Good morning, everyone, and welcome. We are going to get started in just a moment. We're just admitting everyone from the waiting room. And it looks like we're in, Melissa. All right, very good. Good morning. So just a couple of housekeeping things. First I want to welcome everybody to Home Center Care Institute's Essential Elements of Home-Based Primary Care, a virtual workshop. We have a group of experienced and enthused faculty to share a lot of wisdom with you over the next two days. And so we're also very committed to making sure that you leave this workshop by tomorrow having all of your questions answered. So we'll go ahead and get started. If we could go to the next slide. So I'm going to go through some of the other housekeeping things. I mentioned that this session is being recorded, and the recording will be made available to you in the HCCI Learning Hub approximately 10 business days or within 10 business days of the end of this workshop. We will also be providing you copies of the slides, and you should already have access to a workbook that our presenters will be referring to this morning. If you have any questions about accessing the workbook or any other kind of technical issues, please go ahead and put those questions in the chat, and we have folks that are monitoring that can help with that. And then I also want to encourage everybody, because this is a relatively small group for a workshop, you know, is that during our discussions, we are going to encourage you to turn your video on and have some good dialogue with each other and with our faculty. For that purpose, too, it's helpful for us if you could, on the Zoom window, rename yourself if you, just make sure you have your first and your last name. It helps us to be able to identify you and the program you're with, and so we really appreciate it if you could give us your first and last name in the Zoom window. So I am going to share with you that, of course, none of the presenters here today have disclosed any relevant financial relationships, and we can go to the next slide. We are offering CME credit for this workshop. If you are a physician, again, you're required to claim only the credit for the time that you participate, and if you have any questions about what that is, feel free to let us know. You can put that in the chat, and we also do encourage, if you're a nurse practitioner or a PA, nurse or practice manager, so the organization is listed at the bottom of the screen, accept activities that are designated for AMA, PRA, Category 1 credit, and you can contact those organizations for more details. Next slide. I always want to thank our funder, the John A. Hartford Foundation. They have provided a grant that supports, in large part, much of the education that we offer at HCCI, so thank you, John A. Hartford Foundation. Next slide. All right, so our objectives for this workshop, these are pretty broad, but you're going to see some of these themes come up. You know, I mean, this workshop is intended for folks who are relatively new to home-based primary care and house calls, but we also recognize that so many of you may be coming into this workshop from different places and different, with different motivations, and I want you to hear me say, and we'll say it over and over again, that we are committed to making sure that we are addressing the things that are of concern to you, and that may be different from, you know, the person virtually next to you, so, you know, we're going to be covering issues on, you know, kind of the fundamentals of home-based primary care. We're going to talk about the four Ms in the care of older adults, which is something that was brought forward by, through a partnership of the John A. Hartford Foundation, the American Hospital Association, and other institutions around age-friendly health systems, and I think you're going to see how well those four Ms fit into the care of home-limited patients with multiple comorbidities. We're going to be showing you, through demonstration and through practice, how to provide optimal patient care in a simulated home setting, including coding and documentation for that visit, and then we're going to be talking, we're going to start talking about it a little bit today, but much more tomorrow on the business models, the economic drivers, and quality indicators for home-based primary care and their impact on care delivery. Next slide. All right. Well, now I'm pleased to be able to introduce, we're going to share a video with some opening remarks from HCCI's founder, Dr. John A. Hartford, and we're going to start with a video. Hi, and thank you so much for joining us today. At HCCI, we talk a lot about transformation, how home-based primary care transforms the lives of the patients and family members, how this wonderful care transforms the people who provide it, and how this unique model of care has the potential to transform our healthcare system. You are a part of that transformation. You are at the forefront of a movement that will change the way we care for our most vulnerable patients, improve patient outcomes and experience, and do it in a fiscally sustainable manner. We are excited for you to begin your journey with HCCI. You are here with a few of our incredible partners, faculty from HCCI's Centers of Excellence, which have been established at leading institutions across the U.S. Your two days here are an important component