But as long as you're not double counting your time, so, you know, if, for example, in Ralph's case, you did spend that full, you know, however much time you said face-to-face, I think it was an hour and 45 minutes, and then there was a separate four minutes spent on smoking sensation counseling, then that would be appropriate. You just have to make sure you don't double count your time. But it might just be simpler just to count all your time and just still prolong services. It depends on, you know, all in all, I think smoking sensation is pretty low reimbursement. It's more of those documentation and complexity visits. It's just that little bit of extra revenue you don't want to forget about. Thank you. One more. On the CCM, I know you mentioned a comprehensive care plan. Do you have to do a separate one or the one you have in your notice? Yeah, so it's not your assessment and plan. It does have to be a formal and separate care plan document. There was a resource I put in the chat earlier that's also on our website. If you go to the HCC Intelligence webpage with the tools and tip sheets, we have a comprehensive care plan form that goes over the requirements. CMS actually has pretty extensive recommendations, and I always say if the government's recommending something, I recommend we follow it. Like, they want caregiver assessments and evaluations and things like that, so look at that form, but it does need to be a separate care plan. You do it once when you first see the patient and you're getting that verbal consent, and then there just needs to be a schedule for periodic review, so it's not like, you know, you're going to make changes as you're seeing at the patient that might be in future visits and things like that. I wouldn't be expecting you to go back to that care plan every single time unless it was a really substantial change. The important thing is just, you know, like set a calendar alert in your EHR to review it once a year. Maybe you make that part of your annual wellness visit process or something like that. I'm trying to catch up with some of the questions in the chat, so this may be for all the faculty. What do you do with referrals when the patient is homebound? How do you handle that? And this time on clinical, Kosta, maybe I see you unmuted. We really try to interact with the specialist if they've already established. Can they do a telephone visit or a virtual visit, especially now that that's been better established? Can we obtain labs for the specialist to help guide the treatment? We have one very complicated renal patient who really can't get out, and we've been working very closely with emailing within our medical record and getting things taken care of that way. It can be very difficult, but we try and be the interface often. Yeah, and it depends on, also, it depends on the timeliness of the referral that is needed to be placed. So if it's a referral that, OK, they need to see DERM for something that they're suspicious about, the DERM referral can be sent to the office. But if it's something that needs cardiology to weigh in on sooner than later, I have relationships with some cardiologists in the community. And if I pick up the phone with them and I'll say, I need your help about a patient, I negotiate with them to see if they can do a telehealth within a timely fashion or if they can be seen the next day if it's appropriate. Also, some patients don't have telemedicine capabilities, and sometimes you can be the interface. So for example, I had a nurse practitioner, I had a patient who needed an orthopedic evaluation. Orthopedic said I can do a telemedicine consultation. Problem is that the patient didn't have any telemedicine capabilities. So my team's nurse practitioner went to the patient's home and connected the patient with a specialist and got them the care that they needed. And so if there is some creativity that needs to happen with specialist referrals. OK, thank you. So there was a question earlier today also about are there specific protocols that a practice should have in place to make sure they're effective and efficient? Yeah, I think that question has come up a lot, and it's something that we've actually been working on too from some of HCCI's work on best practices on what standard policies and protocols that you need. As far as protocols, the big ones in my mind, and Amanda, weigh in here, but thinking about your intake, your geographic scheduling, your acute and urgent visit process. Then as far as policies, what's your no-show, or do you have financial assistance? Bed, bug, and infection control, your safety and emergency preparedness plan, just off the top of my head. Those are some big ones that come to mind. Amanda, do you have anything to add on that? Well, not anything especially helpful. Like I guess there is just no shortage of entities that would like to regulate you. So some things, people typically remember OSHA, but Department of Labor, Department of Revenue, your state, all of your accounting pieces. Certainly, as you think of HR, there are a lot of resources out there. If you're sitting down and you're like, I need an employee manual, or I need to think about a safety committee, always, always, always start with what's out there for free and just Google your own state stuff. I mean, even Medicare posts. Like we have used the Medicare fraud, waste, and abuse and Part C and Part D testing every year, the ones they've posted. We don't reinvent the wheel and we just have people sign off on a piece of paper. So like I said, not incredibly helpful from a how many people can actually regulate you standpoint, but again, because of that fact, there's a lot of free stuff out there. Yeah, and the VA actually, I came across a user manual that they have available. The VA is a pioneer, I think, in a lot of ways in home-based primary care and they have robust resources. But they have actually a user manual that goes over their policies and procedures that you can find if you look for it online. So again, I apologize if you touched on this already, I missed it, but what consent verbiage is needed for what exactly are they consenting to? I think that question was CCM, right? Like what kind of consent do you need for that