what service area you're going to care for. And a scheduling guide, as far as a general plan, it's going to change. There's going to be flexibility, but what areas, what zip codes or, you know, territories are you going to generally be on and what days? If you have a lot of group home and assisted living patients, that's a great way to boost productivity, but make sure you're setting set days for that. And you're seeing all the patients as medically necessary and appropriate when you're there. And you're not going back to the same facility over and over again within a short amount of time. It really helps if you, I'm a big process person, so documenting workflows, that's how you're going to evaluate it. You also never know when staff is going to leave. So if you, you know, rely on one person that all of their knowledge is in their brain and suddenly they leave your practice, it's really hard for, you know, you might not be firsthand familiar with the processes and things like that. So I would encourage you to document it. That'll help with training guides when you're onboarding new staff or you are at a place when you can bring on an administrative assistant like we spoke about. And for your facilities, you know, knowing which patients you have active. Also from a care standpoint, that would help with some care coordination conferences. You could talk with the facility about patients. It will help you assess where you have the most patients, too. You know, if you're driving to one facility that's really far away and you know you only have one or two patients there, knowing that information could maybe help you make some decisions. Is it worth your time to keep going there? Do you want to meet with the facility and try and grow that relationship to grow referrals? And then share feedback. If you do, you know, work with a new person, again, they need training. And if you have a bad day or, you know, a bad route, share that with them. Talk about what went wrong. Use flags and little alerts and kind of hints within your EHR about special notes or addresses that may be wrong on GPS and things like that. Next slide, please. So I'm going to go over a couple of different technology resources. Please know I'm not personally endorsing or recommending any of these, but there are technology solutions out there. So I'm just going to show you a few of what's in the field. Again, not personally endorsing that thing. You have to use them. But there are tools that we can use, especially in today's technology days, to make this easier. So the first one that I'll share with you is called CareLink. Their website is actually mymobilepracticemanager.com. They have both a practice management software and a scheduling software. You can choose to purchase just the scheduling. There is a fee for that. But they do have a lot of reporting and analytic capabilities. You can actually, like, draw little service area maps and group both patients and create future schedules. If you include visit frequency in CareLink, too, it also will tell you when your patients are overdue for visits. So that could be one plus is kind of preventing those care gaps and making sure they're being seen. And the next resource, if we go on, that might be helpful for you to be familiar with is Road Warrior. This is specific to route planning. So this isn't going to help you with your scheduling. But for you independent providers, you can actually download the app for free. I have it on my phone. You can do up to eight addresses for free, and it'll help you plan your driving route and also track your mileage. So you enter the points in, and then you pick a start and an end location, and you hit optimize, and it'll tell you what the most efficient driving route is. So there is a subscription that you can purchase. I think some UPS delivery drivers and things like that have heard of using this, but you can use the app as far as just creating your own driving route. And especially if you're on your own, that might be helpful. Next slide, please. The next three resources are all very similar. There's a lot of things you can do with custom Google Maps. Again, there is a cost or a path that you can do. But when we talked about assigning those provider territory zones and figuring out where your patients are, especially if you kind of have the luxury of starting small and maybe putting your patients on a map and color coding areas, might be worth the while while you're evaluating your process. Similar to Mapsive is the next resource. The next slide, please. Multiplotter. Again, very similar, but lets you group patients by zip code, color coding, things like that. And you can see the fees associated with that, which are pretty minimal. It's one of the lesser expensive ones. And also, the next slide here, if you have a Google Maps business account. And Megan, I know this is a strategy that you use. I don't know if you want to share anything about kind of how this has worked for you and how easy it was to set up or anything like that. So we found that this was the easiest way. We would plot the patient's address. And again, this is HIPAA compliant because of the business service agreement that you sign with Google. And the color coding in this sample here was based upon the month that they were seen. So we knew who needed to have follow-ups by that and then who was next on the list in this area. But it also, when using the Google program, what we found that we liked is that we can move around. We planned out the day by putting in those addresses, the seven addresses of the homes. And by moving them up or down and around, it'll tell you what's the driving time going to be and how you can shorten it by making a few adjustments. And then, of course, once that provider was on the road, it guides them through making sure to avoid traffic and get the most efficient route. Yeah, absolutely. And again, I would just emphasize really this is one of those processes that's easy, especially when you're starting out and there's so much to put off. But really putting the work in, especially when you're growing, is worth it. It's going to help you meet productivity. It's going to help you be efficient. It's going to help you get to more patients and not be spending all your time in the car. So it really is worth the effort. And it affects your practice in so many different ways. And so moving on to very simple strategies. We're sharing these resources for you. But being in Google Maps, I know practices that they have administrative support that's responsible for future scheduling and planning provider routes. The providers get to review that. So obviously, if you needed to make a change or something like that. But the day before the visit, they just put all the patients on Bing or Google Maps, you know, one, two, three, four, five, et cetera, and give that to the provider. And so they can make sure that they truly are, you know, seeing patients in the most efficient order. There's two pieces to this, which we'll talk more about routing coming up here. But you have to think about scheduling, planning future schedules, and you also have to think about your routing and your driving route. Next slide, please. So we talked a little bit about this yesterday. But again, one thing that stuck out, and if you remember the simulated house call video, is the provider arrived and the patient said, oh, right on time. Realistically, probably not going to happen. So don't put yourself in a hole. Don't tell your patient you're going to be there in an exact period of time. Again, this is where coming in and explaining services right from the start is really important. Either maybe a two-hour window is appropriate, and then you have to consider drive time. You know, we used to always space the start times out 30 minutes in between appointments, but then every patient had a two-hour window. And so, you know, for example, the first patient's time frame maybe was 9 to 11. The next patient's time frame would be 9.30 to 11.30. You know, things like that. So you can figure out what works best for you. I know some practices that will just give a.m. and p.m. All their morning patients will see some time between 9 and noon. All their p.m. patients will see some time between 1 and 4. So there's no one right way to do it, but I would discourage you from telling your patients hard appointment dates and hard times. You know, I'll see you in two months. Our office will call the day before or a few days before to confirm your visit and your time. And that appointment confirmation is so important, too. You know, you might not think about no-shows and house calls, but it's really a waste of your time and resources if you're showing up to a patient's home and they're not answering the door or they're not home because their doctor took them to a hair appointment or something like that. Also, think about where your providers live. You know, are they starting and ending their day from home, like Megan mentioned? You know, where are you going to – that goes back to where you're even going to assign patients to them. And keeping that in mind. And if you do have medical assistants or people traveling with you during the day, don't forget about lunch breaks. You don't want to get yourself in trouble with HR labor laws. And also for the providers, try and take little breaks. You know, I'll give you an example. We had to kind of work with our providers at a previous practice because they would be not getting back to the office until about 3 or 4 o'clock. Their nurses and the MAs left at 4 or 4.30, and then their in-basket would be overloaded with things that had to be addressed that day. So, really try and space that out. Again, from a workflow efficiency standpoint and making sure patients get the care that they need. You really do need to think about that. So, little breaks. I know it's hard, but especially, you know, making sure you can call back patients. Sometimes there are urgent things. You know, is your office going to call you? Are you going to use high-priority messages in the EHR? You know, how are you going to flag things that shouldn't wait until the end of the day? Moving on. Next slide, please. So, again, just kind of tying this all together. Again, don't pigeonhole yourself into one way. Some people that have compared it to Tetris, we do a lot of shifting in our schedules, and that's okay. You're going to have to fit in, you know, a post-discharge patient and maybe move your stable three-month follow-up off to the next week or two. Look at your schedules in advance. Again, I know it's a lot harder if it's just you, but that's why it really takes some good training and getting some good support staff that familiarizes yourself on this and can move patients around. Make sure you don't have, you know, patients in the same area on two different weeks or two different days and things like that. So, making that plan and knowing that you're going to have flexibility for acute and urgent visits. Also considering how far in advance you're going to confirm that appointment with the patient, because if you're confirming a week in advance, but then you get notified of an urgent visit, you know, that makes it harder to be able to add them on the next day. And, you know, don't be afraid to call. If it's truly a more stable patient, you know, not that any of our patients are too stable, but a visit that can be postponed, you know, call and explain that to them or have the staff explain that to them. Like, I'm sorry, you know, we had a really urgent need come up in the schedule. We really need to reschedule your appointment. Would it be possible to come see you next week instead? And that's when, you know, conversations and educating and setting expectations is really important. You do need to have productivity standards and we're going to talk about this more in economics. But you have to be able to keep providing great care and keep your lights on and be sustainable, especially if you're starting off in fee-for-service and aren't fortunate enough to have a value-based arrangement. You know, how many patients do you need to see per day or per month or per week? I know some practices that prefer to work longer days. So maybe their nurse practitioners see 10 to 12 patients, you know, on longer days in the beginning of the week and have an off day or something like that. You know, you can make your schedule, but do have some standards, not to be mean or to diminish patient care. It's a partnership between your clinical leadership and your operations staff. What do you need to do to continue doing business? And that no-show policy too, you can stay on this slide, Danielle, but addressing it when it happens and before it becomes a recurrent problem, you know, call and talk with them. You know, I know we sent Megan out for the visit today and unfortunately you weren't there. You know, can I ask what happened and can I explain how this affects us as a practice and how we can prevent it next time? You know, does the patient have dialysis that day and you need to put a note in your schedule that says avoid scheduling on Wednesdays because, you know, things like that. Those are all things we need to think about. And this is on page 67 in your workbook as a handout. Also page 68 has a practice intake guide, but really just showing you, it doesn't have to, you know, if you can afford some tools and think about that, but you can really take it down to some grassroots efforts and just have a general plan for what areas on what days you're gonna be in. And then when you're scheduling future visits, if, you know, I'm already gonna be scheduling a couple months out for Mondays and Wednesdays, only patients on these days, that kind of already does the process for you. And it allows you to not lose patients, you know, not have them on different days in different areas. And you can really think about this in advance. And moving on. So this is hard to read. It is blown up in your handout, again, between pages 68 and around page 68 in your workbook, but also just showing you why it's important to have workflows and understand them. You know, when a new patient comes in or you get that referral, whether it's a phone, fax, maybe they can send it to you electronically, is someone gonna explain services? Are they gonna explain how scheduling works in your practice? Are they gonna explain to them how they're gonna be notified with visits and times? What kind of information, that intake checklist, do you need to go over, making sure they have an active and appropriate insurance that you can take, that they indeed do live in your area? Any appointment information that provider needs to know, excuse me, or do you need to talk to a family member in advance or get medical records? You know, this particular practice, two days ahead of time is when they confirm that appointment and then they call again the day before with the time. And they don't confirm that time till the day before, and that just gives them that added flexibility. Whereas established patients, the second the provider sees them, you know, the note is routed with the appropriate follow-up time to the scheduling work, to an up scheduler reschedules the patient on an appropriate day when they're gonna be in that area, depending on how many months. So think about the process as a whole and kind of tie this all together. Next slide. So we're gonna talk a little bit about DME. I don't have any magic solutions or, you know, it's kind of one of those things that is time consuming and we're gonna try and give you some suggestions on efficiency, and I would just encourage attendees or even fellow faculty, if you've had any tips that really work for you, maybe throw that in the chat and we can kind of just knowledge share here. For the sake of time, I'm gonna move on now. Next slide. So hospital beds, oxygen and wheelchair, there's a lot of requirements. We've tried to help you out a little bit with this as well. If you look at pages 71 through 74 in your workbook, I have the Medicare requirements for ordering these different things. A lot of times your EHR templates will have these built in, but if they don't make sure you're doing that, because if you're having to go back and forth with a DME company, number one, that delays the patient getting the supplies that they need, but it also affects your efficiency rather than just having all of that information and the documentation done ahead of time. And your clinical staff or, you know, if you have that support staff is really gonna have to familiarize yourself with the documentation and the requirements and what the DME company needs. Next slide. There is a supplier directory. If you're looking for a Medicare approved that has a Medicare bid for supplies in your area, or you're struggling with one resource and you kind of wanna take a look at what else there, you can go on CMS's website and see which vendors have Medicare bids in your area. Again, typically you have to have that face-to-face visit where you're supporting and documenting the medical necessity for the equipment you're ordering, you're signing that written prescription order and the CMN. So if you're not doing all of those things upfront, delaying, you know, the supplies and probably putting some inefficiencies on you if the DME company is having to go back to you multiple times for the information they need. And if we move on, kind of thinking about strategies. If you do have a team, and again, I realize a lot of us are new, so this might be on you, but this is why it's probably worth it in the end to even think about some part-time administrative help. MAs are great because they can do a lot of things and help with prior authorizations and things like that and are a little bit more cost-effective than an RN if you're just starting out. But, you know, are you gonna have a DME specialist or a core one or two people that is really familiar with this workflow? Also, relationship building. We've heard about the importance of that from the start. Every company is gonna have a customer service representative that should be assigned to your area or your practice. So if you ask for that one contact, I can tell you in a practice I used to work for, I was on the phone with them multiple times a week following up on things, but he was my one person, and they want your business, they want your referrals, so they're generally very helpful on following up on things for your patients. Utilize your EHR. I saw someone put in the chat earlier that they've really done a great job maximizing templates and things in their EHR, and that's great. Use that tool. It's all about efficiency. And also, again, educate patients from the start. DME processes are lengthy. If they're expecting that you told them you were gonna order oxygen for them and they thought it was gonna be there right away, talk with them about timeframes. But I would also encourage us to have a process that closes the loop. A lot of errors, unfortunately, happen. Can you set a patient alert for however many your standard timeframe on when you think they're supposed to have supplies and then have someone follow up to confirm it's received? Or really educate the patient and caregiver to call you if it's not received by X date so that you're not preventing, that could go into preventing a hospitalization. If the patient really needs supplies, you ordered it, so you're assuming they got the equipment that they needed, but then you find out on your next visit it never happened. Next slide. So there are online portals to pros and cons to that. Certain DME companies may have that availability. It makes it really efficient. And also, you can track the status. The downside is it's one more system, one more area that you might have to log into. I apologize to such physicians. We usually always try and save provider to be really inclusive of our interdisciplinary team that's doing this. But there are, again, utilize the technology, work with your vendors, ask for that customer service representative, and that'll help you. And with that, I'm gonna pass it to Dr. Chang, I believe, if we go on. Thank you, Brianna. In this section, I'm gonna talk about how technology is fueling the revival of house call medicine and ask us to consider what technology you may wanna consider as you think about your program and how to best care for our patients. It was the technology that led to the decline of house calls, right? Patients were required to go into the doctor's office, go to the hospital for scans and so on and so forth. And ironically, it is the technology or the evolution of technology that is leading the resurgence of house calls. Now we got smartphones, we got apps, we got ever more portable diagnostic point of care tools that are really paving the way to the modern house calls. And the video is gonna talk a little bit of the technology, but even the video, it's a little bit dated because the technology is moving at such a rapid pace. In our society, I just wanna show you a couple of pieces of equipment here in terms of as we're looking at COVID and how to take care of our patients and how to do remote patient care and monitoring so forth. Again, I'm not endorsing any products. HCCI has a policy of that, but this is just something to show you what is possible. Again, I'm not saying this is something you must have. For example, I've here a remote stethoscope, Bluetooth, and I can Bluetooth to my headset and this can add audio to my patient visit and I can instruct a patient and family on the placement of the stethoscope and I can remain away from the patient or even remotely and access some of the audio related to heart tones or lung sounds. Similarly, here is a cardiac device that can help us record a 6 lead EKG, which I'll show you here in a minute. Again, it's very simple to use to help us with diagnostic decisions such as does this patient have AFib or is that simply a PVC that I'm sensing here? So this just to help show you what is possible and also I'll be happy to share with all of you some of the apps that I use in terms of helping me make decisions. We talked about prognostication apps yesterday. There are also apps that I use to help me make a point of care decisions with the patient and family. One example would be atrial fibrillation. Should we put grandma on anticoagulation or not? There's an app that help you calculate CHA2DS2-VASc score in terms of stroke risk and a reverse lead that has blood score in terms of bleed risk. And really it's a teaching and learning tool for the patient and family as well. Can say, hey, let's look at this together. If we put grandma on anticoagulation, we can reduce her risk of stroke by this amount, but reversely, we could increase theoretically her bleed risk by this amount. So again, helping patients and family make informed decisions. That is, I think, really important as we are trying to leverage technology to help us take care of complex patients. So this section, next slide, please. You know, I want to illustrate the impact of technology that's having in the field of home-based medical care. We want to review the various type of technology and equipment currently available and ask you to consider some of the pros and cons of incorporating their use in a home-based primary care practice. Go ahead and play the video. My name is Dr. Paul Chang. I'm the chief medical officer here at the Home Center Care Institute. Let us talk a little bit about how to equip your house call program. Technology is a critical part of a house call visit, but there are so many options that it can be a bit overwhelming. In the first part of the 20th century, house calls were common. The black back toting physician is a familiar image from that time. However, technology advanced, x-rays and ultrasounds and blood testing and therapeutic treatments required visits to a physician, a clinic, or a hospital. And so the house call practice became, in essence, obsolete. But time passed, and with the advancement of portable technology, diagnosis and treatment at home are now possible and often are preferred by patients and families. House call physicians are in a unique position when it comes to the care of our patients. We have to be able to reliably assess and treat the patient at home, often without input from specialists. Along with other basic medical equipment you pack in your bag, these critical diagnostic tools will increase your effectiveness in caring for the patients at home. And so, we have to be able to rely on the patients at home. Once you have covered the basics in diagnostic technology, a wealth of advanced diagnostic options exist. Point-of-care testing enables house call providers to make assessments and treatments in the home, which were not possible only a few years ago. While there are many positives associated with these advanced tools, there are a lot of challenges as well. Let's explore some of these advanced options and the implications of their use. Point-of-care tests are designed to be done while the provider is still with the patient. Point-of-care testing can improve patient care since results are available during the visit and diagnostic and therapeutic intervention can be instituted. Examples of point-of-care testing include radiographic imaging, ultrasound, cardiac monitors, oxygen saturation monitors, glucometers, and portable blood analysis systems. The upsides associated with point-of-care testing include their portability and rapid results turnaround. The challenges to point-of-care testing are cost and maintenance. Some are complicated and require fairly extensive training to be used accurately. Some require specific adherence to storage and maintenance schedules. Failure to do so can result in inaccurate test results or wasted supplies. Just like any device that uses batteries, these devices have to be recharged. You may need to carry around extra batteries or other charging cables. Many mobile apps have made the practice of evidence-based medicine in the home more convenient. They provide quick answers when you are in the field and allow for better clinical decision-making. A potential challenge with these apps is access. For example, if you're in an area without internet access, you may not be able to find the answer you need. Some apps are free, but others require a one-time purchase or yearly subscription. An additional important consideration is the source of the app. While the internet abounds with free medical advice, as I'm sure you know, practitioners need to be sure to access reputable sources for information. One rapidly growing area of patient care is remote monitoring technology. Partnered with Telehealth, this technology allows us to monitor or communicate with patients in between visits. If a patient's vital signs become concerning, triage staff can contact a patient to assess the clinical situation. While this may require additional clinical intervention or a house call visit, it may also prevent an unexpected emergency room visit or a hospital admission. Again, while there are many advantages to this advanced technology, cost and complexity often make it inaccessible to some practices. Perhaps these are wish list items or could be focus of philanthropic assistance. As you can see, mobile healthcare delivery system now have an amazing choices, such as point of care diagnostics, apps for clinical management, and connecting multiple devices through the internet, called the internet of things, to all improve patient monitoring and care. Cost is of course a factor. Some of the devices can be expensive and many monitoring services