one, right? I don't think we touched- Okay, yeah. Did we cover that? Sorry. No, that's okay. So were you gonna say something else, Melissa? Well, then, and then there was another one just now, can you speak to GEO 506 for CCM care plan development? Okay, sure. So let's talk about the CCM consent first. So what you're doing with obtaining verbal consent, or it can be a written consent, I know some practices that'll have the written CCM consent as part of their new patient paperwork. The providers still have to talk to them about enrollment before billing in their face-to-face note and kind of go over that with them. But there's lots of different ways you can go about it, but you're getting their verbal consent for enrolling in a comprehensive chronic care management program. And they understand that you're the provider that's gonna be providing that consent. providing that service to them, what that means, how they can reach your office, if they're gonna have this designated relationship, you're gonna give them a copy of this comprehensive care plan or make it available if they're active on their portal. So that's what the consent is for as far as it's for enrolling in the program. So they understand that they're gonna be billed for services essentially, and what that means and how to reach your office. Some practices, if it's a bigger health system, they have like a CCM nurse, or they just call your office, it's not a requirement, but you're getting their consent for enrollment in the program. You can find some really good collateral and really just talk to them about, this is a systematic process where we can help stay up on your needs. And Medicare encourages us to provide the services to patients. Usually sometimes providers, that can be helpful because you don't want them to think you're just trying to bill them for every service. But sometimes if you kind of blame it on Medicare is, oh, this is a program that Medicare rolled out. And they really encourage us to provide this to our patients that can sometimes be helpful as far as conversation starters. That's one piece, that's the consent. Go ahead. Just before you go on, I would just say, just in general though, you have to get annual consent for all of your HIPAA and your releases and stuff. Like there really is no reason not to get a written consent on anything you're gonna bill them for. Your back office will thank you later if you have something there. So just, I know people do it and they get kind of the verbal but people have goldfish memories. And even at $8, you wanna get everything written down. Hey, Brianna. Yeah. Can you comment a little bit on getting the verbiage consent for ACP discussion? You and I have had some work, had some conversation with people about getting the right wording and consent for that. And I think especially relevant for this group because we deal with a lot of sick patients and we undertake a lot of ACP discussions. Yeah, that's a great point. Dr. Cheng and I have had some discussions with other kind of advocacy and policy efforts going underway to try and get advanced care planning recognized as a more of a preventative service so there's not a copay. And so you wouldn't have to kind of worry about that. But advanced care planning 99497, if I'm remembering correctly, you can bill it when you spend a minimum of 16 minutes on discussing goals of care and patient preferences. It does have to be face-to-face or right now it could be a phone call or telehealth visit. What you're getting their consent for, if we really look at the language very literally is the voluntary nature of their participation in that discussion. If you look at the CMS advanced care planning fact sheet, they said they encourage providers to make patients aware that they will be billed for this service. But what you're getting the consent for is the voluntary nature of the discussion. So I might say something, and I know Dr. Cheng and I have worked on a couple advanced care planning documentation examples. I can even try and look for one and maybe put it in the chat, but it's explain to patient and caregiver who verbally consented participation in goals of care conversation. I spent a total of 17 minutes and then what are their patient preferences? So for advanced care planning, it's your total time that you got their voluntary consent for the discussion. What did you actually address and talk to them about? And then if you filled out any advanced directive forms such as a poster or most form and things like that, always recommend certain stop times. But for that particular code, you just need your total time and that you've gotten the voluntary consent for that discussion. And it does not require the completion of a post form. Correct. It can be just a discussion. It's not like, well, I didn't complete it, then I can't bill it. That is not the case. Yeah, I would say that's a big myth about that code. And I've heard some compliance departments who have tried to tell their providers not to do it, but I will show you the Medicare regulations. That is not part of that code. It's with or without the completion of forms is actually in the code description. So I might ask Nicole to ask her question if I'm not asking it right, but she's got a follow up on the protocol question about outside the VA is a list. Is there a list of protocols somewhere? And I've heard this before where there are groups out there that are selling protocols. And so she was just trying to see if it was even necessary. And she's provided a link here to the VA in the chat. What do you think? Yeah, I found the one, the VA one, I believe I found the one, the VA one that you said is available online. And the reason why I asked the question is, of course, starting home-based primary care, you hear, oh, you need to have these protocols. So I know I encountered someone that was selling protocol manual. And I was just wondering, well, which protocols? I know you, I was trying to write them down as you were talking, as you mentioned some. So I was just asking if there was a list of suggested protocols somewhere, or I didn't click on this link yet. So I don't know. I mean, I didn't go through this manual yet to see if this would be helpful. I was just