comes with a monthly fee. Consider the return on investment on any device you're going to purchase. Many devices and services require internet access. Using dual connective devices with both wireless and cellular connectivity can help maintain a steady, reliable connection. The benefits of these technology in patient care, as well as security concerns, will be an ongoing discussion as technology continue to evolve in our field. In addition to diagnostic and treatment tools, every house call provider needs basic operation and communication technology. Personal safety alone makes remote communication and some type of navigation device necessities. Just like diagnostic technology, options in operations and communication technology are many and varied. Much depends on the size and the scope of your practice, the investment you are able to make in such technology, and the willingness of your staff to engage with these devices. No matter what device you choose, you must ask about device and system security. Consult with an IT professional if needed to ensure you get the information you require to make an informed decision. Smartphones are now nearly ubiquitous and can be an important part of house call medicine. Take a moment to appreciate the capabilities as well as the challenges when you're using a smartphone in the field. In addition to the benefits and challenges shown here, one of the biggest benefit to using a laptop or tablet is the ability to electronically access medical information and perform documentation during the visit. This can be accomplished in two ways. One way is via cloud-based electronic health records, which can be accessed by connecting through your secure cellular broadband connection. The advantage of this approach is that there is no medical information stored on the device should the device become lost or stolen. Cloud-based system allows you to access other parts of the electronic health system to view a patient's information. Although it's important for home-based primary care providers to access and document information electronically during the visit, we recognize this might not be an option for all practices. Another way of accessing and documenting during the visit is asynchronous charting. This method require that the charts for the day be downloaded onto a computer or be completed in paper form, then synced with a permanent record once you're back in the office. This can be a much more time-consuming process. And one critical security issue is the presence of patient data on a portable device that can be lost or stolen. Because of this, data stored this way should be encrypted. We strongly advise providers to not connect to the patient's home Wi-Fi or public Wi-Fi to chart or send pharmacy orders. Other options exist for creating internet hotspots that allow for secure data transmission. These must be carefully investigated. Connectivity issues and cost concerns can make this valuable technology problematic for many practices. Again, work with a reliable IT staffer or consultant to make the best choice for your practice. Many vehicles today have USB ports for charging electronic devices, like a cell phone. But charging laptops and some point-of-care devices require they be plugged into a standard 110-volt outlet. Power inverters convert power from your car's DC battery current to AC current, allowing you to plug in your device just like you would at home. A mobile practice requires that you be ready for emergencies such as having a jumper cable or properly inflated spare tire. Another alternative is enrollment in a roadside assistance plan. Technology well-chosen and implemented can be a house call provider's best friend. Advances in technology have made it possible for our field to thrive again. Examples of devices are provided in your workbook as a starting point. This does not constitute or imply any endorsement or specific recommendation by the Home Center Care Institute. Advances in technology for your practice. Think about how you and your patients will benefit from this. Let that be your guide. And I want to turn your attention to page 78, I believe. That is the, it's a list of the black bag. I think that issue came up earlier in the discussion about what to include in a black bag and, you know, to keep it reasonably light, not to injure your back or anything like that. That is a list for you to consider. It's not, obviously, not any kind of a mandate that you must have all of those. There are a lot of different considerations. But take a moment later on just to review what's on the list and think about what you may want to pack as you go about your day taking care of patients on the road. Now, the purpose of this slide and the next video is to raise awareness of the need for policies and procedures that will ensure the personal safety of your HBPC team members. You know, we live in a very uncertain world. There are a lot of things going on. And it's really important for us to think about policies and procedures and also think about electronic apps, for example, that can enhance personal safety of your HBPC team. Next slide, please. We're going to take a look at a video. And I want you to go to your workbook. And it's about meeting Nora. As you watch the video, I want you to take a minute just to jot down some of the good things that Nora does. And maybe there's some not so good things that Nora does. And then we can discuss it later on as we regroup. Go ahead and play the video, please. Thank you. Meet Nora, a nurse practitioner who's on her way to a home care visit with Sylvia, who lives in a rent-controlled, fourth-floor walk-up apartment. Nora's getting ready to leave for the appointment. She takes some cold medicine before she goes. She has a bag with her tablet PC and charger. Here's her box of supplies. After packing up her car, Nora checks her navigation app to remind herself where she's headed. Then she checks the weather app. She text messages Reg, the coordinator at the office, to let him know she's getting on the road for the day. There's no response, but Nora heads out. Ah, here's Reg with the text message response. Hello, Tony. This is Nora from House Calls. I just wanted you to know I'm about five minutes away. Can I ask you, Tony, to make sure that the cats are secured in the bathroom before I arrive? Thanks to Reg's message, Nora avoids the accident area and arrives at Sylvia's on time. She parks in the first available spot, since Sylvia's street is usually tough for parking. Nora's phone shows it's 8.20 a.m., so she thinks she can be out of the spot before 9. Nora gets out of the car quickly so she won't be late. She gets all of her bags onto her rolling cart. She places her phone and keys in an accessible pocket. Her shoe covers go in her other pocket. It's a quick walk to Sylvia's building. Sylvia's stairwell light is out again. Even though Nora's been to visit Sylvia before, she shows her badge before entering the apartment. She also pulls her shoe covers out of her pocket and slips them on. Hmm, Sylvia's daughter wasn't able to get both cats into the bathroom. At the end of the visit, Nora goes through her mental checklist to be sure she's repacked everything she brought. It all goes back on the cart so that she doesn't have to struggle down the stairs. Sylvia's daughter, Tony, grabs a flashlight and escorts Nora down the stairwell. After Nora leaves Sylvia's, she notices her cell phone is below a 50% charge. She pulls her car charger out of her glove box so she can charge on the way to her next appointment. She remembers to text Reg before she starts the car. All right, so as you reflect back on the video, we'll have an open mic now. What are some of the things that Nora did well? Let's start with that. Anyone? She checked in with her staff. Yes, it's really important in the world that we live in. She checked the weather before she left. In case there was any dangerous road conditions. Good. Did she call ahead about the animals? For all the good it did her. She tried. She had her keys and phone accessible and she had like a charger. Yep. Did she wear a badge? She also communicated after the first patient where she was going next. Excellent. Anything else? Good. Her box of supply was in a opaque container so nobody can see what's inside. That's important, depending on the neighborhood that you're traveling and servicing your patient. And also she had a wheel cart that prevents struggling with heavy bags and potentially injuring her back from carrying heavy bags. However, she had that big thing to haul up four flights with no elevator. Yep, that's a challenge, right? That could be a challenge. That would hurt her back far more than just packing lighter. And also depending on where you live, there are a lot of you that live in Florida, there are from Florida. We struggle with snow up here. So to drag a bag with wheels through snow into a patient's home might not be the best thing to do. So again, depending on what you pack in a bag and the location that you're servicing your patient, you may wanna have a wheel bag or just carrying a shoulder bag. In my practice, I think I'm the only one that carries a bag bag that doesn't have wheels. My APPs all travel with a smaller wheel bag. But the equipment all depends on who you're going to see too. This is not our first time seeing this patient. She probably could have packed lighter for that specific patient. Yeah, absolutely. And I think later on in the afternoon, as we do some of the visits, we're gonna work through some of this particular idea, I should say, about it is really important to look at your patients and prep for the day. Obviously, it would be terrible if you got to the house and said, I forgot, let's just say a G-tube or a tracheostomy tube. The whole reason that you were there to go visit the patient floor and now you have to travel back, say 20 minutes or whatever. That's just untimely. So it's really important to prep for the day, look at your patients. What do they need for us during the cold and flu season now? And then I look through the chart and say, how many flu shots do I need to bring today? So I don't waste them in case the refrigerator broke or the ice wasn't keeping the vaccine at a correct temperature. And that would be a loss. What about some of the not so good things that Nora did? What can she do to improve her safety? First, she needs to make sure she have enough gas based on where she's going and that her phone is fully charged before she leaves home. Yep. Who's the jury? Anything else? So I probably- The jury, yes. Yes, the jury, it's, yes. I probably would have stopped when I got to the stairwell on four flights up in the dark. I might've just called and said, we're not going to do this today. Yeah. Also the parking. She parks in a mirror in a place that has only 20 minutes. You don't like to see your car removed when you're back from the visit. Especially in a bad mood. Yeah. Yeah, she's living kind of dangerously. She's there at what, 8.20, and the street restriction starts at nine. Just like, I'm not that risky, so I might've made a different decision. Yeah, also, how can you prove that you were there before nine, you were out before nine or so? They can't go and take the car, and if you don't take a picture or so, there's no way of proving that they did it on the right time. It's only a sign. The trucks are going to be waiting there. Believe me, Miami's like that. Some areas, you have to be careful. What else? It was a little low on gas. Yes. And there was traffic, so you never know what can happen with that. Right, you don't want to run out of gas on the way to see a patient and have to take a detour or some extra time, or heaven forbid that you break down on the side of an expressway, for example, if there was a traffic jam and you couldn't get off and you run out of gas. She took cold medicine before she left. Right, yeah, you know, infection is both ways, especially now we're talking about COVID, right? Certainly, you shouldn't work when you're, if you're feeling sick, you shouldn't work, and we want to protect our patients from any infection that we may be carrying to them, and that's, we just don't want to do that. Well, and not only that, but some cold medicines can kind of make you feel a little wonky. Right. What else? Texting while driving. Yep, that's a big no-no, right? Depending on the state, you can really get into serious problem if you got caught texting and driving, and also it's a road hazard, it's really dangerous for you to be doing that, and in terms of endangering yourself and other people on the road. So texting, driving, texting, other people on the road. So texting, driving was not a good thing, that she should not have done that. She had a mental checklist of the items that she was going to leave with rather than maybe an actual checklist. Sure, yeah. I don't know about anybody else, but my mental checklists are quite discombobulated. I'm right there with you, yeah, I think I depend more and more on a physical checklist, and you can certainly have a checklist in the back of your vehicle in terms of what you need to bring in, and what you brought in should be the same as pretty much what you brought out, especially in the era of COVID, right? Did you pack the wipes? Did you pack your face shield and your mask and so on and so forth? So yeah, I'm a visual checklist kind of a person, definitely. All right, next slide, please. Be sure like homes. Definitely when you go into neighborhoods, when you go into a patient's homes, keep your eyes wide open, observe, observe, observe, and listen to your gut. If something doesn't look right, ask questions, ask, what is this about? And so on and so forth. And if your gut tells you this just isn't right at all, then we have provided our providers know that they feel free to leave, end the visit, say, I'll finish up, and maybe I'll call you later, but terminate the visit if your gut tells you that things are just not right here at this particular visit. And create a process for your practice on how to deal with emergencies or urgent issues. One of our practice partners at University of California, San Francisco, they have an emergency plan. It's called Dr. White. So all the providers and the office staff knows that when we get a message saying, please page Dr. White, the staff members are prepared to respond with a series of wellness question checks, such as, do you need us to call the police? Are you able to leave the visit immediately? So that is one way that UCSF is coping with, say, an emergency in the field in a coded fashion that gets the communication across in a discreet way. I'm curious, how are you handling any personal safety issues at your practice? We set a policy pretty early on that if I was ever going to a new home, I would have somebody with me. So for me, I have learners often. So I would always try to, or not try. I'm a little bit more risk-taking, so it's helpful to have a team that keeps me in check. So if I'm going somewhere new, I have someone with me. And then I always tell the learners about a code word too. And we just say, I like the Dr. White idea. We just say like, oh, I need to step out for this call. So I tell them also, and I empower them too, that if you feel anything concerning, you also have the right to say that. Thank you. Anyone else? I know some practices will use even location tracking services. They make it optional for their team, like such as Life 360 or things like that, that you can turn on and off during work hours. You know, it all depends on your comfort zone, but there certainly are, you know, technology options as well. Thank you, Brianna. Yes. And don't forget your office staff back in the office regarding personal safety as well. A couple of years ago, we actually had an officer from our local police department come and give us a talk about personal safety, not only in the field, but also in the office. Again, you know, our world is very uncertain and there are people who are just with bad intentions out there and how to deal with personal safety issues. And then just as Amanda, one other note, a lot of your states may regulate your organizations and having safety committees. So having someone look at your safety protocols on a regular basis is also a good idea. You know, we were a smaller organization and really hadn't put a lot of time into that, even though our department of labor really wants that. And maybe two years ago, we had a patient pull a gun on a nurse and, you know, we had a lot of learnings after that and certainly started a safety committee and, you know, multidisciplinary safety committee to talk about safety options, code words, the things then, you know, we talked about all this, but, you know, what you're gonna ask going into the homes and adding, making sure all of your firearms are locked up was added then to our list, so. Thank you, Amanda. Next slide, please. In this session, we compared the roles and functions performed by HPPC team members in different practice sizes and configurations. And we consider what kind of community services could be engaged to provide more comprehensive care for our HPPC patients. We explore tactics for geographic scheduling and DME ordering process. And finally, we looked at various technology options for diagnostics and operations, as well as review recommended practices to ensure personal safety for your HPPC members. Next slide, please. Turning to your learning plan, I want you to think about the session and review the session objectives, compare the roles and function of your team members in different practice sizes and configurations, and explore resources and strategies for identifying and connecting with community services. Think about geographic scheduling and DME referral coordination strategies, and look at options for diagnostic and operational technology to improve patient care, improve your efficiency, and staff personal safety. And think about policies and procedures aimed specifically at promoting staff safety. Next slide, please. All right. All right, I think that brings us to our break. We have a 10-minute break here. So if you can return by about 10.55 central time or five minutes before your hour, we'll see you back here to start Economics of Home-Based Primary Care. Thanks. Brianna Plensner. So if we're all set to go, why don't we go ahead and queue up that slide? Danielle? All right, Brianna, take it away. Can you hear me? Yep. Brianna and I are gonna be tag-teaming this, but I had to start with a funny email. I know we're all getting emails during this. You guys, I had a community, I have a community member, this is from one of our care coordinators. I have a community member who two years ago had a mouse problem in her house. So she got a cat or two to combat the mouse issue. Now, two years later, the cats have had a couple sets of babies. So she has 10 to 12 cats of all different ages now. And the question is, do I call animal control? Is this a member choice? It's very sensitive because she has no family and her animal loves her. No lie, she ends with this question. How many are too many cats and who gets to decide that? Guys, when are you ever gonna get an email like that in your life? I just love my job. How many cats are too many cats? Okay. All right, let's see, the rubber's meeting the road here. We're gonna talk about the economics of home-based primary care, slide. So here's some of our objectives today. Many of you outlined in our initial talk, we said, or your initial introductions, and we said, thanks, thanks, Debra. How do I make the business case? How do I keep this sustainable? How do I increase my revenue? How do I think about my value proposition? We're gonna start that conversation. We're gonna continue that conversation into just a phenomenal coding session coming up. Again, always a fan favorite and one of the most popular. And then as you think about building on this, the advanced class in two weeks is also another opportunity to keep talking about this. So there's a lot of these socioeconomic drivers, the business case. You're all in different places at different organizations, academic health centers, private organizations, independent organizations, health systems. How do you think about growing that and sustaining that? We're gonna talk about some core components for success, financial core components. Talk about some budget considerations, productivity, funding sources. And then Brianna will take us out with all sorts of different marketing ideas. So it's a really exciting time. Next slide. My mouse here. So you probably sent this when you registered or you can find it online at HCCI. And this is the founder, Tom Cornwell, wrote really a business case and an economic case and a community case called The Perfect Storm for why we should be doing home-based medical practice. And just a couple of stats that you know. But as I start to talk about these things, what I'm trying to get across as a CEO of running a mobile practice is these stats you know, but not everybody knows them. So you're building your business case right now. You take these dots off of these slides and you start using them. You start saying the same thing. What I find is when I'm trying to build a business case for something, finding the common language that I'm gonna use and continuing to use that over time, people repeat that back to me, right? By 2030, more than 20% of the population will be older than 65. That's a business case alone on why we should think about a different type of practice. When you go in in a future world to a payer, to your hospital, to your boss, or you're trying to sell this to an investor and they repeat that stat back to you, you're gonna know you did your job. So a couple of things, right? We know that we're in the silver tsunami, an aging population over the age of 65. With that comes multiple chronic conditions, polypharmacy, complicated family situations and now we introduce technology and all of the components of how we care for patients. Now, we often talk about how expensive Medicare is and the rising cost of Medicare. And it is, right? A fifth of the expense of Medicare is spent in the last year of life. And Medicaid is the largest component of the state budgets and it continues to grow. In 2009, 20% of Medicare hospital discharges were readmitted within 30 days. And then another third were readmitted within 90 days. How many of the, any facilities you work with and hospitals you work with, this is on their main dashboard that goes to their board. What's our admissions and readmissions, right? So as we think about building the case of the value proposition, we think about what are the stats that your people that you're talking to are already talking about. These are those stats. And half of the 30 day readmitted patients had not seen a physician since the hospital discharge. So again, enter home-based primary care, slide. So in 1996, Ian Morrison wrote a book called The Second Curve, Managing the Velocity of Change. And he essentially argues that after you have a traditional business curve, you then a new innovation, a new wave, this new world comes in of innovation. And now you can start strengthening whatever your innovative business model is. Many, now we've taken this right for healthcare. So now we have fee-for-service environment that can now propel us into a value position. We can talk about addressing today's concerns and issues as we start to outline them. And this continued evolution into this, what we would call a comprehensive home-centered solution. Right, how do we take people, we take technology and we take processes and medicine and put them all around one patient. So any questions so far? I know, I see the chat popping. So maybe if someone could help keep an eye on it and when maybe Brianna, if you, you know, when we're flipping around, if you keep an eye and say, oh, there's a good ad here or a question. Otherwise, take your video off or turn your video on and just jump right in. I certainly, as CEO, I can certainly be stopped but I'll keep going if they'll let me, you know. Okay, slide. So different payment structures. So the traditional fee-for-service payment structure that we're very aware of, right? You do a service, we bill for a service, we collect on that service. Now healthcare has managed to convolute it to no end with how health insurance works and negotiated costs. But regardless, I think we all live and die right now with some component of fee-for-service. Very few groups am I running into where they have very, very few. I'm trying to even think of one where it's full angel investor and we don't use some mechanism of this fee-for-service. Then there's something that I have, I've just kind of coined augmented fee-for-service. I don't know if it's actually a thing. So an HGCI has been nice enough to run with it. But this idea that there's still a widget-based component but it's still based on a visit set and now we're going to get money back. Transitional care management, you know, TCM, the care management coordinated of service, right? You have a time-based where you have to hit. So it still is a mechanism for volume, but now it's not just kind of your more traditional fee-for-service. So now we have, we can get on top of fee-for-service as long as we do some more things, we can get some more visits for touchpoint or some more money for touchpoints. Then there's a per member per month or per enrollee per month. So both have kind of become more common, especially if you work in any sort of value contract. This doesn't really require you to do anything. This requires as soon as they're a member of yours, they're on your roster, you just get a payment. You're expected to do something with that money and you have expectations under that, but it's not totally tied to a visit, a coding level, a touchpoint, the number of calls. You can get fee-for-service plus care coordination. And these are just adding these two ideas together. Now we get some form of care coordination payment per member per month, per enrollee per month, we're adding them together. You could have a shared savings model, right? If we improve on the product, we improve on a measure by a certain amount, we will receive money back just by doing that. A quality bonus, this P for P, everybody remember that? I don't hear P for P as much anymore, but paid for performance quality bonuses are still a big part of an add-on to any type of structure that you're thinking about. Hey, I think I can reduce readmissions. Hey, I think I can increase pulse usage. Hey, I think I can, whatever. And you fill in that blank of what you're working on. And there's then some quality bonuses that's paid to you for achieving those things. Then there's the option of like, now we kind of get into gain share, capitated care and bundled payment. Well, let me actually, I'll go to episode of care bundled payments first. So a bundled payment again, total knees have made these very popular. Hey, I care for, I take a DRG, I care for every component within that, and then I get a payment back for doing that work. You may, depending on your work, I know someone is doing some hospital medicine work too, you may be able to tag into an existing bundled payment. Here's an existing bundled payment, and I'm gonna take some of that money out of that and be able to put that into my program, or I can negotiate that. And then you get into gain share and full risk, right? So gain share says, we recognize that health insurance organizations take in a certain amount of income, they take in a certain amount of expense, and whatever that bottom line is, that net gain or loss, we, if it's positive, we share back in some of it. So I say, hey, I'm gonna look at the whole picture with you health insurance plan, ACO, and I'm gonna get some of that gain share money back. And then there's the full risk capitation. You are a Medicare Advantage plan, you participate with a Medicare Advantage plan, and I'm getting, I'm seeing all the money coming in, all of the risk adjustment money coming in, I'm seeing all of the expense going out, and I am getting the bottom line at the end of the day. There are lots of different things you can put in there. And like I said, our advanced course goes way more into, how do you think about value-based contracting and care there? Chat note. The comment in the chat was about frequent flyers in the hospital. So, how do you have a patient that was going back two to three days, and she couldn't stop her because she loves going to the hospital? Okay, Rita, is it from a financial perspective? How do you adjust for some people are more expensive than others? So- Sorry, I couldn't, I was trying to hit the mute button. The problem is that she's a psychiatric patient, and she doesn't take her medications, and she does very crazy, crazy things. And it was back and forth, back and forth. And I couldn't understand, why are you sending her so soon? And she's going back with the same thing two or three days later. I don't know if they were discharging her too soon, or what, because I couldn't figure it out. Or something else would, she would start developing something in the hospital before discharge, and they would discharge her anything, and then she would go back. Yeah, so typically I advise before getting involved in any sort of game share capitated program, maybe anything where you are responsible for the dollar of expense is a couple of things. One, you want to think through how many patients are going to be in your pool of patients, because you're going to have high utilizers and low utilizers. And you want to understand how many of those frequent flyers there are, and what your patient population looks like. The other thing is, you can certainly take a really high risk population and build an interesting value-based model off of them. You just have to understand that they are very expensive and make sure that your counterparts understand how expensive they are. So an example would be, let's say you had a program where you're like, I'm just going to follow everybody who comes out of the hospital with a specific, I can't remember again, someone was doing some interesting hospital work. THS is, yeah, like congestive heart failure as one common one that I know there was a pilot for. Yeah, it's a great example. We know that they have congestive heart failure. We know that they're in the hospital, and now we're following them outside of the hospital. By the time they get to the hospital, and probably there are multiple visits to the hospital, and there are multiple heart doctors, whether it's cardiologists, cardiac surgery, whatever, whoever has to get involved, and it's probably varies based on need. We're talking about a very expensive patient to start with. And so then how do you say, here are the things that move the dial. Maybe I'm not going to have the gain share because I'm taking a $500,000 patient and I'm making them a $300,000 patient. It's still a very expensive patient. But you say, I'm going to tie some quality measures to them. I'm going to talk about the measures that I can control and I can start getting paid for those. So functionally, I argue that when you think about payment structures, it's not about changing your work. It's about highlighting the work you're already doing and finding the people who are willing to pay for it. And typically, as you think about these things, there are groups who want to help pay for that. And actually, if you go to the next slide, it kind of takes us into who might want to, what are some of the programs that exist today? So Independence at Home is a demonstration project under Medicare. Let's see. The Medicare Access and CHIP Reauthorization Act of 2015, and then subsequently MIPS, the Merit-Based Incentive Program, are some options to look within that to see if there's kind of any value. And they do have a, what's it, like a value track within that. Now, they continue to add every year to the value track, the advanced payment model, the APM, different options. And so there might be some options there where you say, hey, that's a really good fit for my organization and, or my home organization is already getting involved in it. I may want to tag into that. Accountable care organizations made a big splash, what, 10, 15 years ago. They still exist. They have waxed and waned in various areas of the country. So, you know, but the general idea is still that you take a set patient population and you're trying to impact their care. And so if you have a home organization, you're either part of one or you work near one and they have an ACO, you may want to talk about, hey, how can I get involved with your organization and take care of some of your sicker patients? And when I do a good job, I get X payment. These APMs, alternative payment models, these are a couple in the last two years that have come out, primary care first, the seriously ill population and direct contracting. And so what I do, I really love generally CMS and CMMI. I do think that they, as a collective organizations and throughout whatever presidency is in place, I do think that they have acknowledged a couple of things. The cost of Medicare continues to go up and we need to start continuing to think outside the box on how we're going to bend the cost curve, meaning we need more people that are willing to take some risk. And put some more skin in the game. Primary care first and the serious ill population are two pilot programs in direct contracting, I guess, are these pilot programs that CMMI have come out with. And online, you can find quite a bit of, on the CMS, CMMI website, you can find quite a lot on if you qualify. And so they're just kind of two different functions. Direct contracting is like kind of contracting with Medicare Advantage, but directly through CMS. Directly for CMS original Medicare. Medicare Advantage plans and shared savings arrangements. Some of you may have the big player in town, Humana, Blue Cross, Aetna, Cigna, Part C Medicare Advantage plans that would be interesting to talk to their programs and say, hey, you guys are already taking risks for those patient populations. Maybe I can help you out and get some money for it. There are managed care organizations, of course, so HMO still exists. And as everybody becomes more competitive, how do you think about an HMO or PPO and how they're taking risks and how you can tie into them? And finally, dual eligibles. I kind of lump the dual eligible Medicare, Medicaid in with all of the special needs plans. Some of you maybe are familiar or might work within institutional special needs plans. Special needs plans have been around since 2003 or so, made popular in a demonstration form since the late 70s. And so I think there are some interesting programs that exist. Again, I encourage you to go to the CMMI website and Google your state and see what demonstration projects exist in your state, because then you'll start seeing what other work is happening And Amanda, kind of building on that, Adarunke had a good comment about, how do you get set up with some of these programs, such as bundled payments and value-based care? And I can touch on it a little bit and maybe you could share a little bit about how you've secured some of your contracts at Genevieve. The alternative payment model, there's typically an application period, like primary care first and SIP and direct contracting. That period has actually closed. Those practices who are participating in the first performance period, starting in 2021, have ended, but you can actually follow CMMI's listserv. I can put up the website for some of these in the chat and you can take it out. But like Amanda said, look at what your state is, the demonstration projects, there'll typically be an application period, but you can also approach these MA plans with data and approach organizations that are already participating and see how you can support and come up with some really creative solutions. And Amanda, I don't know if you have anything to add on that. No, I mean, we kind of introduced all these ideas here and then we continue to talk about how do you think, in the next couple of slides, we'll talk about how do you think about value? Like what are the measures that you want to be tracking and bringing forward? It goes to the conversation yesterday around quality measures. And again, how are you tracking those and bringing those forward? So what I, as you think about revenue, the most popular is always Brianna's coding and fee-for-service. And once you get that to a place where you feel like, it's good and I'm ready for the next thing or I'm ready for some supplemental pieces of this, or I can't figure out how to pay for X, Y, Z, I can't figure, I really need a social worker on hand, I need a behavioral health social worker on hand, can't figure out quite how to pay for that. That's when these types of programs open themselves up and you say, I have enough data, I have enough patients, I think I have my value proposition, I'm ready to take these around and start shopping. So you go to Brianna's website, you go to the CMMI website and demonstrations, but you can also, all your members are getting all the flyers. Does everybody know who offers the Medicare Advantage plans in your areas and what the differences are? Who's putting more resources into utilization management and who's putting, which means claim, like claim denial and who's putting more resources into community services, right? So go to the community service organization and say, I see that you are investing in heart monitors or investing in X, Y, Z and I'm also interested in that and it takes some work. This is a multi-year process to start getting contracts up and running. And Rita says, simply has a capitated that only pays a hundred dollars a month for complicated patients. Yes, a hundred dollars a month is not enough money. Usually I can't always be like, oh, how much is enough money? That's not enough money. Okay, slide. So, I'm gonna get rid of my chat. So how do you think about the return on investment? Now we need to demonstrate the value. As you think about these things, data's really important. There's also the story you're telling. Find a couple of things that you really wanna talk about and collect data over time in the same story over time. Enhanced, what you're doing today is enhanced access and quality. There's, your result of this will be less inappropriate utilizations, inpatient admissions, readmissions, ED utilizations, short inpatient, average length of stay. Patient and caregiver satisfaction and decompressed office-based primary care physician visits. Are there other things that you think, hey, we have started collecting this and we've been repeating this back to the community of value that's been successful? So, I'd open it up for questions or comments. Well, that's okay. This is a good start. This is a good start of a list, you know, and We have a chat I can read you So we have a question that says what would be the financial measure of patient satisfaction? You know, I I don't necessarily know if you have to quantify that I do think the people that you would be talking to Could could understand that as an independent value in and of itself without the financial component I think you know if you could say We do we have we have a patient survey and 95% of our patients are happy with our services then You know Oftentimes you're not hearing that return from patient satisfaction In the community, so then then you can kind of turn that around So, you know, I think there's some components to where We're gonna provide some value to quantify some of these things as you know from a financial perspective But sometimes you have to extrapolate a little bit right like sometimes we have to say you know an inpatient admission is $20,000 and we have reduced it by 20% and the result of that is, you know $5,000 or $4,000 decrease, you know, and so you kind of You won't know each every person's admissions. So you start to create this story, which In my experience working especially with practitioners who are working to create the business model of this component It becomes a little bit harder because you're like, well, I'm kind of making up this number I'm kind of using someone else's number. It's like that's okay But the patient and caregiver satisfaction and then I'm trying to think someone someone fill in the blank. There's the two patient The two patient question, would you recommend? What is the name of that one again? Are you talking about like the net promoter? The net promoter score is really big here. So as you think about like I'm not gonna spend a lot of money on You know on a patient caregiver satisfaction you could you could literally look up net promoter and just use that question You know, are you likely to recommend us and then be able to repeat that back that that is enough of a measure And it's becoming more and more common in health care Yeah, and then I would just add too I love what you said about the patient story because I think we always want to go in with the cost and the data and You know, there's some really great You know, I'm not sure if anyone on this call is familiar with Tori fields But she works for Blue Cross Blue Shield for a long time about benefits for palliative care And her best advice, you know when I've heard her speak is that we don't lead with cost to go in there with a really impactful patient story or Talk about patient and caregiver satisfaction because especially with MA plans that affects their star reading And so there there's things you can do about the value of the care that you're providing you need to have that data piece So I'm not diminishing it but also don't be afraid to leave with a really good You know patient success story that before she came in my care, you know She had 12 hospital admissions afterwards after a year of caring for her. Here's what we did for her And so and then Rita to your question on the patient and caregiver satisfaction HCCI does have a sample form available on our website And if the HCCI colleagues haven't already put that link in there, we will do that for you Yeah, I mean some of our most impactful stories are You know, we had we had one where it was a Friday afternoon and You know a five-foot walk up in the summer this was years ago and the air conditioner went out and we had a we had a nurse buy an air conditioner and install and get the and Find someone to install the air conditioner over the weekend, right? Like that's that's a story when you tell it to other people you they people start to think Oh if it were my mom or dad, I would want that kind of service like oh I've been in that spot and that's really hard. I can't imagine being 80 in that being the case Um How about staff retention job satisfaction, you know, that's that's a good question It is not something I've ever externally reported. So the things that I externally report about culture we've received a few awards and so I'll report those out, but generally as I'm Generally as I tell the story it's not with data. Generally I tell the story and I say kind of like we talked yesterday Health care is continuing continuing to enter into a high stress high burnout rate because of the functions That have gotten outside of our control and when we really strip some of those things away and we allow providers To work the way they intended to work when they were bright-eyed and went to medical school in their first day. We we see We see our providers happier. We see them. We see them live You know more they repeat back to us more meaningful things. So we keep a staff retention and job satisfaction Internally, but I haven't reported those out mostly just in storytelling, but I certainly think as you have a high staff or storytelling Component, you know that I think it's value add Slide And then the next Okay, great So, okay This is this is the idea of value value essentially is better care lower cost right quality divided by cost These are these components, right? I want if we want it to cost less than it to be better. So I'm not clinical I'm not going to be able to write to talk through all this but you know, Amanda great name Obviously 35 years old type 1 diabetes. She's on dialysis She has CID after that she has four stents and she has chronic pain This is from the Northwestern Medicine home care physician data and you can see the dates 17 and then Well start of care is mid 7 2017 and then throughout 2018. I think there might even be a picture for if you press the button again There she is There she is um, okay, so prior to this given everything going on again 35, so we're not not a geriatric patient, but chronic condition and and before a home-based intervention She has 10 ed visits 8 hospitalizations and spends, you know, 37 days in the hospital after that, you know as towards the end of 2017 you can see the ed visits in the hospital days are going down and by 2018 that She really has no time in the hospital and she's not going to the hospital now We know as a storyteller as you build your business model that this is one piece of data But one piece of data to Brianna's point is really important Tell that story and you can tell it in data find your everybody has their one patient who sticks out in their mind that they made a really big difference for tell that story and then say something like You know, I care for 100 amandas every day You know, that's my average daily census and if I had more resources, I could care for a thousand How many of your how many of amandas are showing up in your eds? Today that we could look at you know, I can I can track the ed. Let's just pull your diabetes Um CAD patients and see how many you have that I can make a difference in So again, it doesn't change anything you're doing you just start to build this this value proposition Next slide Next button So the value of house calls, you know as and then as we start to think about You know, how do we talk about the dollar saved Again, it becomes a little difficult I have found in my in my experience if you're not already in a value contract Just to say how much you would you would have saved because sometimes you're talking about things that haven't happened So if you if you saw amanda from last time you're saying, okay Well, the average ed is in the average hospitalization or xyz dollars. I've built those in i've saved this much this many dollars I multiply it by this many patients. Boom. I've saved some certain amount of dollars I you know If you really have someone and it just depends where everybody's coming from if you have someone who really is interested in the data You know start start looking and pulling these more global metrics 25 of 550 billion medicare dollars are in that final year, you know For us deaths in 2009 and that there might have some updated data somewhere, you know at home is 33 percent in hospice is 42 So, you know As you think about how are you going to collect data? We have been talking at ahcm and age Hdci and and our organization and others around now How do we start collecting how many people die at home as a real measure of success for these programs? is it an easy data point that you could start collecting and And show to others as this is this is meeting the goals of care that someone would want for their own life um As you can see here as a counter that northwestern medicine Says, okay. We've had a thousand deaths in from 2014 to 2018 76 died at home Again, is it just a quick button you can add or a metric on an excel sheet that you can start tracking? Because we're trying to say as a counter Home-based medicine. Look how many people can die at home. Look how many die on the on hospice medicare wants that hospice utilization They they built it as a benefit The median house call is 1.3 years reduced hospital mortality, right? So lots lots of different options I think but as you start to create that story You don't have to do anything different You just pick a couple of things that you want to track and that you think might be important to other groups any other ideas around this I have one more value slide Metrics you could be doing Yeah, there was a chat. Oh, i'm sorry. Go ahead What about wound healing Yeah, certainly so tell me tell me uh expand on that i'm trying to find her she's talking to me well, um Just because I provide care for a lot of patients with chronic wounds Um, a lot of them either get you know, infected end up in the hospital I don't know if this is something You know, we're healing them or we're keeping them stable so they don't get infections end up in the hospital if that's something we could track absolutely Absolutely. And so, you know, let's say you have um, what would also be cool is if If you can find any local data, right? Does your state? Does do we have any national comparative data around the cost of wound care? The cost of wound care to hospitalizations the cost of wound care to a patient's life, even if you can say, you know It decreases someone's life Satisfaction ultimately their productivity in the world It decreases their length of life and you know, and I take care, you know 50 percent of the patients that I take care of With when I you know at home because of wound care don't return to the hospital which saves money But it increases then their length of life and their productivity for our economic greater benefit as a community So I think it and I I mean it's such a great thing, right? Because you you we all have focus points of things we want to focus on are things we do really well And so it's again just finding that data point and then seeing are there any other comparative data points that we're doing it Better than someone else Yeah, mary had shared a few ideas in the chat as well too which are really good You know quantifying the number of patients who would not see a pcp without their hdpc services And that's actually fragmented care is how they're identifying eligible patients for the sip model that we talked about So, you know, that's really an issue and also how many patients they've helped implement an advanced care plan That's a big quality measure is you know, the percentage of your patients that have advanced care planning And how many medication errors were identified by their team of providers? well, and Uh, did you say did you say mary? mary wrote that Yeah, mary so, um, you know one one thing is so we have a couple of dual contracts the majority of our Revenue comes from value-based contracting. So either d snip dual or institutional special needs and um you know, we we spun off a house call program and from our dual program and Kind of the way the referral system kind of went is brianna's outlining here is how did how do you get into these programs? Sometimes it was a care coordinator filling out a sheet and we really did. This is a couple years ago. So What it's functionally come out to is we look at the forms We really have a care coordinator kind of go through the forums and talk about those But one of the questions that we ask on that form which I haven't heard other groups doing it I encourage you to do it as as a referral process is are they just falling through the cracks with traditional health care? Yes, or no Has someone looked at them and they're just falling through the cracks? They they need care every day, you know every time friday at five o'clock. They are always in the hospital They they can't get transportation whatever those pieces are and they're all the social pieces But just a yes or no and that that alone was an automatic entrance if if we had a an rn say they're just Falling through the cracks here Hey, amanda, if I can interrupt there was a chat question about the death data I'll be happy to uh, get the references. Uh, there are three references, uh one from Uh doing new new england journal and there are two other from um other publications. I'll get that Uh data, uh to the learner here And uh just on this particular side slide just uh, two, uh, well two comments I want to make regarding, you know, uh Finding data and having talking points. Um, um, if you look at the icu stay nationally is 29. Um, uh, 29 uh percent Icu stay prior to death, you know of our data from home care physician is five percent Uh and hospitalization 90 days is 69 percent. Our data is i'm looking at the numbers. It's 37 So that's um, you know, we talk about high cost of care towards the end of life and just the dramatic savings that we can uh, we can demonstrate to payers, um by providing um, Goal consistent care, uh at home the care that they want the care that they desire uh, and uh at the same time reducing cost Uh regarding the amanda slide earlier. Um, yeah, you know, there's there's power to numbers, uh, obviously But you know and finish it I tell uh, I tell learners finish it with a great Story, you know, we all still want I think that I don't know that a feel-good disney ending I think many of us despite maybe being a little jaded, uh dealing with money all the time, you know Amanda, we gave her life back, you know, she is selling her crafts at one of these, uh market, uh on the weekends That's the picture you want to leave with with uh with your audience and say yes, you know, we save Er visits we save money and so on and so forth But look at her we gave her life back and imagine if we as amanda said this amanda said if we have more money Imagine the impact the more impact we can make in the lives of patients like this other amanda Yeah, no, it's such a great point and we talk about contracting two in the advanced one But one tip I always share with people as you think about talking to other people, you know, tell that story but You know also, you know recognize your audience, right like the um There are you know, it's really hard to get the intro Consultant who's gonna or you know, um pay a representative to care as much, you know But if you can get a medical director at a pay at an organization to hear you say those things it has some real impactful components, too, um You know and and then understanding sometimes people's stories I I I can also say that I have I have google stocks. Is that still a word term? I've google stocked people i'm meeting with what are they into? You know, what are what are they doing? What on linkedin? What non-profits to the are they involved in? What are the common threads of how we make these connections and what's important to them? too, so next slide So So this is an so again as you you I really encourage you guys, you know before you go and say Oh, I got to start boiling the ocean with collecting all this data, you know Pick a couple of things but if you want to take numbers like just take this slide. This is an impactful slide this is the result of the um In you know, I think it wasn't this this is the va independence at home and you can see here Before the home-based intervention and during it and the change and what the cost is and you you make this argument of like you know home care and Outpatient go up. Yes and nursing home and hospital utilization utilization go down It's it's not like we get rid of all the health care for people who need it the most It's just we redirect it to where they need it when they need it and how we're going