asking, is it really necessary to purchase? I think it was like, I think she had a program and protocols for about $3,000, protocols alone for 1,500. I was just wondering, is it really necessary since you may need to tweak it personally to your practice and everything may not apply? Like, is it really necessary? Or is there a list somewhere so that you can go through and say, okay, I do this, this, that? Just wondering. What I've heard is that a lot of times those are really home health kind of protocols. So I don't know. Brianna, do you have? Yeah, I think you have to be careful. When I talk to people, and that comes up a lot, Nicole, I need policies and procedures. I'm being told I have to have a compliance plan and I need to have these things. I mean, if you're just purchasing cookie cutter templates for as far as like safety and things like that, they might not be even really relevant to your practice. And to Amanda's point, you don't wanna over-regulate yourself. Certainly on the HR and the legal, that's where I would work with your legal department. You have some sort of healthcare attorney, even if you're just starting out and find out what's actually required in your state. If it's a requirement, that's where I would say you need to have those formal policies and procedures and things like that. The protocols are really just best practices or how your practice is gonna operate and things that you need to have. I'm sorry, I don't have a better answer. It's something that comes up a lot and that we're doing some ongoing work on. And I hope to be able to share some more resources in the future. Amanda, I don't know if you have anything else to add. That was kind of what I was picking your brain about the other day. Yeah. I'm sorry. In the state of Florida, I know we can go on our state website, Board of Nursing, and they actually have listed on the regulation part of it and protocols, sample protocols that the nurse practitioner can actually download and personalize for their practice. But it's actually a template of what is the state of Florida requires. So it has everything in there, the basic information, and you can add to it. So you may wanna start with your own board of, the health department or board of nursing or whoever regulates your license, and they may have some there. Talking about a collaborative agreement slash that type of protocol? And they have those, they have sample templates for a collaborative agreement protocols. Try your board of nursing website. Yeah, I wasn't talking about that. I was talking about practice protocols for home-based primary care. Oh, okay. Yeah, yeah. I'm actually independent right now, but I still do have a collaborative physician and a protocol, but more like home-based primary care. And as far as I know to jump in here, I think unless there's a body that regulates it, then there's not someone, then there's no requirement to have a protocol. So in reality, you have protocols around starting a medical practice, HR, EEOC, labor laws, but there's no one that says, these are the geographical scheduling functions and protocols you have to have because no one regulates that. So hopefully that is more helpful because you probably are 100% on the right track getting all the things you need to start your business. And all of the other things we're trying to help are really additive things. As we talk about, you may wanna put this kind of process or procedure in place, but if there's no regulating body, then you don't have to have it. That's my official opinion. I don't know if others would disagree. Okay. So you know what, we're gonna pause here. We've got just a few more slides and a brief closing video. And if questions still come up, we're gonna make sure that you know how to reach us at HCCI and we can definitely continue to help and support you. So I'm gonna throw it back to Dr. Chang, right? To bring things home. Hey, thank you. This is the closing session for the workshop and it's a little different. And we're gonna, Melissa, I don't know if we get the slides up. We're gonna focus on the next steps after you leave here. But first I wanna take an opportunity to introduce the HCCI business plan and a budget template for you guys to consider. So next slide, please. Let's go back. So before I get further here, I just wanna say thank you so much for spending two days with us. We have just poured a lot of information out here and I hope it's not, you know, the proverbial, you know, drink from a hydrant kind of stuff. I really, really, we really, really hope that it's been helpful and useful. Again, it's something you can really put into action come Monday morning for your practice. I love the energy of this group. I love all the questions. I love the interaction. I really enjoyed the last two days with you. And it's kind of sad that this is coming to an end. So the business plan. So the business plan, quickly, you can turn to page 134 to 140 of your workbook. It talks about some of the SMART goals, the SWOT analysis, understanding your financial, financials of your practice, the mission, vision, and value of your practice, as well as some marketing strategy for you to consider. And moving forward, you know, how to help your practice financially viable and to grow. I just want to point out again that even though we are wrapping things up here, this is just one component of a comprehensive educational program for HBPC professionals that HCCI offers. In addition to the essential element workshop in a couple weeks, we're going to be doing an advanced application workshop where we get into even more deeper topics related to HBPC. There's online courses that you can access at your time. And again, the House Call Practicum that you spend a really intimate, close, one-on-one relationship with a seasoned provider and get some of your questions answered. And also the virtual office hours and the webinar series that's every month. So we look forward to meeting you there. Next slide, please. Before we get into the closing video with Dr. Cormel, I get asked, Paul, why do you do this? Why do you do this? They see some of the comments, and I get comments from the ER, from the hospitalists, and so on. And why do you do this? Again, you know, I