to pay for it and so your argument is Payer aco investor We want you still to pay for this this care We just want you to put it in a place that's going to make the most meaningful difference for this patient's life And for the total cost of care for our community I don't want to lose track of one really good question too about how data in the covid era affects the value of house calls and the value proposition and Amanda and dr Chang, I don't know if you have anything any thoughts on that There was a couple people that were asking the the covid data question and how that affects the value of house calls Well Well, go ahead paul, oh no, no, go ahead amanda, uh, i'm i'm still trying to type in the uh, the uh, the the death data, uh references, um, but uh, but go ahead, uh, i'll be happy to add um to uh, To your comments you know I I have I guess a couple of thoughts as much as we so um I think as I've tried to take our covid data I've had some some success with talking about it, especially with our utilization of it Of home-based medicine and and of covid deaths of what we've been seeing but I also like I run a little bit into um People are like oh this is you know, covid's going to be short-lived any and You know in our entire history of the world, right? Covid will be short-lived. It just feels really long right now And so I think it depends kind of what what you're doing with it and what you're trying to to prove out uh, too and also, um You know Health insurances are like health insurance companies are making a ton of money So it's it's sometimes they're a little like I can't i'm in a mixed bag of Do they want to do more with us right now? Because they're making a ton of money and they need to start redistributing some of this money back into community programs Or are they like no, this is really short-lived. We're not going to give you anything So, you know i'm kind of in a mixed bag depending on the payer with who's willing to talk to me more about this work and about the value that we're we're doing so i'm only 10 months into You know my negotiations around this the other the other I guess final pieces around the actual financial benefit that it's bringing so Like I mentioned we have the majority of our patients in value contracts and Um, they're either full or you know substantial risk contracts, um, and It's been very fine It's been it's been I hate to say it's it's been so bizarre because our fee for service has taken a hit and we're going To talk about how you budget and think about those things but fee for service has taken a hit and our value contracts have done Fantastic really? I mean we have had very low utilization of health care And then we always have high utilizers who are using a lot with covet and so i'm in the next six months We'll see how 2020 financially actually turned out as we get all the the data in But I actually you know, I think again health plans are making a lot of money so if you're in risk with health plans right now, you You're not having a bad year financially You know for me and going through covet I think it really highlighted the value of a home-based primary care Um, many of our patients really don't want to go to the hospital They want to be treated in the comforts of their homes. And this is what we can intervene. This is this is our advantage Um, this is what we're good at this is what we're passionate about Is supporting the caregivers and their loved ones at home taking care of them? help Ovid be their point of contact if they have questions or concerns about treatment and whatnot That's a huge plus for us in terms of highlighting what we can do and the value add In in home-based primary care during covet and flip side would be and we're really helping the hospital and the emergency room By keeping some of these patients and i'm looking at the dashboard of our our of our hospital now It's all yellow and red. They're full Um, so we are helping our colleagues decompressing the er decompressing the hospital by taking care of our patients at home be a Colleague to our patients be a support for our patients and family members Um, this could be really a highlight and I think in a weird way an unfortunate way Uh that covet has has been a plus for a home-based primary care Absolutely Slide Slide. Okay, core components for home based primary care success. Cash is the lifeblood of any organization. So, these are some for those just getting started, I certainly don't mean to overwhelm the senses with all the things you have to think of from a business person, you know, standpoint. That's why HCCI is here to help, too. But there are a lot of pieces. I know Rita was talking about contracting in the chat a little bit, right? Who do you contract with? You know, how do you get information, document it, code it, bill it, get it out once you get it? How do you manage the report management? Okay, now you have a denial. How do you manage that? How do you think about productivity? We have a graph for that coming up and then all the new payment models. So, this becomes kind of the center of how you think about your organization. Most of us are living in a cash world. You know, some of us have accrual-based financials, but many small organizations have cash-based financials and we need the cash to be there. We need it to be on its way. So, I guess one question I had was, this year, did anybody get any CARES money or get an SBA PPP loan for cash components to help keep you afloat? I guess I got the PPP loan back in April, and then applied for an SBA loan and I got approved on June. That helps a lot for, you know, the initial COVID-19 downturn. Yeah. And we have been dealing with that. The PPP loan is in the process of getting dismissed. And of course, the SBA loan, we have to pay back, but it's only 1%. Okay. Interesting. We should start, you know, payments on next year, June or July, something like that. There is another site with UnitedHealthcare that also is providing a second wave of payments. I just got an email today that I got approved for a second wave of payments. I don't know how much or how it's going to be, but you have to look out for all the possibilities. Also, there is a website with Optum that you can apply for payments for the uninsured COVID-19 patients you take care of. Yeah. March 5th to, you know, going on. There's still $17 billion available for that. Just to let everybody know about that. Even partial payments from COVID-19 things and, you know, the patient has to be positive. Also, you can care for patients that may have insurance, but you are not a provider of that insurance company and you took care of that patient, you can submit the charge to Optum and you get paid for that. Just to let everybody know. Yeah, no, that's great. Yep. Wow. I didn't know about that. I'd be interested in hearing more about how to submit the, because I did take care of several patients with COVID who didn't have insurance. I did get the PPP money as well. And just learned that we don't have to pay that back because obviously we met all the criteria for that. But also to let anybody know, everybody know who's, who's, who submits Medicare. I also received the, I think it was the, the HHS money as well, but I didn't have that. I think it was the, the HHS money as well, but I did not apply for a loan because with all of those things that all of the availabilities, including the PPP and the HHS, it was enough to make sure that we were taken care of. Yeah, but the HHS is having a second wave of payments. That's the one I'm talking about. You have to go to Optum from UnitedHealthcare, register yourself with the password or username, give it forever because Optum is going to be administering several things on the COVID-19 programs. And right there, you will see the website. This is the link to apply for the second wave of HHS payments and the COVID-19. That's both things. COVID-19, yeah, uninsured payment. So I can, I was going to say too, I'm going to try and politely move us along too, but HHCI has a COVID-19 resource center where we link to a lot of those fact sheets on the different payment programs and things. So I can, I can put that along too, but I'm going to turn it over back to Amanda and try and respectfully move us along a little so she has time to talk about budget considerations. Could you go back one slide and I'll wrap up my thoughts super quick. So, from a cash perspective, yes. So I was going to say, you know, keep looking. As long as COVID's out there, you know, there may still be money out there to get. And in reality, like, you should go after as much money as possible. So yes, you know, if it's free money, start there. Even if you think you don't need it, you start, you start there. So state has money. CARES Act continue is doing a second wave. Rita mentioned, I think, in the chat that she, there was automatically money deposited. You did have to go in and attest to keep that money. You know, and so there, and there may be another wave of money, you know, go through and look at those things. If you're part of a larger health system where you could maybe tag on to something there, you know, go through and look at those things because a couple things will happen. I think from a cash perspective, one, you know, we have down fee for service and we're all struggling with cash because of COVID. Eventually that money will dry up and there will be kind of a backswing too, right? Like, it always happens. And so, you know, as you guys think about budgeting for the future, we're going to go right into budgeting here. But as you think about budgeting, you're managing your expense, but you also need to keep a really close eye of your revenue. This money is a one-time only option. And so what are you going to do after that? That's a component of cash flow. Okay. This slide, I won't spend too much time on. I think you, oh, could you go to the next one? Because you get it on page, thanks, Michelle, on page 90. I just think it is really a great program to really look at. This is the kind of function around how do you think economically about what organization you're in? Are you in an independent practice? Are you in a health, academic health center? And then what, what is an ideal payer mix? And so a lot of thought has gone into discussing or into this sheet around what's their payer mix? Are they Medicare? You know, how is Medicaid being reimbursed? And are you monitoring your patient mix at all times? I encourage people, as you think about your patient mix, I have worked, or I've done, you know, recently I was on a finance nonprofit meeting for a health center. And I said, we need our payer mix on the dashboard that goes to the board. It needs to be on the page. We need to understand what our thresholds are for all of our payer mixes. So just, I think this is really helpful. Next slide. Budget considerations slide. So really, there's no kind of one size fits all with how you do this. But right now, under fee for service, they're very thin margins, because you know, and and you guys are feeling it, right? I need a lot more productivity. I don't have the right staff. Everything is costing more legal marketing, rent, etc. You know, working with HCCI, or, you know, and, and all of us talking in your chat of kind of hacks, Brianna just emailed me last week and said, you know, what do you use for just getting HR policies? You know what, and I said, I have this great site that, you know, is free for me, but there's probably some nominal costs, and I just go in and download policies. You know, and I think especially when you start up, there's this big thought of, oh, I could do something wrong. Well, yeah, you could, right? But that's why you kind of get all this information, you pull it all together. You know, when we didn't have a lot of money a few years ago, when I started, there was a lot that I would draft myself of legal, just to get it completely drafted in all free forms. So legal did a review instead of drafting the whole thing themselves, right? Or our first website didn't cost that much money and was built, you know, on a pretty basic platform for the first few years, because we didn't have any other resources towards it. So it's finding, it's finding the right mix of what you're going to spend money on. And then what, you know, people are always the most expensive. Are your providers working at the top of their scope? If yes, great. I typically find that not everyone's always playing their position. So as you have enough volume, you start to think about what is a physician and a nurse practitioner or PA, what are they really going to do? And then who else is going to help support some of the other work? Is the other work really RN work, LPN work, MA work? Is it non-clinical work? What's a legal requirement in my state to do that work? And have we looked at it? Have you considered using advanced practice providers? You know, that question is a really, is a really good one. I think most people have really started using APPs appropriately. There was a question early, early on around how do we use APPs if they're independent practitioners? I think the question came up yesterday. First of all, I'm a huge proponent of APPs being independent practitioners. We've written many letters. The state of Minnesota is in that, is in that space. And we still have a collaborative practice. We just define for us how we're going to work together. You know, this just meant that APPs finally could get credit for their work and could sign off on more forms. But how they work together and the exchange of information and how, and the education that both NPs, or excuse me, APPs and MDs bring to the table is one that we just figure out internally. And we just use it all as an opportunity to recognize the great work and the licensure that they should be having. So, and have you considered utilizing physicians in any sort of different ways, right? Like, are there other, are there other revenue streams here? Medical directors for assisted living, SNFs that you might be already working or doing a lot of work with, you know, medical director for a local plan, additional consulting, can you bring in a different contracting with providers before you hire them first? So this is kind of a component of like, how do you figure out your people component as you, as you bring them all together, they're always going to be your most expensive piece. Sorry, slide. So some variables that impact the bottom line, and you know, this, we talked, we talked about this, right? What are the positive and negative volume components? So eight to 10 visits per day, if you're really seeing, you know, the four to six depends on your patient population, how you're being paid under fee for service, it can be difficult. Can you start to geographically group them together? You know, are there senior communities or ALS? If I'm going, you know, and I'll tell you, our home visit program has had a lot of struggle, and we would never have been able to make it work on a fee for service basis. Because of the great geographical difference, or distances that people are going a lot, a lot more driving means there's not billing happening. Telemedicine is helping with the correcting and payment is telemedicine is helping with that. You know, how do you think about lean staff model? But also, how do you think about your incremental costs as they go up? So when do I hire someone? And at what point do they continue to hire, right? So I have a new MD, when did they get a support person? When do they get more information? Or when do they get to support people? When do they get a back office person? And what level do we need? Do we need five MDs before we hire a back office person? Brianna will argue this till kingdom come, and I will completely agree strong documentation, coding, billing operations, right? We need to understand the most up to date information on coding and billing. And we need to make sure that we use that and we keep line of sight of that. It is the goal of Medicare. And as you all take fraud, waste and abuse every year, as you bill for what you do, you get paid for what you do. We talked about value based payments till, you know, it's always blue in the face a little bit, but we keep talking about those, you know, urgent care clinical services, you know, how do you think about 24 seven access without breaking your own, your own spirit in all of this strong EHR documentation, private pay for uncovered services, and Moses was completely right. Optum is, is helping to pay the uncovered service for COVID. Are that that infrastructure, if you haven't heard much about it, or you are not having the bill of that are that infrastructure for us is happening with the lab that we're using. So when they find a bill that's not being collected, they're billing Optum. So it just depends if you're like, Oh, I don't know about that, but I haven't received a bill yet, it may be happening automatically through your lab. And then other revenue streams, are there things that I'm already doing that I can get, you know, more money for? What does that look like? For us, we've increased our medical directorships quite a bit to try to get some additional revenue. We recently started managing a local TCU practice, and we are the management group. And so we're trying that out with our geriatric expertise. So slide. Okay, budget busters, right? Staffing, we've talked about the expense of people. But, you know, as you think about we don't want to, you know, how do we manage that top of licensure work? Don't underestimate the value of RNs, LPNs, and MAs. Under our ISNEP model, so our Institutional Special Needs Plan, we use RNs to the top of their license. They go out, they collect vitals, they do really all of our acute visits, if you will, they can't bill for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, they can't pay for them, but it's under a value contract. So, as you think about who's going to be doing the work and how are we going to get paid for it? Can an RN be standing there these days and be doing it with a, you know, a cow or a computer screen for the telemedicine? Yeah, they can. And they can get, you know, accurate vitals for you. Physical office space. Many of us work outside of our homes, you know, as we start up our practice, and that's okay. So, what kind of space do you need? How can you rent it? But luckily, the world today continues to evolve in a space where there's more options. And EHR, it's worth the expense, it's very expensive. When I negotiate an EHR contract, almost all, just generally across the board, almost all the contracts I negotiate, whatever it might be, EHR, other technology, I do a one-year deal. Even if the five-year deal is going to give me 20% off, I do a one-year deal, I test them out, we try it, and then I'll do one year at a time, because you never know when things are going to change or leadership changes over. So, just something I always do. This is my last slide before I turn it over to the expert here. But, you know, productivity matters. You know, as you think about it, you're reviewing it. We have a great slide coming up that talks about how do you think about productivity and the ratios that you have and the staffing and watching it. You know, cluster the patients to the same area, the neighborhood, whenever you can. Use other staff to relieve that triage burden. Monitor work RVUs. For us, we really monitor a couple really close things, like, you know, and it really came to play a lot during COVID, too. How often after you see a patient are you opening the visit? How long is it open? How often is the chart closed? And then what was the work that was done? What was the coding level? And did it match the work that we were actually doing? And do you understand how to use prolonged visits? And we talked about geographic scheduling to reduce that window shield time. The easiest part that I see for providers is they say, I want to help everybody, so I'm willing to travel anywhere. Get your core function of what you're doing and your productivity in a tight geographical area first and then move out. You'll learn and you can try and you can try to you'll fail, if you will, in a small area before you really expand and then you'll learn some really big problems when you're going that far out. I'll turn it over to Brianna for a few slides, too. Thanks, Amanda. So if you haven't already told, we're kind of sticklers for productivity and geographic scheduling and operations, and that's kind of what we're trying to help you with here. But one of the burning questions that I probably get at least once a week is, well, what are people doing? You know, what are the national averages? So this is just based on our experience. A big pool of the providers that we know, I would say, on average, high performing productivity, especially if you're in fee-for-service is 8 to 10 visits per day. However, there's a lot of factors. So Amanda mentioned the geography. Also, if you're doing all ALS or assisted living or group homes and you're able to just go to one or two facilities per day, then that's where I see visits more like 10 to even 14 visits per day. So it depends on the type of visit it is. You know, if you're seeing all new patients or all transitional care management visits that are more complex, or annual wellness visits that are very time consuming, there's a lot of factors that you have to consider. I know some practices that as far as visits per day, they count new patients as two. So that's one less visit for their providers. So you need to, you know, we're not trying to compromise clinical care. It needs to be reasonable. It needs to be a partnership. Rural geographies are providers who are traveling completely alone. I sometimes see averages go down a little bit closer to 5 to 7. I'm a stickler for trying to stick to that 5 per day if you're on fee-for-service, just when you're looking at ROI. And then also consider if for your practice model, a goal per week or a goal per month makes more sense to give people flexibility on their schedules and the hours that they work. And going on here to the next slide. Amanda talked about this. So revenue really matters. So in the coding and billing talk, we're really going to talk about your bread and butter and your E&M data. But are you part of a health system? You know, can you help with their ACO patients or the patients that are at risk for what kind of grant funding? I know Anna mentioned she's been really successful in getting grant funding, I think especially because of the COVID era. There's a lot of people that want community-based models and you are a solution for them. Does your city have a division on aging? I'm thankful that we have representation, excuse me, from a local area on aging here with us today. They're great resources. Don't forget about them. I know one practice in Michigan that was struggling because they didn't have social workers. So they actually partnered with their local ANA and did a pilot where they used their social workers as part of their program and contracted their employees for chronic care management and have had some really creative solutions. So there's things that you can do. And I'm sure Amanda, she would agree here, you have to review those payer contracts. Are they being paid? Are all of your providers contracted with all of your payers? Are they up to date every year? You know, don't let things fall through during negotiation. Next slide, please. So how can you maximize reimbursement? I wanted to sprinkle a little bit of what I call advanced coding opportunities in. I can tell you right off the bat, if you're in fee-for-service, you should be doing some sort of care management, billing for some sort of time, whether that's chronic care management, care plan oversight, general behavioral health integration management. There's a resource in your appendix called the advanced coding opportunities. Looks like this. It goes over all the requirements for these services in more detail. But just to give you some examples, advanced care planning, a minimum of 16 minutes face-to-face with the patient and caregiver on goals of care. You may or may not complete an advanced directive form. You can bill for that in addition to your E&M visit, as long as there was a minimum of 16 minutes just on that advanced care plan. It can also be billed for audio only right now during COVID. So if your providers are having that advanced care planning conversation over the phone for a minimum of 16 minutes, it pays about $89. I talked about chronic care management. Annual wellness visits, those are going to be important, especially in value-based contracts or with MA payers for their quality scores. And transitional care management, if you're not actually billing for it, we've seen now two years in a row where Medicare has increased the payment, increased the reimbursement under WorkRVU for TCM. And last year, they unbundled it with a total of 16 care management services. So for example, you used to not be able to bill TCM and CCM together during the same calendar month. You can now for traditional Medicare purposes. Some commercial contracts, because CPT still says they're bundled, you might run into issues. But CMS is encouraging the use of transitional care management because they believe it's a model that works. So they continue to increase the reimbursement and make that easier for you to receive payment for. So there's documentation requirements that, you know, again, we'll talk more about in the advanced course as well if you're attending that. And then Amanda talked about the contracts and the opportunity for MIPS. For the MIPS program, there is a point where you don't have a choice. Generally, I believe it's if you bill over $90,000 of Part B revenue and have greater than 200 patients and a few other requirements, you're required to report data to CMS and participate. Otherwise, you'll actually get a penalty. It's a small penalty. Some practices evaluate the ROI on that, but a program that you'll want to be aware of as you grow. And moving on here. Oh, go ahead, Amanda. Oh, I was just going to take us into budgets. I got us behind, see, on the other talk, so I'll try to catch us up in budgets. Slide. Okay, so just a couple of thoughts. This is a, this is kind of how you kind of can think about revenue and expense. There's not one size fits all. I think at the, at the, at the core of this as you build out your income statement and your balance sheet is what is the level of detail that I need for clarity and I want to see information over time. I can tell you, for example, we have three in meals and entertainment categories as expense categories. I have no idea why we have those. Those don't make any sense. You don't need three for an organization. You need one. You know, and so it's stuff like that where you're like, okay, do I really care about every paper supply, you know, you know, all my eight and a half by 11s or do I care about every envelope. And you may say one or another. What's really great is, you know, Michelle put in there, go to the slide or go in your workbook to the different ways that you can start to think about what you want to track over time. Those things can change, but the best way to set them up now in your P&L is to say these are the categories of information that I'm interested in. I want to see time and time again, month to month, year to year. Slide. Here are examples of expense, again, expense categories. Beverage services, you know, office supplies, business meals, those types of things. You may be able to roll some of these in. These are all just different