come back to, you know, what the power, I keep coming back to this idea of the power of the presence, of our presence, next to our patients. And I just want to share a story. Maybe that'll kind of bring home some of the ideas that has been discussed over the last two days. Recently, I've been taking care of this elderly patient with dementia. She has been really agitated and combative. And through multiple visits and a series of medication adjustments and being right there with the care, with the family, with the husband, and taking care of her at home and bringing some peace and calm to the situation as she was declining and passing away. And I remember recently at one of my visits, at the end of the visit, you know, I knelt next to her, and I held her hand. And I've gotten into a habit of kneeling next to my patient. You know, it reminds me of three things, that, you know, I'm a servant, I'm here to serve my patients. It reminds me that I'm limited, there's a finitude in terms of what I can do, you know, when I kneel. And it reminds me that, you know, there's a bigger calling, whether, you know, people who are religious, you know, we believe in God, or a bigger service to humanity. So I often, and I often kneel, and I was kneeling next to her, and I said a silent prayer for this patient. And before I got up, I, you know, I got this hand on my shoulder, and it was from the husband. And he said to me, and he said, Dr. Chang, thank you for, thank you for taking care of my girl. After 60 years, you know, we're inseparable. And, you know, at that moment, you know, my medical assistant, you know, started to tear up and I was tearing up, you know, at that moment, just for that brief period of time, you know, all the complexity about billing, coding, and the challenges that we face in home-based primary care, all of that went away. If it was just for that period of time, you know, it reminded me of why I do what I do. And just the beauty of home-based primary care. So to answer the question of, Paul, why do you do this? And I do this because I desire to serve. And HBPC gives me the opportunity to use my skills, all the stuff that I learned in medical school, all the complex stuff, use my skills to the maximum. It challenges me to do my very best in difficult circumstances. The second reason, and it's an opportunity to serve patients, especially those who are really at risk and they're disenfranchised and they really have very little access to medical care otherwise. And the last is, you know, this is an opportunity for me to change healthcare, for all of us to change healthcare that is broken in many ways. And all of us, all of you can play a part in this, what I consider transformative care. It transforms ourselves and our patients. And also in this transformation care of how healthcare can be better, can be improved for this particular group of patients across the country. So I'll just leave it at that. And we can go ahead and play the video. So how did it go? I hope the workshop was everything you hoped for and more. I hope you feel my same sense of awe and amazement at the dedication, the knowledge, and the generosity of our Center of Excellence faculty. They are incredible experts in home-based primary care. I hope you are headed home with a deep understanding of the valuable work you do and a growing confidence in your practice's ability to deliver extraordinary care using a sustainable business model. I hope you understand the potential you have to make a lasting, transformational impact on healthcare in our country. As you know, there's a tremendous need for home-based primary care. And right now, there are not enough people doing it. I would like to ask you to help us spread the word and build the workforce. Tell your colleagues on your network, tell everyone about this program and encourage them to get involved in this very special field. From all of us at HCCI, thank you for embarking on this learning journey with us. We wish you much success and a rich sense of fulfillment in the important work that you are doing. Now get out there and transform healthcare in our country. All right. Thank you all. On behalf of HCCI, I want to just take a minute and I want to thank our faculty. You are the best. And it's always such a privilege for me to serve on these educational activities with you. And I want to thank our learners for staying so engaged through this whole, you know, through the last two days. It's been a lot. And of course, I want to thank our staff who have just been behind the scenes making sure everything was working exactly right. You guys are awesome, too. Everybody, I put something in the chat. I want to make sure that you watch your e-mail. This will likely come on Monday. But it will give you instructions about accessing the recording from the last two days through the HCCI Learning Hub. It will also give you critical information about filling out your evaluation. Yes, yes, please do fill out your evaluation. And then, of course, I want to thank all of our faculty and staff who have just been behind the scenes making sure everything was working exactly right. You guys are awesome, too. Everybody, I put something in the chat. I want to make sure that you watch your e-mail. This will likely come on Monday. But it will give you instructions about accessing the recording from the last two days through the HCCI Learning Hub. You guys are awesome, too. Everybody, I put something in the chat. This will likely come on Monday. But it will give you instructions about filling out your evaluation. And then, you can claim your CME or other credit in that way as well. So, again, on behalf of HCCI and our faculty, please go out and be safe. Keep doing what you're doing for these vulnerable patients. And we look forward to speaking with you and working with you again at another activity like this. All right? Thank you so much, everybody. Thank you. Thank you so much, everyone, for being here and for doing what you do. Take care. Thank you. Bye, guys. Thank you. Bye-bye. Thank you. Thanks, everyone. Thank you. Thank you, everyone. Thank you very much.

home-based primary care

business plan

budget template

education programs

personal story

gratitude

encouragement