ideas. For us, you know, sometimes you see, and this was another pitfall, a small pitfall, but as you're building your P&L is we had like telephone expense. Well, we couldn't really figure out if telephone expense meant what we paid other people to have their telephone or what it costs us to run our telephone system. So creating just some clarity, what we do too is we use bigger subcategories. Here are our HR people, here are our supplies, administrative, here's our physical resources to kind of go through and say, here's what's meaningful. You know, especially if you're getting started, some of you may be parts of large groups that have lots of different systems and structures to manage that. When you get started, you can buy something as easy as QuickBooks and just start writing it down. Or if you're really, really, really new and you don't want to spend any money on it, you can buy, you can just do it in Excel and just do your credit and debits there. And that makes a lot of sense for a period of time. And especially if you are doing it as your own sole proprietorship, it's going to go on your own taxes anyway. So, you know, just make sure you have some details and you save all your receipts. Breanna and I are going to kind of split this one. This is a great example of productivity. Yeah, this is just an example of really how simple you can start, right? This is an Excel spreadsheet. You can still typically run visit per day reports out of your EHR, so it's not like you're manually tracking this. And this is blown up in your handouts as well. Michelle put the page number in there. But I would just really encourage you, there's outcome metrics and there's quality metrics. And then there's practice performance metrics that you have to be able to track and measure to make decisions and to evaluate your performance. So, I mean, as simple as starting with how many visits per day and months by your providers, you know, accounting for, you know, different days that they're on holidays. The days in blue, this practice uses a scribe, so they expect 10% more productivity on the day their providers have a scribe. And they've also been tracking phone call visits. So just an example, you know, there's lots of different formats and lots of different ways you can do this, but I would say tracking your productivity is really important. Great. And for us, we actually track number of visits and then total billed charges. So it does, you know, and, you know, that way we can see maybe visits are down, but billed charges are up. So it's still a level of productivity for us. Slide. Absolutely. So here's a P&L. And again, more information, Michelle's put it here on 94. I, you know, I encourage you to kind of go through this, do match them up as you end a year, year to year. You can see here, they broke it down on the revenue side and then just expense, direct and indirect expenses. But under direct, which is going to be most of your expenses, they have those again, sub categories of how are we breaking those things? How are we breaking those things out? Benefits, insurance. So a lot, lots to be put in there. I certainly have dealt with my fair share of P&L. So if you have any questions, you know, shoot me a message. Final slide for me. I think. So, you know, what's my cost versus my actual revenue? Understanding, again, that expense and revenue component, understanding and considering your geography, what types of visits you're going to do, and we're going to talk a lot about coding and billing. What are the standards of care that you want to do? And then how do you, how do you break down your, your, your payer structure? Again, most of it may be fee for service today, but, you know, keep your eye on the bigger picture for value based or shared savings if you're not there yet. Slide. And this is just an example. This is using 2017 claims data of benchmark, you know, how percentage of what level of service people billing for house calls and domiciliary visits are using. If you're not familiar with comparative billing reports, there's data that's publicly available from CMS. You can also look at audit reports. There's one that's called the CERT report, which stands for the comprehensive error rate testing. So if you see that improper payments with a focus on a service that you're billing for, that should be a flag. You can also compare percentages of what you're billing to colleagues. And I would encourage you to do this within your own provider team, too. You know, is there any outlier trends that someone may be really under billing compared to their colleagues and maybe need some documentation and coding education and help. And without comparative billing reports, you're not going to be able to have that data to use it and to improve your accuracy. Next slide. I have a question. Go ahead. I'm looking at the on page 90. It's a model. I'm sorry. I know you guys have gone ahead, but I was just noting that on this form, you have documented that house calls every home visits every four to six weeks. Is that a standard? Or the reason why I'm asking, because I typically, you know, do a visit for a stable patient maybe every two to three months, but am I like missing out on something? Should I be doing a visit every four to six weeks? Yeah, I'm sorry. What? No. So that's when medical necessity comes into play. Maybe if you could put in the chat what documents that is, I'll take a look at that and make sure that wasn't an error. But I'll talk a little bit more about this encoding, but it should be based on the patient's clinical complexity and you should individualize visit frequency based on the patient, especially in fee-for-service. It has to be medically necessary. It's a stable patient every two to three months. You know, if there's something, you changed the medication and they just got out of the hospital and they're more acutely ill than maybe a four to six weeks. I leave that up to the provider's clinical judgment, but you're going to get yourself in trouble. If you see all your patients on that rotating schedule for me as an auditor, especially that's a red flag. So I apologize if there was confusion on that. No, and it actually it's a slide around what Penn Medicine is doing specifically in their program. Yeah, but we've had to kind of pull that apart because a lot of people are like, I'll just see you once a month. I'll just see every other month. And we've had to say, can't do that. That is what we would call, you know, fraud under Medicare. So fraud, waste and abuse. Yep. Yeah. And this is just kind of wrapping up everything we've talked about. You know, really, I encourage you to take a look back at these materials, you know, think about these big buckets. You know, what does your structure look like? What do you need now? And what can you start planning for as you grow? And what's the best way for staffing that enables people to work at the top of your scope and not putting all of that administrative burden as you and the provider? And we're going to move on now to talking a little bit about marketing. So if we go on to the next slide here, you know, where do you start? How do you even locate patients? So you need to start by identifying what population do you want to care for? You know, not necessarily a payer contract, but you certainly can say, you know, generally, they need to have some difficulty leaving the home, multiple chronic conditions, or maybe you have a telehealth model where you see everyone. But decide what that looks like. And then we've talked a lot about community services. That's how you can start building referrals, especially your home health agencies and hospices and the assisted living facilities. They can be sometimes hard to get into at first, but they have to give patient choice. So even if they tell you, you know, they already have a provider, you know, would you consider keeping my information to allow patient choice? And then maybe once you get one or two patients in there and word of mouth spreads and they realize the value of your service, that can grow. I know another phenomenal physician assistant on our advisory board who says she constantly hunts down new construction. She's driving and is making introductions. And I think she's fabulous. And she's gotten a lot of referrals that way. So pay attention to new communities that are in your area. Even not else. Think about just senior living buildings or, you know, communities and things like that. There's a program in Vegas that's piloting doing annual wellness visits through a mobile clinic for like the Dell webs of their area, if you will, or just those senior living communities. So think outside of the box. Take on speaking opportunities, grand rounds at hospitals, things like that. You know, can you attend even a local chapter meeting from Parkinson's or, you know, Dementia Association about your program. So think about things like that too. And moving on. And again, we talked about a lot of these. The other suggestion that I've heard from a lot of providers is being on board. So being on your local board with the APS or other organizations that can cue exposure. Not only can you help really vulnerable patients, but they also become aware of what you have. And the Coalition for Advancing Advanced Illness Care at VTAC talks a lot about working with faith partners too. You know, people that can confide in their community faith leaders. Can you make sure they know at least where to go to get access when they need in-home care. So that's another kind of out of the box solution you might think about. Moving on. Just a couple website examples. I really like Grace at Home's website. You can see it here. But think about how you're talking about your services and how you're portraying yourself externally. You know, I've seen a couple of websites recently, which look really great, but I was having a hard time. Like, do they make house calls? You know, it should be very front and center. You want all types of stakeholders and potential referral services to understand what you do. You know, this particular practice calls attention to mobility assessments and Alzheimer's and dementia and Parkinson's and certain diseases that they really can help care for too. Because sometimes patients don't identify. They think it's, you know, that my biggest pet peeve is they think home care is skilled home health services where they have to be completely homebound and have a skilled need. That's not true. So make sure they understand. And there's just another example on the next slide here. Of another program outside of Chicago. And I think they do a really great job of just really listing out all the different kinds of services, you know, transitions of care, annual wellness visits, wound care. So think about how you're portraying that on your website as well. Next slide. Next slide. So how do you approach partnership conversations? And I think we've kind of given you some tools to frame that up. But do a business plan if you haven't and you're a new practice. What's your mission and vision? What are the goals for your program? What are the outcomes you're going to do? Think about that enrollment process, especially the intake process. That's another. When I do workflow evaluations, I see a lot of breakdowns on. So think about that intake process. What kind of information do you need to get off the bat? Especially verifying insurance before every visit. Every patient thinks they have Medicare. Medicare Advantage is Medicare Part C. They won't know if they're on an M.A. plan typically. So make sure you have someone doing that. And then, you know, think about what your partner needs. Where are your shared interests? Like Amanda talked about, you know, the small wins of initiatives they're already doing that you can help them make that difference. And for the better of the patients and their membership if it's an M.A. plan, for example. Next slide. So the other thing is once you get these relationships, you really need to stay connected with them. And maybe not every single one, but especially your main, you know, assisted living or communities or home health agencies. Do you have quarterly meetings with them? Do you get their feedback? Do you even do surveys on, you know, partner surveys on how you're doing and how it's going? That's really going to go a long way in building relationships and growing your practice and your reputation. So make sure you're exploring those kinds of things. We talked about the website and the other marketing tools. A few of us have mentioned welcome packets. Patients love paces. So if you can put, you know, panel cards or little brochures with all of your care team and who they are, that kind of gives them that opportunity to introduce them to everyone. Discharge planners, too, at your local hospitals and care coordination, the hospitalists themselves, the discharge planners, they know who the frequent flyers are. You know, Megan has a great practice model example of that on how she's able to kind of be that ER liaison and follow patients into the home. There are companies out there, if you really want to get advanced, like Eclivity, that have predictive analytics. You know, they'll tell you which areas and which patient populations are at risk and can identify that for a fee. So there's a lot out there, but you really want to think about what's the service you're providing for what population, who's going to be your allies, what facilities and community partners are in your community. Who's going to be your allies, what facilities and community partners are in your neighborhood, if you will, and then relationship building and go from there. And for us, like this, think about your website and other marketing tools, we've kind of gotten new into social media. And I would tell you, it's, I mean, it's obviously not for the 85 plus population we're serving, but it is for our, it's for us to sign a legitimacy, I think, right? Like we're putting out content, we're putting out relevant content that our peers want to see. And then the people we network with want to see and want to click on. And then, you know, maybe loved ones would also be interested. But for us, it's really more of a B2B strategy to say, well, look, we're still leading the pack here. Yeah, Adelronke said social media has worked really well for her too. So I think, you know, especially in today's now and age, the caregivers that they're watching, they listen. My great grandmother calls me every time she sees something new on the news. So I'm sure they know about it. And moving on here. So we talked about a lot of this, but you also have to be ready to grow. And I would say this kind of twofold, because typically new practices ramp up as slow. It's, you know, you're, you have a lot to get over, unless you get a big pool of patients from one place. So I always say marketing from day one, start networking. But you do need to know your limit. You know, what are your panel sizes going to be? What are your goal panel sizes for your provider and your active daily census? Are you tracking referrals so you know who they come from? You know, have a referral master Excel sheet, something as simple as that, if you, you know, need to understand that, or can you track that systemically, ideally? What about patient turnover? These patients are frail and they're sick. You know, they generally have a high mortality rate. So if you're not getting a steady stream of incoming referrals, then you're not going to be able to continue to grow and sustain your practice. You know, we've stressed community services, can't stress that enough. And then you also need to have data to be able to evaluate your own performance, as well as all of these opportunities that we talked about. So really just start small. You know, you don't have to track everything at once, but identify what core practice and kind of quality and outcome metrics you're going to need to evaluate your success. Next slide. And so just to wrap us up, you know, there's a lot of factors in healthcare now. I will say, unfortunately, you know, we're in very challenging times, but I do think it's lead to attention of home-based primary care and the importance of it. And I think we'll continue to see community models grow. And regardless of the business model, you know, you have to be able to demonstrate that value, but there is no one-size-fits-all solution. You have to do what's right for you and your practice. And you can look at that graph that we provided. You can see lots of different staffing models and examples. So take a look at that, but figure out what's correct for you. You've got to stay ahead of accounts receivable, you know, denial management, that revenue coming in, clean claims, productivity, and make sure you're preparing for value-based care now, because I really believe that's where healthcare is going, and you don't want to be left behind. And then, of course, market your practice to be successful. And Melissa or Michelle, are we going to be taking a lunch break? And also, please encourage you to take time for your learning plan. Jot down things we haven't talked about. I know I had to kind of give you a lot of information on scheduling very quickly, but I love operations. I love workflow evaluations. So if I didn't answer your questions or you want to chat more about it, maybe Danielle can put the help email in the chat box, reach out, and I'd be happy to talk more about anything that we didn't have time to cover. Yeah, at HCCI, if you need a phone, a friend, Brianna is your person. So we'll put that help email in the chat. Anyway, we're breaking now for a 30-minute lunch. Thanks for hanging in there. We will reconvene at 1255. If you stay in the Zoom, please mute your Zoom and stop video. Okay, thanks. Sorry, I have a question, Ms. Melissa, before we break. You mentioned that you were going to send us the HCCI learning plan. You were going to email those or somebody was going to email them. Is that still the case, or do we have to go into the booklet and retrieve that? I'm going to work with Danielle as soon as we break here, too. I can create that for you real quick, and if Danielle can email it to you, that'd be great. I just wanted to let you know that those were just examples that were given of different practices, and there's maybe six on that page, and those are just that one practice in that column. That's how many visits they were making. If you look at the one right next to it, they say every one to eight weeks. So it's just examples that were going on there. Okay, I figured as much. I just wanted to be sure. Thank you. Yes, and personally, we will be seeing people anywhere from every two weeks to every three months, really depending on their need. Okay, understand. Thank you. Sure thing. Welcome back. We are going to get started here very soon with Brianna and coding and billing. We are making a few little scheduled tweaks for the rest of the afternoon and just know that Brianna is going to get through most of her coding and billing content or all of her content but we'll then hold some questions until the last session of the day if we run out of time. Okay so I'm going to go ahead and turn it over to Brianna. Are you ready? I am ready. Thank you everyone. All right so coding and billing. We've talked a lot about it and and here it is. And so what I like to spend time especially in our essential elements course talking about is really the core documentation requirements for your E&M services. Quality documentation that's compliant and making sure you're appropriately being reimbursed for the levels of service is really important. So we spend a lot of time focusing on if you will the basics but really quality documentation which can never be overstressed and you're not really taught as a provider in medical school from how auditors look at documentation. And then in advance we'll go into more detail on some of those other opportunities. So if we move to the next slide. Just a disclaimer to everything that I teach is federal guidance for Medicare purposes out of the Medicare Part B. Again your local area has what's called a MAP or a Medicare Administrative Contractor. So you always want to make sure you're up to date on their policies or if you do have certain value-based contracts sometimes there's flexibility. But what I'm going to talk about is our Medicare standard documentation guidelines from a federal level. We're going to identify some risks and red flags that you want to avoid. Talk about what those CPT codes are and when you need a modifier and then also describe documentation and how you support really the work you're doing and how sick your patients are. So the three golden rules and I actually like to change this first one because I don't believe it doesn't count but if it wasn't documented you can't validate it. From a payer standpoint they're looking to say did you really do the work that we're paying you for and if you're billing at a high level of service was the patient really that sick or that complex or what did you have to do as far as your intervention that supports medical necessity. We'll also caution you that more words does not equal better documentation. You want it to be clear and concise especially when we think about collaborating with our partners and then being able to clearly identify the status. I'm a fan especially of the HPI is bulleted documentation you know tell me the chronic conditions and the status tell me the patient's acute concerns any other screenings or important information that you need to care for patients and then move on to the more comprehensive exams and other parts. And when we say cloning what cloning is is when two entries or two notes are exactly alike or even very similar and this is constantly a red flag. EMRs have made this possible you know sometimes it's okay to carry forward information. If you are going to carry forward information you have to identify it as past information that you want there to care for the patient and not what you're going to be using for that date of service to contribute to billing. I will say the other really why I would encourage you to create fresh documentation and not carry over especially you know the HPI or review of systems or exam and parts of your assessment and plan is because errors happen. I can tell you in even the last couple of audits that I was doing a lot of what I was finding was contradicting each other. They would tell me in one place the patient has no pressure sores but then the other place is saying that the patient has a stage two and that happens by accident. It's not malicious but when you're cloning documentation and you're carrying over and that's what happens. So that's really why from a integrity standpoint and documentation quality you want to avoid that. So what do you need as a whole when you think about your EM notes? There has to be a chief complaint and I'm going to talk about that more. It needs to be a specific medical focus for the visit. Your history of present illness that I was talking about that's your HPI. Your review of systems is part of your history as is the past medical family and social history. For new patients you need all three history areas. Established patients you could have just two. Obviously your physical exam and then your medical decision-making and we'll talk more about that because that's usually not fully understood. That's not just the complexity. There's other components that we look for and then overall are you documenting all of the work that you did and are you supporting why the patient needed to be seen and needed to have the care? Are they as thick on paper if you will or in the EHR as they truly are in real life? That'll support your medical necessity which is always the overarching factor for payment. So a lot of people still aren't aware of this but we actually had a change in 2019 as a result of the Medicare Physician Fee Schedule final rule. Prior to the start of 2019 providers were actually required to justify a medical necessity reason. A reason the patient was not able to be seen in the office. So you had to actually include a statement in your documentation that said you know due to patients cognitive impairments and limited mobility unable to get to a provider's office and required a home visit or something along those lines. You actually don't need that statement. They're leaving the justification to see a patient at home up to the provider and the patient on where you feel the patient is best cared for. The encounter itself still has to be medically necessary and you as a practice may say you know I'm still only caring for this high-risk population but from a Medicare standpoint again this is not skilled home health services where they have to be deemed medically homebound. You have more flexibility than that when you make a house call. Next slide. So this is my checklist if you will for how how if I'm looking at your documentation you're going to support medical necessity every single time. Why did you really need to see the patient that day? Yes they have chronic conditions but what else was going on? You know what is the patient and caregiver been struggling with or did they have a recent fall or decline that you're focusing on a medication change that may have happened and words really matter. I think sometimes people like to get in the habit of telling stable continue when it's one of their ten problems that aren't really being addressed that day but just be cautious. You know it's the arthritis really mild but controlled by Tylenol. Be as descriptive as possible and that and really again just painting that picture of what that patient status is and don't forget to document what you did. You do a lot during these visits. Are you educating the patient and caregiver? Are you talking to them about resources or about their diabetes or about those goals of care? A lot of what I see is missed opportunity that may not always make it in your progress note but it's really important to do that and it doesn't have to be an extensive narrative but you do need to support everything that you're doing to care for that patient on that date of service and it needs to be relevant to that date of service. If it's not, take it out. Excuse me one second. Can you repeat that what you said about continuing? I didn't catch that. When you said that be careful about writing stable on this. Repeat that? Yeah so as far as stable continue, I mean there are going to be times where you're continuing the current traits the treatment and the patient is stable but if I'm looking at an assessment and plan in the note and every single problem just says stable continue and you're billing a high level of service, it's hard for me to justify that from a medical necessity standpoint even if they're stable. Did you say you know hypertension, well-controlled, we discussed listen a pro continuing same medication dose. I mean I'm not saying be accurate you know don't lie or fudge documentation just to make the patient thicker but can you be descriptive rather than just telling me stable continue. And Moses I want to give you credit and a shout out in the chat yesterday I meant to give you kudos for because you mentioned that you make sure your provider is complete and signed your documentation within 72 hours. Big fan of you for doing that. Here's why it's important. Every single audit I've done I talk about timely signatures but you really want to make sure that as much as possible encounters are signed as close as possible when you saw the patient. Check your specific map because NGS in Illinois for example they actually probably say that they want the documentation completed and signed almost on the same day or within 48 hours otherwise you risk denial of payment. So let's say a payer did an audit they pulled a bunch of notes and you know there was 21 day lag times they could actually choose to deny that service for lack of medical necessity. So you can run open encounter reports and try and help your patients or I'm sorry your providers stay on track with that. So timely signatures and again that's a Medicare and Medicaid program requirements. CMS so the guidance is vague a lot of attorneys will tell you they can you know defend your your late signatures by attestation statements but here's why it's important and as a best practice get those notes closed and signed in 72 hours. Moving on. So what can you do to stay under the spotlight and we can go ahead and move on here. We talked a lot about medical necessity already again really understanding if you are going to see the Dietrich to your point earlier patients every four to six weeks we know that high touch care volume results in better care but you need to justify it. If you truly are seeing certain patients more frequently then make sure your note is telling me what disease is compromised or what kind of education or follow-up or all of that work that you're doing. There are times where it's completely appropriate to bill like for example a joint injection and an E&M code on the same day but when you're using that modifier 25 again you really have to validate that the work was separate and distinct. If you just added a patient on because you were in the area and all you did was the joint injection then you would only bill for the joint injection but typically health providers are not going to make a visit without actually seeing the patient and doing a more comprehensive exam but you need to make sure that documentation identifies itself as separate and distinct. And I talked about cloning again that comes into the integrity it's okay you can go ahead and move on of the encounter just really make sure what's in your note is what really happened on that day with that patient and paints an accurate picture of their health. So EMR is friend or foe right they've made this easy for us. You know Amanda talked about that earlier too and and I don't want you to not use your EMR for templates or for what's called macros or smart phrases for example for advanced care planning. Build your providers a template on the billing requirements and then they can just enter that information pull that template and fill in the clinical details just make sure it's personalized. Where I see this becoming a problem is when I look at a note and everything is so generalized it really doesn't tell me anything specific to the patient and that's not what you want that's not meaningful care and that's not you know doing the patient a favor of having an accurate health record. So place of service and this is something you may not pay too much attention to it's kind of a back-end claim process but it is important to understand are you seeing the patient and what's truly considered a private residence that's their home or are they assisted living or a group home. There's different places service for all three and you would also bill a different CPT code. Assisted living and group homes would both be billed with domiciliary codes what are called which we'll talk about. If it's truly a home where they're not receiving any personal care services now they're paying for private duty caregiving on their own that doesn't count but if they're if they're not receiving that you know personal care scheduled services in a organized manner you know a building that has a lot of seniors or a senior living community that doesn't have that assistance it's still a home. So here's the modifier they talked a little bit about 25 that's when you're billing to E&M services on the same day and you're trying if there's a bundle you're trying to tell the payer you need to get paid for both. 59 is used for procedures so when it's not in E&M there's a distinct procedural service. Again be careful with those make sure you have you know if you have access to certified coders and things like that. What I wanted to talk about here though is GW and GB. So you as home care providers often have patients that go on hospice. You can continue to see them while they're on hospice. You may choose not to different practices you know there's not one rhyme or reason but you need to be the patient's attending physician or attending provider can be a nurse practitioner or physician assistant as well in order to be able to continue to see them. If you are the attending provider and you're seeing them for a condition that's not related to whatever their terminal hospice diagnosis is you use GW. GV is when that attending provider that's not part of the hospice sees them related. Now the exception is if the patient doesn't have a primary community provider and they elect let's say you work for the hospice as a nurse practitioner and they elect you as the attending provider. GV can be used when you're seeing when in that situation as well. And Nicole I see your comment. Again the way that I would kind of summarize that is typically you're seeing your hospice patients and you're managing their other aspects of their care. So if you as an outpatient provider not affiliated with the hospice you should probably be using GW. If you are employed with the hospice or a palliative care provider that also works with the hospice but you had there's exceptions. I know it says not employed but that there's exceptions where you're deemed the attending provider and you're using GV. So how why am I talking about intake? Because they can help you identify you know why you're seeing the patient that particular visit. So rather than that chronic follow-up you know what do they need to be seen for and also what you know on intake when you're first seeing that patient is it really an assisted living community or I've even seen it where a patient technically resides in a facility but it's in a separate wing that actually is considered a private residence. So that can be really confusing and that's where you want to get that on intake. So here's some examples of chief complaints. What I don't want obviously the red and what I do want. Something more specific. Yes you're going to be doing follow-up on chronic medical problems but can you name a few or again what is the patient's most significant concern that you're really going to be focusing on that day? You know for example a patient presents with edema due to a recent CHF observation after a hospitalization. That's really your primary focus not that you're not going to address the other conditions but there is a reason that you're seeing the patient or focusing that day. Next slide. So here's what I meant by bulleted documentation. So the HPI is one of three things when I score history from an auditor's perspective. So to get an extended HPI I need you have to go one of two routes. One which is more relevant to this population give me this the clearly identified the status of at least three of their chronic conditions. And in the history section this is what the patient and caregiver is telling you about their conditions. How have they been managing since the last time you walked in the door till now? You know what are some recent blood sugar or BP readings? Again you're giving us really meaningful documentation that's not very long but you're still capturing HPI. If there is an acute problem that's where we think about you know things like location, quality, timing, duration. So for example where is the pain? It's low back pain. What's the quality or the characteristic of it? It radiates. What's the severity of the pain? It's a seven out of ten. When did it start? It began two days ago. Have they tried anything to make it better or worse? That's what we call modifying factors. Tried Tylenol with no release. You need at least kind of four of those individual characteristics for an acute problem to get credit again in the auditing world for what we consider an extended HPI. Review of systems is the second part of history. I mentioned there's three parts. So HPI being the first. Review of systems being the second. A complete review of systems is all ten systems. You always again you want that documentation to be meaningful. So you could record abnormal or positive findings or any pertinent negatives and then say all of their systems are reviewed and negative. That would still give you complete ROS credit. But if you do have abnormal findings make sure you elaborate them and it's not just a non-specific you know usually I'll say joint pain. Oh what kind of joint pain? Where is the pain? You know try and be specific and again we don't want our documentation to be too generalized. So past family and social history that's that third part of history that I was talking about. Again really important for new patients. Get all three. Don't forget about the family history for new patients. That's usually where I see and why that's important is because that'll bring your whole level of service down if you're missing that for new patients especially. So past history obviously is their last you know past illnesses operations. You can get credit for allergies and medications here as well too. With family history make sure you're identifying the immediate family members. Their specific disease history. That family members health status and if they're deceased what age they expired. And I know that's hard to do sometimes so it's as much information as you're able to capture but that's where having this on your new patient enrollment and intake form and using staff to kind of update charts and prep that information in advance can be appropriate. And also don't forget about the social history. You know marital status, economic status, smoking, things like that. So physical exam. Sure go ahead. Yeah no that's a great question. So it does. So for established patients if you're documenting that you reviewed and it's unchanged that's completely appropriate but you need to tell me it's unchanged from where. Unchanged from previous encounter and give me a date or unchanged you know where in the medical record or when was that history first obtained and you verify that there was no changes. And that's where you want to be careful with templates too because I've caught a couple audits where it's a new patient but you're telling me the history was reviewed because that's part of your EMR template. Well it's a new patient so we wouldn't have had that history yet. And then getting back to exam. Generally all providers audited the 95 exam and what that means is a comprehensive exam you have to have a minimum of eight organ system findings. You can have body area findings but I always encourage you to have your templates be the organ system. Generally that body area finding relates back to a system anyways and when we get to the general multi-system exam they only count systems and not body area findings. So medical decision-making. So here's that again this is a three-in-one if you will. There's three pieces of medical decision-making again from an audit perspective on how you're going to be scored if you if your documentation was reviewed and we're going to have some graphs that hopefully make this easier for you to wrap your head around. So let's go ahead and move on and we'll talk about each one of these. So the first part of MDM and generally I'm going right to your assessment and plan. I want to know the number of meaningful diagnoses or conditions that you meaningfully assessed and addressed that day. Were they new or established problems? So that's where you know again being clear words matter telling me if it was a new problem to the patient or if it's established and what's the status of the provider? What's your clinical impression? In the HPI you got the status from the patient and caregiver. Now you've done workup and exam you know is their hypertension well controlled? Is their dementia declining and increasing hallucinations? Think of things like that. That's the first part that you get points for and in your handouts I believe it's actually in the appendix you'll see something that hopefully you can't see it because my screen goes blue but it's called HCCI home visits E&M guide and these are all blown up there for you as a cheat sheet on what requirements for each level of service are needed. So that's part one. Part two of MDM is the amount and complexity of data to be reviewed and this is usually kind of the one that gets overlooked but if you're ordering or reviewing labs making a note of it. If you're reviewing them more than just review labs is you know helpful so reviewed CDC was normal or within normal limits or something like that. Did you have to obtain and review medical records? That adds to complexity. Did you have to talk to a POA or a family member or another specialist or home health care provider? All of those things add complexity you're probably doing it but are you making a note in your documentation? And so moving on to the last part and Kosta I see your comment the changes in 2021 are actually only for office visit codes. I with HCCI with our advocacy partners I serve on the regulatory task force for the American Academy of Home Care Medicine and for CTAC and so that's something that we commented on. There's a lot of work ongoing right now about documentation burden relief and how to make the documentation and coding requirements easier but unfortunately they're only focusing right now on the office visit code set. So all of these documentation guidelines that I'm talking to you right now about home visits are continuing in 2021 unless they make a change. I'll get the final rule in December and we'll know more. So moving on to the last part of medical decision-making I think this is what most providers in my experience think MDM is but this is only the third part of it. It's you know overall the complexity and risk for morbidity and mortality. These bullets are examples. This is a CMS you know you'll find it on any auditing form. This isn't something I created and it's just one of the bullets. So for example moderate complexity. If you prescription drug management newer or continuing a prescription or two or more stable chronic illnesses. So this is a really easy bar to get to for our patients. High complexity though really is almost a patient requiring hospital level care and this is only one of three pieces for MDM. So this doesn't mean you can't build a high level of service and we'll get to how you tie this all together but it's a chronic illness with really a severe exacerbation. So that's when you being as descriptive as possible and telling me that in your documentation is really gonna help. So how do you score MDM again from an audit perspective? And this is what your payers, if you ever have to go through that are gonna be looking for. All of those things we talked about in those points, again, these graphs are in your handouts. I need two out of the three. So it's okay if maybe a amount of complexity and data was low or limited with only a two, but you already got to moderate complexity based on your assessment and plan on how many conditions you assessed and the overall complexity, just being at moderate that already supports a moderate complexity for MDM. And MDM stands for medical decision-making just in case that wasn't clear. So the acronym, this is used a lot in risk adjustment too. You're probably all familiar with SOAP, still a great practice. But when I think of assessments and plans, I like to think of meet, monitor, evaluate, assess and address and treat. Make sure you're prioritizing your assessment and plan. Start with the conditions that really matter the most during that visit. What's the patient's overall level of risk? Are there any contributing factors? Again, if it's a problem you really didn't address that day, it doesn't need to be every problem in their problem list shouldn't be in the assessment and plan unless you did some sort of kind of monitoring or consideration of that diagnosis during your visit. So other points to keep in mind, again, we talked about those status words, but also what's your clinical impression for all of this? There's a lot going on, you've got a lot of data. What are you telling the patient to do? How are you gonna keep them out of the hospital? What kind of decision-making had to go on even just between you and the patient and the caregiver and all of those complexities that you have to do when you're caring for patients? Just make sure your documentation reflects that. And so the other thing that gets missed a lot is treatment options. And this can be important too, especially with referrals. Hopefully your partners are kind of holding you accountable, but if you're sending a referral, why? What was the medical reason that the patient needed that treatment? Or what were their instructions? What medication changes? Or maybe even if you had a conversation about continuing a dose for now and seeing if their anxiety kind of stays stable rather than adding. Things like that need to make it into your documentation and that'll help as well. So tying this all together. So there's two ways that you can decide what code you're gonna fill, what CPT code. Hopefully you're not always filling on time because that's another red flag. You should only be billing on time if the visit was dominated by counseling and coordination of care. You could also, all of these things we just talked about, looking at the overall level of history, exam, medical decision-making, and that your documentation supports medical necessity, that alone can easily support 99349, the level three or 99350 to level four for established patient house calls, which is the highest level code. So you have that option. As long as you understand the requirements and your documentation supports it. But if you do have a visit and especially those extended time visits, and you wanna bill on just time alone, I don't have to score those other elements if you give me an appropriate time statement. But I need to know three things. Total time that you spent with the patient. So I spent 45 minutes directly face-to-face. We're talking about face-to-face time when we're billing on E&M on time. That greater than 50% of it was dominated by counseling and coordination of care. I need that exact phrase. And then the third step is the nature of what kind of counseling, or what kind of coordination of care activities. So here's a pretty relevant example. The visit was dominated because on coping skills to deal with social isolation, emotional stress, and uncertainty. If you really have that clearly identified elsewhere in your note, it doesn't have to be at the end in the time statement, but I would recommend just kind of summarizing because usually documentation is pretty extensive. And if you're billing on time, you want to support that it truly was documented by counseling, or dominated, excuse me, by counseling and coordination of care. So total time, greater than 50% of it was dominated. And on what? What kind of counseling of care, or what kind of coordination efforts? So I'm not going to go over each one of these, but this is kind of that cheat sheet I was talking about. If you can go to the established patient home visit slide, I'm just going to keep going. I'll tell you when to stop. Here we go. So, I'm sorry, one more. So this is, we can use domiciliary. So again, if you're seeing patients in an assisted living or a group home, you're using the domiciliary CPT codes and not E&M, or I'm sorry, not home. So if we just look at the 99336, which is the level three, if you're billing on time, the threshold is 40 minutes, but a detailed history, already would get that by status of three chronic conditions, two to nine review of systems, and just one element of that past family and social history. Exams, for a detailed exam is all that's required for that level. So that's just two to seven areas or systems. And then you only need moderate medical decision-making. But what I want you to pay attention to is it's moderate or high medical decision-making for the 99337 too. So you don't, you know, I'm not telling you to go with the highest level of service every single time, but generally if we think about those comparative trends, you're at the three or four level for the majority of the services. So you do have to think about that when you're coding and make sure that you're, you know, if I see a lot of level twos, usually I'm like, there's something going on here. You're probably down coding sometimes. Not that you're not gonna have some level twos if you went out or added a patient on for a rash or a skin tear or something like that. We can go ahead. So coding is really complex. As you can see here too, I would think that I don't, I think you should at least do annual training. I would encourage you to, you know, really work with your providers, especially new providers, give them documentation and coding training. You know, we have an online course for that. That's great too. But then also do annual internal audits, maybe even peer-to-peer audits. You know, have your clinical leadership look at the documentation from their clinical perspective and then also from a, you know, documentation and compliance perspective. As part of your compliance program, you should at least be doing annual audits, whether they're internal or externally. And then maybe you could consider external audit every two years. But, you know, familiarize yourself with, you know, fraud and abuse laws, coding red flags and areas like that. And so I did save time for questions. I'm gonna ask, if everyone can kind of one at a time unmute themselves, or we could put it in the chat and I could have HCCI moderate to me. And then Melissa, Michelle, if you guys can just kind of keep me on time and let me know when we run out of time. So I'll look in the chat, or if anyone wants to open their mic and turn their video on, please feel free to chime in. So Anuragi, you're saying a lot of your Medicaid patients are being rejected and new visits to established care, they're not paid. I'd have to look into that denial reason more. I'd make sure you're contracted with Medicaid though, and that it's not an HMO plan where you're technically not in network and they're trying to, you know, have a certain provider be seeing those patients. That would be my first guess. But something I can look into a little more is if you're a provider, and then the TCM codes do have higher reimbursement. The 99358, which we talked briefly about yesterday, is that 31 minutes of non-face-to-face time. It's a balancing act, right? So it used to make more sense to bill the highest level home visit E&M code, 99350, established patient home visit, rather than the TCM code. And so that's a balancing act. Rather than the TCM. But they've kind of flipped that on us because now depending on the code, TCM reimbursement is higher. And they're talking about, I'm waiting for the final rule. I don't know yet, but they're talking about increasing that even more. So right now, two years ago, I would have told you maybe consider the E&M, but right now TCM is pretty favorable. With the prolonged services too, I do want to mention that 99358, that non-face-to-face code, that is bundled with TCM, meaning you can't report it within the same calendar month. So you do have to watch. You can't bill all of these services every time all at once. So figure out what aligns best with the type of care you're already providing, and then use those kinds of services. And again, that advanced coding handout that's in your appendix, I did the leg lifting on that for you. And anything that's bundled with certain codes, it tells you what that is there. Brianna, I can help moderate here. Thank you. I'm not sure where we left. Did you go backwards or forwards? I went backwards because it was moving too quick on me. Okay, so let me go back and start. So let's see here. I do have a question while you, I guess while you're, I'm thinking that you're looking to get a question, but for the labs, typically we have labs collected in the homes and we may get the results back in a couple of days and we call them with the results. Are we able to document that and get paid for that? Or what can be done about those services? Yeah, so that's why I like chronic care management. So if you have implemented chronic care management, it's not just capturing time, but it's any medical management, care coordination time by you and your clinical staff throughout the calendar month. That if you have at least 20 minutes per month, then you can build a code, the care management code at the end of the night. Just traditional CCM alone, just that 20 minutes is about $49 a patient a month. So it really adds up. But if you're not, so that's one way, because reviewing and talking to a patient about lab results, you could count those minutes. A member of our practice advisory group will tell you that almost all of her work is billable hours. You just have to figure out how. Not, if you're confusing it with what I was talking about with MBM, if you told me in your notes that you reviewed lab two days ago, that doesn't count. I wanna know what you're doing within that visit itself. But if you're doing a care management service, there are options. Care plan oversight is another one for home health and hospice coordination time where you can count your minutes throughout the whole entire month and bill for it at the end of the month. And we are gonna talk about that. For those of you that are registered and advanced, I talk about CCM pretty extensively, but we also have some free HCCI resources and I'll put the links in the chat for that once we're done with this session. All right, so Mary shared our best practice when we see a new patient who has recently left inpatient facility or observation in the hospital room. Rather than bill as new patient, we are seeing patient within 48 hours to capture TCM CPT. Do you feel that is good practice? I do. You could look side by side at the revenue, like at the end of the visit and see which new patient code and then compare it to the TCM revenue. But again, I talked about how CMS is encouraging. That's the exact language they use in their final rule. They are encouraging the use of TCM services. Value was increased last year and in the proposed rule, they said they're gonna increase it again. I don't know what that amount would be, but I have the TCM page open actually right here. Let me see if that's it. And a follow up while you're looking, I mean like, so will they not be able to bill for a new patient ever for that patient? Good question. So the new patient rule, any service billed for that patient under your tax ID number, so any provider within your practice or you within the last three years. So yeah, so you do miss out. Again, that's why you'd have to look at the reimbursement side by side. It might make more sense depending on how complex the new patient visit was to bill it as the new patient E&M code. But if you've billed for any service for that patient within the past three years, they're not a new patient. We used to actually even be challenged even further because for some reason our hospitalists were under the same tax ID as our practice. So because we were with the health system, our home care providers actually couldn't bill new patient visits when we got a referral from the hospital and we saw them. So you do really have to watch who's under your house, right, who's under that tax ID number in the past three years. Okay. Let me see. I'm trying to, there's a lot of comments too. So I'm just trying to... I have one here from Jennifer. It says, what if a patient requests a monthly visit, just basically a check, even though they're multiple, even though their multiple chronic conditions are stable, is the fact that the patient requests the visit enough to justify medical necessity? Good question. Probably a very common problem many of us run into. That's where if you are in a value-based care arrangement, you'll have flexibility. Under fee-for-service, it probably wouldn't be enough. It depends. So are there other strategies you could offer that patient? Maybe even a virtual check-in or a phone call or other kind of check-ins with them. If you feel like from a medical standpoint, you truly need to see them every month and you can justify that in your documentation, then yes. But typically seeing every patient every month or seeing a patient because they have to be seen every month, that would not support medical necessity. Are there any other questions from the group that you wanna ask live? Otherwise we can, I know we have time for Q&A at the end. So if you guys think of them, feel free to put them in the chat and we can look at that. Rita, let me look at your question really quick. As I say, there was one more from Rita. Yeah, so Rita's asking if she's understanding correctly that TCM can be billed with GEO 180 and GEO 179 because these codes, Medicare will not pay the point of care. So GEO 180 and GEO 179, those are for home health certifications and recertifications. So they used to only be billable by MDs. That actually changed because of the CARES Act and then CMS finalized it as policy in their final rule. It can be billed by nurse practitioners or physician assistants as well. When you first sign the 485, that's when you can bill GEO 180. When you sign that recertification, that's when you can buy GEO 179, that once every 60 days for the recertification code. Yeah, that shouldn't be bundled with TCM. It actually never was. What was bundled was the care plan oversight code. So the ones for 30 minutes of oversight per month, which is I think GEO 181, if I'm remembering correctly. And another one, those are bundled with TCM and they still are. Or I'm sorry, no, they were unbundled. I'd have to double check. But the recertification, every time you sign that 485, you can bill GEO 180. And then the, I'm sorry, the initial certification, that recertification, the GEO 179, what you have to watch on the back end is it can only be billed once every 60 days. And sometimes your signatures don't always match up with that. Okay, and Anna, I'm sorry I missed yours earlier, but Anna has a time blurb in her template for everyone, but now she's wondering if she shouldn't have that and make it clearer when she's billing on time. She says, I originally set up my templates so that we would hit, excuse me, both the time and medical complexity for most patients, but I only use the time blurb when I'm specifically using time-based. Yeah, that's a great question. So yeah, if you're gonna bill on documentation and complexity, I would recommend removing that time statement because if I see a time statement, that, and again, an auditor is gonna think you billed on time and that's what we're gonna look at. So, and then billing every encounter on time every single time is a red flag for audits. So I would recommend removing that time statement and only including it when you truly do bill on time. Now, I mean, in palliative care especially, majority of your visits might be billed on time and you can support that as long as you can truly support when you're billing on time, but it shouldn't be an every visit every time thing because honestly you're probably leaving money on the table if it is because documentation and complexity can get you there too. All right, Brianna, you mentioned code G0181 was care plan oversight. They can only be billed once a month. Is that, did I hear that correctly? Correct, yeah. So there's a couple of different care management services, but the G0181, I'd have to double check the Super Bowl, I'm almost positive, but it's care plan oversight for a patient that's on, there's one for hospice and there's one for home health. It's billed once a month, but you as the provider, this one has to be all your time, has to spend 30 minutes per calendar month. And there's a very specific list of billable activities like they, you know, talking with the home health nurse, doing or changing care plans, reviewing orders and things like that. It actually doesn't count family discussion time or time with the pharmacist, which CCM you have more flexibility can. So that's why I'm personally, I like chronic care management more than I like care plan oversight because there's more flexibility and you have smaller visit thresholds. But some practices do bill for care plan oversight. It's 30 minutes per month of either oversight if the patient has to be on home health or hospice and it has to be all the provider's time. And with the chronic care management oversight, you have to have a documentation that patient agrees to have those services because can't they be billed for their co-payment for their 20% if they only have the Medicare and no secondary? Yeah, that's a great point. Like I said, CCM, you really have to think about the whole picture because there's a lot of requirements. You have to get consent and for new patients, it has to be during a face-to-face and initiating visit could be telehealth too for new patients or patients not seen within 12 months. You also have to use a certified EHR to build chronic care management. They want a designated relationship with a care team member and you actually have to have a formal comprehensive care plan that's delivered to the patient. So there are steps. I will tell you it's worth it for the reimbursement in the long run because if you just think about even at the lowest level threshold of 20 minutes and extra $40 per patient per month, that's really gonna add up. But I'll put some resources in the chat and that advanced coding opportunity talks about everything. So go back and look at that and make sure you kind of know all the requirements before you roll it out because you're absolutely correct. There are a lot of requirements that have to be considered and your documentation needs to support those who are all met. What I see people forget about the most is that care plan. Okay, so we are gonna go ahead and move on. Thank you very much, Brianna. I have before we move to the next session, it's very important I need to let you know, if please avoid logging out of Zoom, if you can at all avoid it. It's causing some problems with the way you're assigned to breakouts and so on. So thank you for your help. All right, let me pull up our slides. I'm gonna be, I'm gonna toggle between two presentations here for COSA. All right. You should, oh, wait, no, not yet there. Okay, all right. Costa, you wanna get us kicked off here? All right, thank you. And there's been a lot of information and thank you all for your attention and your engagement in this entire process. And now we're going to put it all together at this session. So next slide. So the objectives for this session are, we're going to prepare for and conduct three simulated house calls. And we're going to discuss the impact of home-based care on patient outcomes and demonstrate optimal coding for these three house calls. So next slide. So what we're going to do, the three simulated house calls are going to be in Zoom breakout sessions. And we're going to spend about 20 minutes per patient in the Zoom breakout session. And then after those breakouts, we're going to have a small break and then we're going to come back and do a debrief afterwards. And so we're going to see Ralph again. So our three patients, it's gonna be, we're going to leave the office and we're going to go see Ralph. And Ralph, just as an aside, so we're not seeing him the day after, we're seeing him one month after, when we saw him last, when we talked about him yesterday. And so just as a review, he's a 76-year-old African-American man with COPD, pulmonary hypertension, heart failure with reduced ejection fraction. And we've been seeing him for several months, but over time, he has, you've noticed that he's been increasing his trust and the rapport has been getting better between the both of you. And at your last visit, he seemed to open up more about his worries and his sadness about his brother's recent death. So next slide. So your plan for today's visit is going to be follow up on his chronic diseases, follow up on his medication management. It's also going to be, the plan is also going to be about fall risk assessment and emergency planning. We visit the goals of care and discuss his brother's recent death and talk about depression. So that's him. So the next patient we're going to see on our list is Betty. And just as a review, she's our 60-year-old morbidly obese Caucasian woman with multiple comorbidities. A new concern Betty has expressed is some darkened areas on her lower legs. And she's worried it might be something serious and that she'll lose her legs. Next slide. So the plan for Betty is to follow up on chronic diseases and her medication management, to examine her legs where she noticed, she noted the discoloration, to revisit her goals of care, and also to further assess the safety concerns that you identified at the first visit. Next slide. And then we're going to finish off with a new patient, MJ. So he's a new patient. He was discharged yesterday from the hospital for abdominal pain. And we're going to review his case in the workbook. And I believe the page is, oh, let's see here. I can't find it, but someone will put it up on the chat. We'll review his case in your workbook. And you'll see the chief complaint, the HPI, his history, his medication, screenings, physical exam findings, and go over goals of care. So those are the three patients. So I wanted to have people just chime in, you know, either off mic or on the chat, and just talk about kind of like what things you would like to put in your bag and supplies that you would need when you're going to see our three patients. I want to make sure that we have our pulse ops or simple stuff, you know, the blood pressure kits and everything. And any new patient welcome packet or documentation items that you use for the new patient, MJ. Great, thanks. And I see it's on page 105 MJ's cases on 105 Nicole, thank you for for that. That feedback. Yeah, you know, whenever we do a new patient, we have a packet ready to go. And, and that's kind of like our, our, our, you know, it's in a folder. And we go through it with our patients at the at the homes for new for every new visit, including most forms post forms, etc. Anyone else. Oh, I think I saw a comment in the chat wound care supplies for our second patient. Yep, advanced directives paperwork for the for for Ralph Yeah. Great. Make sure you have a scale for that first patient to weigh in, get away a baseline weight on it, so that when you do a return visit you can compare the weight. Excellent. Great idea. All right, I think we may be ready to go ahead and move into our, our breakout breakout. Okay, and we have 20 minutes per patient. Right, Michelle. Yes. Okay, I'll let you, I'll let you. Thank you so much. Okay. Hey, thanks for letting me in. Oh, you're on mute. See, I said, I'm not sure how I did it, but I do. I had to log off for a meeting. Let me see. You are in. I have a magic list that they just gave me. Hold on one second. Deborah, you're in breakout room B. Okay, I'm gonna send you there. Oh, maybe not. Okay. Do you have a button where it says at the bottom, right breakout rooms. It's in between. I do. Yes, I do. I see. Can you hit join breakout room and Deborah you're in breakout room. It says B on here. Breakout room one on mine. Okay. Do you have a way to. Oh, I do. Okay. They just went in a few minutes ago. Okay. Perfect. Sorry. I had to take it. Extended time away. This is our sanctuary. We can find shelter in peace. You are who you are. You're free to be free. Health department director in St. Francis County has stepped down. Why? Because of public threats and harassment. Hello. Hello. Um, everyone is in their breakout rooms. Um, if you go to the bottom right of your screen you should see some dots will say breakout room or more on there. And you can head me look on my list here. Okay, you're in breakout room one. So underneath at the bottom of your controls, where it says mute start video Do you see that little control strip at the bottom of your screen. Yes, I do. Yes. Okay. Do you see a more button or breakout rooms. Click on there as it say more breakout rooms. Participant invite chat and report on computer. Okay, so you don't have a breakout room versus join breakout room do. Okay, let's see. Is there a share screen button or read to me the buttons you have on the bottom left, all the way. Start video. Okay. Participants chat share screen. Record and reactions. Okay, don't have a break. Hold on one second. Oh, sorry I was on mute. So, welcome back everyone. So I think we're going to just have a mini break. Is that, is that right, Melissa. And then we're going to go into the debrief. Oh, I think you're on mute. Yeah, I didn't realize that. So, again, please don't log out of zoom because we have one more quick breakout that will be doing in the, in the next little bit here so till take a 10 minute break and come back at three o'clock if I'm not in my right Michelle. Yep, three o'clock. Okay, great. We'll see you in 10 minutes everybody. Thanks. And please don't log out of zoom. We're going to start with a debrief of the last little bit here that we did our visits, and then we'll be moving on later in the hour to another coding activity. So Costa, do you want to go ahead and start your debrief? So first of all, I just wanted to say thank you all for just being part of this activity and congratulations. We did three virtual visits. And so let's talk about each of these patients. So first patients first, Ralph. So let's just share the different groups. Just have a spokesperson talk about what you all had selected for Ralph as things that you assessed and problems and things that you were going to follow up on. So anyone? Well, we decided that we were going to make sure that the oxygen was on properly, the tubing was working, connected to the oxygen, and that he was getting the oxygen through the nasal cannula and it was actually working. And then checking the pulse ox, making sure that was working. And then overall assessing him. And then we were assessing the nephew and his caretaker needs. And then we did a medication compliance check. That was our third thing. Is that kind of what you want me to say? Is that okay? Yeah. And kind of like what were the next steps in that, you know, what were some things that you wanted to do and possibly tackle for a plan for Ralph? Oh, sorry, not necessarily for Nicole, but for others, for other groups. Does anybody from Dr. Cheng's group want to chime in here? Oh dear, I think we've hit the afternoon slump. So we pretty much did the same thing. We made sure that his oxygen saturation was, or his oxygen equipment was working well. It wasn't, so we fixed that and brought his O2 SATs back up again. Made sure he was compliant with his medications. He has sort of a history of running out of meds. And what else? We talked a little bit about goals of care, because he doesn't necessarily want to go back to the hospital. How about another group? Just like Amanda, I'm not afraid to be quiet. Our group before, we talked about reviewing his medications, obviously, maybe adjusting his diuretics if necessary. We talked about, again, goals of care. He doesn't want to go back to the hospital, but yet on his paperwork, he indicates that he wants everything done. So maybe we need to have those types of conversation about what his options are and what would best suit what he really wants. Is it underlying depression that we need to treat, or do we need to make the next step into hospice? And educating his son as well, not only about fixing something his son could have done, rather than calling for a visit. Okay. Now, just shifting gears a little bit, we're talking about the medical side and the care side of things. Now, I wanted to take a look at the business side of things. So you prepared for a follow-up visit, and then all of a sudden, something urgent, like an urgent slash emergency issue came up, or urgent slash emergent issue came up. And so, how does that affect the rest of your day, affect the rest of your schedule? I'm sure people have run into this scenario multiple times. And how do people deal with an abrupt change in schedule like this occurred? I think somebody mentioned earlier, but when do you need to be okay with canceling a later appointment or rescheduling a later appointment? You're going to take a productivity hit, but this one, if you bill this visit correctly, you should be able to bill this pretty well. You also can look at the necessary urgent things that need to be addressed at this visit, and possibly the things that could be addressed by referring home care social service that would, in his case I believe he had Some issues stemming from what we contemplated whether the depression and the mood with the recent loss was affecting the way that he felt about his care and, you know, rolling over into his physical aspect. So you, you can look at what things you must address that and are necessary to address in this visit, and then the things that you possibly can address in a follow up. In case your mind is thinking that you have to address everything today. Also, you can involve your staff in your office, and with the way you found the new things that the new events are something that happened every week. They say happened to me once or twice or three times, and I encountered things that I didn't expect, and I have to adjust my time and the traveling time and I have to notify other patients that maybe are waiting. And most people are really resilient in that, and they accept that you know what's going on. You know, that's something you have to get involved your staff, don't try to do it yourself. And having all yourself, because you're going to get burned because of that. Excellent points everyone, and, you know, and, and it's one of those things where, you know, yes, you know involve your team, and, and just, I wanted to, to say, you know the. Let me ask, did anyone, our group did but did anyone go into the nutrition assessment for for Ralph, during the group. No. Okay. The, the, the reason why I bring that up is because. So, you know, we had. It just brought up the importance of just connecting different things so, you know, his, his brother passed away. And, you know, there's the depression that's related to that, but the other important part that we realized at the visit was that his sister was away for the funeral. And she is the one who would buy him nutritious foods and low salt foods. And so when he was now the, his nephew who's taking care of him in her place. You know, he wasn't, he wasn't doing all of that and so he had a lot of salty soups that he was having. And so we needed to do a refrigerator biopsy, and so I just wanted to bring that up because, you know, it's it's yes it's the mental health issues from bereavement but it's also the indirect connection, you know, from the, the brother's death it's the, you know, the sister being away who's also taking care of his meal prep, and, and so it's there, there are a lot of things to do, and you can't, you can't do them all at, you know, within the time allotted and you need to have, you need to have your team involved, and, you know, to, to really tackle all these things so. So, let's go into the next patient so we have Betty, who, who is next. And again, let's hear from the groups as to what you all tackled and what you all addressed. And what you have in terms of next steps for her. Well, the first thing we addressed was her main concern which was that she had gangrene and her leg was going to fall off. We found out that her legs were just dirty. So we just started to gently clean them up a little bit. We talked to her about medication compliance and she said that she was afraid of her medications because she was afraid of side effects and she had no idea what she was taking them for. So, we went through all of that with her so she had a better understanding, and hopefully could be more compliant. Great. Other groups. We also addressed her top priority, her primary concern, being that she thought she had gangrene and is she going to die. And then we delved into that statement of, is she going to die and how we're going to handle that. And is this some form of like passive suicidal ideation. And then we kind of went on a tangent discussing that. We discussed her polypharmacy and her non compliance. We looked at a list of her medications, we decided to reconcile our medications and find out what she is and is not taking. We decided that she's pretty passive in the process not engaged in her, in her care. And then in terms of stopping the visual hallucinations we noted that the duloxetine was stopped, and she hadn't been taking it by another provider so there was some clarification that was needed on the duloxetine and is the abrupt stopping of the duloxetine causing some of these visual hallucinations. So we just, you know, we wanted to go into looking at that. And then, you know, accessing our, our team getting some active mental health counselors psychiatrists psychologists involved. And then just getting help and resources in the home with social services, etc. I was really happy to hear is there was a recognition that they needed to get home health PT OT involved that they couldn't solve all those issues, and that might also help with the depression by having the activity of all the different providers coming in and out for a while. And that might be motivating for her so again that goes back to you, you can't try to do all these things yourself in one visit. Excellent. Thank you. And anything surprising about babies visit. It doesn't have to be an answer about that, but it's okay. But I, I kind of wanted to, I was pausing as we were reviewing the case, and I just wanted to just, just reflect on, you know, the fact that we are in the homes. So, for, for all these patients but but, you know, the thing that really struck me for Betty was that if, if we saw her at the clinic we might not get a true picture, and we might get like more of a facade as to how she's doing, and seeing her in her home in, in the context of her life, you know, we're seeing a truer picture and I see that as just a, you know, as just as an amazing area that we're in this is an awesome field and we're seeing or delivering you know right care to the right care to our patients at the right time at the right place. And, and I, you know, I just, it just, it just made me pause like these, these cases really made me think of wow this is this is a really great field that we're that we're in. And so, let's go into the last patient, MJ, and any, any feedback sorry any, any things. Sorry. What did you all address and any next steps that you had planned for him. I think one of our major concerns for MJ was his, his physical safety, you know as frequent falls as risk for falls. So, getting him a life alert and maybe some physical therapy. Also, with maybe his progression of his Parkinson's, having that conversation about what's the best supportive environment for him, you know, is an ALS possibly an option for them, and then we also discussed some language barriers, getting a translator, and assessing his competency to make some of these decisions. Obviously reviewing his medications and his goals of care, you know, he, he hasn't seen his cardiologist and quite a long time and can't get to his office so you know different options there whether we take over his warfarin management or getting a telehealth visit with the cardiologist, maybe those are some of those options. Great, thank you. Other groups. I know, we'd also kind of talked to him on a related note with the falls risk, commenting on his being on warfarin and whether there was really good risk benefit profile on that. That being the main thing we, we'd also discussed his ER visits and whether he'd really like even tried to reduce his hernia and knew how like kind of knew how to assess whether you know whether it's incarcerated and whether you know what his goal was and kind of going to the ER. It didn't seem like he'd had any follow up on it and you know was continually going in. And we discussed adjusting some of his medications because he was clearly orthostatic with his blood pressure readings. And we also discussed the fact that he is supposed to be on a dysphagia type diet and he is not because he doesn't like the texture he's got popcorn and cookies in the house for a diabetic who's supposed to be on a period diet. We looked at the polypharmacy and the sliding scale insulin and is it something that is feasible for him to do given that his blood sugar was elevated. We looked at the financial stress and caregiver stress. We recommended home health, some long-term services, getting PT in the home, OT in the home, and then we were assessing the chronic multiple disease management and trying to tackle that bit by bit as it was such an extensive list of complex medical issues. So, I would think that this is somebody that you would do a fairly frequent follow-up on to try to address these issues in a timely fashion, because it's gonna be impossible to do it at the first visit to try to manage all of them at once. So, that's great. I mean, how, so going along that line with the follow-up visits, because you can't address everything at the same time, have people been in a similar situation where they do an intake for a patient, there's a lot to address and you want follow-ups, how do you all schedule those follow-ups? Do you do a couple of follow-ups? Do you do them the following week, the following day even, or a couple of weeks or a month even? Just if anyone would like to share, that'd be great. I think our group talked about, it was reasonable to come back in a week in a case like this, if they're unstable. And then from that visit, you can come back a couple of weeks and then it becomes a month until they're stabilized. Since I am the only doctor in my team, I have a nurse practitioner, but her schedule is very limited. If I'm not going to be in the area, I make sure he's with a home care company that I trust and the nurses are very competent and it works out pretty good because then I can schedule the next visit, hopefully in one week, if I can't, two weeks. And I'll make it a point to make sure that he's doing well and he even called the nurse to find out and it works out pretty good. I haven't had a problem with that. Now, some of them will become unstable the next day. Of course, they have to go to the hospital then. Excellent. Well, thank you all. I mean, it sounds like the main takeaway and if we can go to the next slide. The main takeaways is definitely there are a lot of things that need to be addressed in the visits, whether they're new patients, acute visits, follow-up visits, and having a team approach is very helpful. Oh, sorry, can we go back one slide? I think forward one slide now. One more. Okay. We're looking for the one that says key takeaways. Yeah, thank you. There we go. So it's important to have the charts in advance and plan, but there's a lot of information, there's a lot of stuff that's done, whether it's acute, chronic, or new patients, and involving teams is important. When emergencies arise, involve your staff and see what needs to happen for your schedule. And also it's important to not just think about the patient, but also think about the patient and the caregiver. So I'll pause there, and now I'm going to hand it over to Brianna. Yes, thank you. All right. And I can share my screen for this. So similar to kind of what we have done and talk about, we're gonna use patient cases again. The goal of this activity is really to kind of get you more comfortable with the level of service coding, hopefully tying this all together. We're gonna look at our three cases again, but the details in this coding practice worksheet, which I'm just gonna kind of share my screen and go through together. Can you all see the one that says buddy coding practice? Yes. Okay. So the details are a little different. So if you've seen a lot of different kind of versions of cases, but we're gonna look at these three pieces of documentation. And then I'm gonna take some time talking us through all of that together, and then we'll have just a short breakout where you can talk amongst your small groups again. So I'll start with Betty. This particular visit was that follow-up. She complained of depression, anxiety and her weakness and pain. In the HPI, this was also the visit where she had that abscess under her right arm, but that has been cleared. Today, she's focused on her legs. They're dark colored. You're telling me the severity of her pain. Her pain level is at a 10. You know, when I mentioned earlier about the HPI modifying factors, anything that makes it better or worse. So she's getting very little exercise and states that she has not been up the stairs and out of the basement in six months. She's feeling depressed and lonely. Her husband, that's that truck driver that's always gone. And her daughter, who's her primary caregiver, they're fighting all the time and she relies on her for medication so she's not getting what she needs. If we look at her review of systems, occasional cough and wheeze and shortness of breath, the sleeping in the recliner and the shortness of breath on exertion, edema in both legs. She has some heartburn when she's reclined in the chair at night, a red swollen lump in her armpit, which this is actually, it says it could be an example of a learning point of something that, you know, is your documentation consistent and all matching up. That pain in the neck, that's worse when it radiates to the left shoulder. Numbness in both of the feet and difficulty getting up from the chair. Again, depressed, you know, a big concern for her physically, socially, those visual hallucinations, excuse me, and those erratic blood sugars. So here we get a Snapchat of her entire past medical history. I will say too, one note, just a kind of common thing that comes up in the ICD-10 coding perspective too, is coding for active CBAs really is only done in the hospital. So what you're coding for in the home is any residual effects or that history of CBAs. It's just another thing that comes up kind of frequently that you might not be too aware of. We have her social history too. Again, new patients, make sure you're getting all that past family and medical past, I'm sorry, family and social history. You can see her medications here and some changes. Make sure you're documenting all of those things. If you're doing complex medication reconciliation, bottle by bottle, especially for TCM, that's important. I'm just gonna pause here and kind of let everyone glance at her physical exam. You can kind of, again, from the coding perspective, I'm looking at how many systems. Then if we go down to her assessment and plan. So there's really three things that are focused that I would, you know, the meat that we talked about earlier. And you can, you know, see the information that's listed here. And, you know, the detail of what was really being discussed or done and how you're gonna keep her healthy until the next time you see her. I want you to keep this in mind. These cases aren't going away. You'll have access to them. And we're gonna look at MJ. So MJ's case, this is that one we talked about, the importance of transitional care management. So let's say you were gonna plan this as a formal TCM transitional care management visit. He was discharged from that hospital one day ago for that protruding hernia. So again, you're giving me a very specific medical reason for the visit as your chief complaint. And then he's presenting as a high-flying patient. He's presenting as a high fall risk with limited mobility. An example of that bulleted documentation that I mentioned and how you can really clearly give me the status of at least three chronic diseases, but also still make sure you're, you know, addressing things you need to know about the niece, Olivia, and the caregiver and the home health nurse that he has involved. We move on to his review of systems here. Again, I'm really focused on what's relevant to this case and not listing, you know, every single one, every single time. And you'll notice the statement about the complete medication reconciliation. Again, important for TCM visits that you're showing a comprehensive medication reconciliation was done. So here we have his social history. And we, you know, Costa and many of you talked about during the last visit about that concern that he's alone for stretches of time. You know, we have a social history about as far as his wife that has dementia but lives in an assisted living facility and that cost puts a strain on them. Then going down to the physical exam, looking at the number of systems from a coding perspective. And here we have his assessment and plan. And again, I would encourage you really to, you know, prioritize and put what's really the most exacerbated issue or the thing that you spent the most time on. Also kind of rotating those diagnoses can be important to capture all the HCC coding for your patients to make sure their risk score is accurate. And this particular case, which you have a example of in your notes, I mentioned that those smart phrases are those macros that you can create. This would be, you know, the bold here is the recommended template. And then the non-bold, these are the personal details that you as the provider would fill in for the patient. But things they wanna see from a TCM perspective, you know, when was the patient discharged? Cause you're showing that you saw them for a face-to-face visit within seven to 14 days. That you reviewed their hospital discharge information. That a clinical staff member had what's called an interactive contact call with the patient or caregiver within that's within two business days of discharge. So someone on your team has to contact the patient by phone. You can create a template for that as well. And we have a resource on that. Just, you know, are they safe at home? Do they have all their medications? You know, going over any need for follow-up testing or refills they might need and when the provider is scheduled to see them. Again, that medication reconciliation that you followed up on any pending, you know, test and treatment, other healthcare partners that they have in the home. And again, you can see from your home health and you asked your clinical staff to follow up on start of care and things like that. What patient and caregiver education was provided. Again, all of these things are TCM requirements. So there's certain things that happen, you know, non-face-to-face and certain things that happen face-to-face, but this is a, you know, you build the TCM visit when you actually see the patient and for that post-discharge visit. So this is how you're showing that all of that work that needs to happen within that 30-day period occurred. And then, you know, any other referrals, you can see that a PT order was placed and there was no other for this particular scenario. So again, we're going to skip, come back to these templates, but just kind of keep all of these things in mind. And I'm trying to give you a few, just kind of leading hints here. So if we think about Ralph, and again, this is what we're focusing on, you know, his main concern of that shortness of breath due to his severe COPD and this being a hospital follow-up. Your last visit was four weeks ago, but he's called in and he's not here. Four weeks ago, but he's called 911. Again, that shortness of breath has caused him a brief hospital observation stay. His Reggie is still the caregiver and appears to be at his wood end. Ralph is still smoking. I know several groups had brought that up and not listening to the caregiver about that. And this is where you enter the living room and see him in his recliner trying to adjust his oxygen, stating that he's short of breath and irritated, denying his recent cigarette use and that his oxygen is set at three hours, but must be broken because he still can't breathe. Thank you. And the coding activity is in pages 113 to 128 in your workbook if you're trying to follow along. So again, let's look at this review of systems. I'm really focusing on, you know, those abnormal or positive or pertinent negative responses here. You can always consider that all other systems are reviewed a negative statement. You can see his past medical history. Got some social history here too, which is really important with these patients. You know, he's living alone. His wife died five years ago. Reggie, who's checking on him. And again, talking about kind of what matters most or building that rapport about his history, him being a past veteran and things like that. Also might help with, I know our group talked about health from veteran services. Here you have his medications. And again, looking at those systems and exams. And here we have his assessment and plan. And you're gonna look through these here, but you can see some additional note about how much time this took down here. So just keep that in mind. And there's not really any right or wrong answers here. The thing that I would like to, everyone documents a little bit differently, but you're really taking the time to document everything that was discussed with the patient. You know, what did you have to do? Who else did you have to call? What other services did you have to order? You'll notice here there's some information about smoking cessation. So thinking about if that means anything to you, if you're educating him on the importance of trying to quit smoking and what kind of resources were provided. So again, just kind of keep in mind. And then again, you notice we have a time statement here. And I know we technically, Danielle and Melissa, do we need about five more minutes or can we go to the breakout? I think we could, Danielle, is that a problem on your end? No, I can, do we want to give 15 minutes in the breakout rooms then or? We'll just come back early and then we'll just still use 10 minutes. Okay, sounds good. I will set the breakout rooms and everyone will be whooshed away. Okay, thank you. Well, if your group was anything like ours, we ran out of time before we ran out of discussion. But I know Brianna is going to catch us up and debrief and tell us what we should have coded. Yeah, that's okay. Sorry. I know we're all learning the timeframes and the different breakouts. We just didn't want you to be lost. Sometimes I ask people to talk about coding and I get a little deer in the headlights, so I didn't want to give you too much time and then make you talk about something you didn't want, but let's talk about it. Let's start with Ralph. I know what our group talked about, but maybe just one of the other two groups want to start. Did you have any thoughts about what you saw in that documentation and how you would code it? Maybe I'll just share my screen. No, never mind. I can't. If whoever's sharing their screen maybe just wants to pull up Ralph's case or give me permission, then I can do it. There we go. Now I can. She's already ahead of me. All right, let's go to Ralph. So looking at Ralph's visit, and again, there's lots of different ways that you can go about this, right? We tried to just give you different examples, but you want to think about, am I billing on documentation and complexity or is it an extended time visit? And what are all the factors and ways that I might be able to get appropriately reimbursed for this encounter? So right off the bat, if I look down here, I see that this was an hour and 45 minute visit. So I'm pulled up this little cheat sheet that we have, that E&M guide for house calls, because if you notice I have the columns here where it says the typical time and then your prolonged services code. So to Megan's point too, this is a really sick patient that you had to do intervention in almost hospital level care. Her mind already goes to that high level visit. And you know, you spent an hour and 45 minutes and you only need to get to 90 minutes to bill prolonged services face-to-face, right? That 99354. So right off the bat for that kind of visit, I'd be thinking about, okay, am I gonna bill a 99350? He was an established home visit patient and prolonged services face-to-face for about 90 minutes of time. And if we also look back at his session too, just another kind of coding opportunity that might get missed sometimes, you know, you spent time on the smoking sensation. Now you might've all captured that in the time that you did, but if you didn't, just kind of flagging this for you all, not even necessarily for this visit, but if you're spending more than, you know, a minimum of four minutes on smoking sensation, that 99406, CPT code 99406 is an opportunity for you there. It does have documentation requirements that we laid out for you in the advanced coding opportunities as well. So thinking about that. Anyone have any thoughts on Betty? Her documentation? So we can see this was a, you know, a really chronic visit follow-up focused on documentation and complexity. Overall, I got this to a 99349. So the second highest level would be what would be appropriate for Betty here. And again, there's a lot of varying factors and things like that. I'm gonna stop sharing for just a second because sorry, there's something wonky going on, but is that something you guys are regularly doing? I mean, raise your hand or use the chat. Are you guys, you know, are you making, being sure you're at least considering when to bill on time and when to bill on documentation, or are you using prolonged services and smoking sensation and doing all of these things in your practice? I see some head nodding, that's good. And then we had a lot of discussions here around the TCM visit. Again, there's not always, you know, one right way to do things, but certainly with the increased reimbursement opportunities you saw that MJ's case was set up with that TCM documentation and might be an opportunity for you to consider there, you know, really making sure that when it is a TCM visit, that 99496 was what I would have billed for that. Alternatively, his visit could have supported a 99350 if you wanted to bill the E&M rather than the TCM visit. So again, there's really no right or wrong answer sometimes as long as your documentation supports what you're billing. You don't want to get into a situation where you're, you know, if I, especially if you look at your provider trends, there's a lot of low-level codes or not being paid, you know, not just billing E&M and never billing these other advanced coding opportunities. Not billing for extended time when you're there. You know, all of those things affect your bottom line. You heard Amanda talk to us during economics, you know, thinking about revenue. And unfortunately, you know, and fee for service is something we got to think about. It's really just getting paid for the work that you're doing and making sure you can provide excellent clinical care to your patients and maybe even expand your services someday. So just really just encourage you to think about what you're doing and make sure you're getting fairly reimbursed because you guys deserve it. So Melissa, that's all I really have for the debrief. I think, you know, with moving on and giving some time for Q&A and, or wrap up, you know, that we can, oh, sorry. I can, yeah, pass the doctor chain. Yeah, so I think we were going to do just kind of a catch up on the Q&A and let's start by any questions on coding, any lingering questions. I know we went through that activity pretty quickly and we're going to give future learners more time, but did you have questions about that? I do have, oh, sorry. Yeah, go, go, go. Ladies first. Okay, thank you. Go ahead. I do have a statement about TCM. You know, sometimes we'll get somebody home from the hospital and we have not had time to get the correct documentation. And I always tell the providers, you know, it's okay if you don't do your TCM visit, although our payers want to see those types of outcomes for us and they want us to give them data. And if you don't have that, it's okay because you can almost build the same coding and then get the same reimbursement with your higher levels and the additional things you do. So sometimes they get discouraged when I say it's okay, you know, we'll get it the next time. So sometimes it's really hard getting all that information ahead of time and you've got to see them quickly. So, and there is a difference between the seven and 14 days. Our standard practice here is seven days. And, you know, we really within, as Megan said, 48 hours is best, but sometimes you're just not in the area, but that's what I would say. Yeah, that's a great point. I mean, honestly, before the TCM reimbursement was increased, you know, typically we weren't billing for it, but I said, you can still track that, you know, you could still have a unique visit type, whether you're billing for it as a TCM or not, especially from a value perspective, you know, showing how quickly you can get to post-discharge patients or weigh the value, you know, Megan shared in her practice, they spend more time usually doing care management time and billing prolonged services before and after the visit. So they don't always bill the TCM and that's okay. You just have to make sure, you know, you needed to make the best decision for you and your practice. And there's, I believe, you know, principles of the TCM framework that can be helpful and appropriate, whether you're using it as a billing opportunity or not. I agree, yes. Yeah, I just wanted to add to everybody that nobody has mentioned that. When you go to a patient house or you do a triage call or you do a telemedicine evaluation, always look for, based on patient benefit, the other procedures you would do in the house using Modified 25. And for example, a needle lavage, if you find that the patient has a sediment accumulation, joint injections, if you're comfortable doing that. And apply an ebulizer medication if you see the patient short of breath or doesn't have an ebulizer at home. And that particular case that we were talking about with the respiratory, you know, the pulse oximeter on 78, after you solve the problem, he went back to 90, then you can improve that and see the difference between the nebulizer medication, and all those things are available and can add to your revenue. On one side, on the other side, you can benefit the patient with all those, you know, the procedures you can do. You can have it in your own bag, right there. Even the nebulizer machine, we have a little one that we carry with us at all times with all the drugs. And the drugs are very cheap. You can buy it on the suppliers online. Henry Chang, McAuliffe in California, they are very cheap. You can have a sort of a, you know, pain management. It's a big issue. You have an opportunity to do that with the patient. You're just gonna start an antibiotic and you're gonna put it intramuscular. Then you start the first dosage and you can have rosepin and you can have other things. And also, those are available. They don't pay much. You can have portable EKG. You can do an EKG and do also Med 525. Those are, for those that are starting business and doing business, and that's very important considerations. We do all those things. Even the skin tags and small, you know, in-situ and drainage of abscesses and, you know, those things. Yeah, Melissa, you bring up a great point, too, about just making sure, you know, especially in the grand schemes of the providers being responsible to finish their documentation and do all their callbacks, but not forgetting to bill for procedures when you do them. You know, any missed revenue opportunities and things like that is something that I look for in audits. So, again, just really make sure you're being reimbursed for all the work that you're doing. Capture the information and code it and bill it properly. You got it. Yep. Thank you. I don't know if this question belongs here. It's about CCM. Okay. So, I'm always confused between CCM and care plan oversight. Can you throw some more light on that? Yeah, absolutely. So, let me see if I can show this super bill really quick, actually. Oh, sorry. No, never mind. It's okay. It's not 100% necessary. Oh, well, never mind. You did it. So, chronic care management is when you or... There's a couple different options. When you and your clinical staff are spending a minimum of 20 minutes per month, now you have to, you know, for new patients or patients not seen within the past 12 months, you need to get their consent. CCM requires it can be verbal consent, but that you do that during a face-to-face visit. So, this 99490 right here, that's on the super bill, which actually it looks like it's traditional chronic care management services of at least 20 minutes per month. And there's other requirements that need to be in place, like the creation and implementation of a comprehensive care plan. But with CCM, what you're doing is you're getting their consent, you're enrolling the patient in a service, you're explaining that to them, you're the provider that's going to be providing it. It's a way that you can help manage their health and provide them with a comprehensive care plan and have regular touch bases with them. All things you'd probably be doing, but you're just letting them know, you know, this is a service that's being built for it. They will have a very mild copay. I think it's about $8. But there's other opportunities. We have, if you're a solo provider and it's just your time and you spend a total of 30 minutes per calendar month on chronic care management time, that's when you would consider this 99491. You can't do both. It's one or the other. Or if it is you and your clinical staff time, but you're spending more than that 20 minutes, we have this add-on code for G2058 now that was introduced in 2020 for each additional 20 minutes. And you can do that up to 60 minutes per calendar month. There's also complex chronic care management codes, which you see here. But those require moderate to high medical decision-making and a little bit more active care plan management changes. But that's chronic care management. The difference with care plan oversight is very similar, but care plan oversight is only for patients that are enrolled in home health or hospice. And they have a specific list of billable activities that you can count and things that don't count. So here are care plan oversight for home health. Again, it can only be the provider's time, has to be a full 30 minutes. And if it's on those billable activities, you could bill G0181. If it's for a hospice patient, again, only your provider time, a full 30 minutes on approved billable activities, then that's when you would bill the G0182. I'm sorry, excuse me. But that's really the difference is personal preference, honestly, you know, what are you spending the time doing? And is it your time or is it yours and your clinical staff time? I personally think chronic care management gives you a little bit more flexibility because one of the non-billable activities for care plan oversight is like discussions with family members would be one of the big differences. Thank you. I don't know if I missed it. In the workbook, is there a place that shows us exactly what is billable for CCM and what is billable for CPO? What kind of activity? Well, if you go to that advanced coding opportunities, that'll tell you a lot of the detail about the chronic care management, the care plan oversight, the billable and non-billable activities. This is for Anne, right? I'll make a note to follow up with you. I'm not sure, that might not be on the resource, but I could provide that to you, either me or a colleague in email. Okay, thank you. Brianna, we had a question come up in our group. Does the amount of time spent with smoking cessation take away from the other time codes? And I did have to step away for a phone call, so I'm not sure if you answered that or not. Yeah, no, that's a great question. So with time-based services, the important thing that you wanna keep in mind is not double counting your time, right? So it gets a little tricky if you're billing, you could argue it might just be simpler to count your total time for the visit and just bill if it is a time-based visit and bill the service and the.
Video Summary
In the video, the importance of setting boundaries and creating efficient operational processes in a home-based primary care practice was discussed. Clear communication and regular team meetings were highlighted, as well as the use of technology tools like CareLink, Road Warrior, Multiplotter, and Google Maps. Geographic scheduling and community services were emphasized, with resources like Eldercare Locator provided. Strategies for efficient scheduling, such as territory zones and appointment confirmation procedures, were advised. Overall, the video offered insights for managing a successful home-based primary care practice.<br /><br />The video also discussed the process of getting set up with bundled payments and value-based care programs, including identifying programs, understanding requirements, assessing readiness, developing partnerships, implementing care coordination and management, monitoring performance, and engaging with payers and stakeholders.<br /><br />In addition, the video discussed various topics related to home-based primary care. This included alternative payment models like primary care first, SIP, and direct contracting, as well as the importance of value-based contracts and securing contracts with MA plans. Revenue generation strategies, the impact of the COVID-19 pandemic on home-based care, and the significance of carefully managing expenses were also discussed. The importance of accurate coding and billing, as well as the use of time-based codes and proper documentation, were highlighted.<br /><br />Overall, the video provided valuable insights and recommendations for managing a successful home-based primary care practice, navigating bundled payments and value-based care programs, and ensuring accurate coding and billing practices.
Keywords
setting boundaries
operational processes
home-based primary care practice
clear communication
team meetings
technology tools
geographic scheduling
community services
efficient scheduling
bundled payments
value-based care programs
care coordination
monitoring performance
alternative payment models
revenue generation strategies
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