in your home-based primary care learning experience. After this workshop, you will have numerous opportunities to continue your learning through HCCI's online courses, covering both clinical and practice management topics, as well as our next workshop in the series, Advanced Applications of Home-Based Primary Care. You will also have the opportunity to register for the HCCI House Call Practicum and travel to one of the nation's leading house call programs to participate in a unique field experience. There, you will shadow expert preceptors as they perform both clinical and practice management functions at their program, allowing you to observe up close how HCCI's Practice Excellence partner puts into practice the very concepts you will be learning at this workshop. Before you get started, I'd like to ask a favor of you. Please take a moment right now to write down two things you want to get out of the next two days. Maybe it's insight on staffing. Maybe you find end-of-life discussions challenging. Maybe you struggle to increase the number of visits you make each day. Write down those two critical takeaways and share them with the group. We will keep an eye on them over the next couple of days and make sure you walk out with answers. Thanks again for joining us. Enjoy the workshop. It's going to be amazing. Now let's get transforming. All right, thanks so much. Why don't we just advance to the next slide. I am going to be turning this over to my partner in crime here, Janine Lyons, but I realized I never introduced myself. My name is Melissa Singleton. I'm Chief Learning Officer for HCCI, and again, I welcome you to this workshop. So, Janine. Thank you, Melissa. Everyone, good morning. My name is Janine Lyons. I am the Interim Director of Education with HCCI. You've seen my name on some communications. We are supported today also by Sarah Tolan, and a number of people on the backstage side of this webinar are here to support you throughout the day. So, we're going to start with an icebreaker. We do ask, like Melissa said, that you turn on your camera. We would love to hear from you your name, what practice, health system, or organization you're from, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your background. So, we're going to start with an icebreaker. We do ask, like Melissa said, that you turn on your camera. We would love to hear from you your name, what practice, health system, or organization you're from, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your background. We're going to start with an icebreaker. We would love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. Finally, we'd love for you to put in the chat your name, where you're from, and your current level of experience in home-based primary care, and your current level of experience in home-based primary care. level of experience in home-based primary care, and your current level of experience in We've actually done a secondary analysis of that data to try to show the cost improvement for our system, the cost reduction, the cost improvement, the ED reduction that we saw with this 60 patients that we had in our training with our trainees. So we've got triple-A and quadruple-A outcomes, and we've done some additional financial analysis. So I think my main reason for wanting to participate in this is we're trying to build this program out to be sustainable. And I'm the only one, I think, in our whole county that does home visits. So, you know, trying to improve the appetite for it and make it appear more sustainable than it is at the moment. Well, thank you very much. And yeah, I mean, the way you got started, I think, is a story I hear from a lot of nurse practitioners, you know, where they're in an office or clinic setting, and they are just recognizing there are patients that, you know, are on our panel that we haven't been able to see. So, you know, let me kind of get behind that and see if I can go out to them. So thank you. Thank you for sharing all that. Sarah, next. All righty. Next, I'll have Chris Williams, if you could unmute yourself and introduce yourself next. I'm Chris Williams. I'm with Premier Medical House Call in Alabama. So a lot of our demographic is between urban and country area, if you just want to put it bluntly about that. So biggest things we face is efficiency between traveling between patient to patient. We do a lot of facilities, assisted living facilities, the bench awards, retirement communities. That's our primary. But we also do home-based. And that's where we find our sickest patients at because they're homebound because of the sickness. And the farther out you get away from the city is where we find our sickest patients because of just lifestyle habits. They don't come in to the doctor until it's too late. So we come out to them. We find that a variety of things that would have been missed had they not ever been into the hospital. So we're working on ways for efficiency and how to balance our quality time among patients. And we've established a lot of relationships with key third party vendors that we can do anything from echocardiograms, chest x-rays, venous dopplers, ultrasounds in the home setting. So that's improved us a whole bunch. And the biggest thing that I've recently come into is we've upgraded, I guess you say, our system to where we're using a Prima for charting and it's streamlined everything because it's a lot of just point and click and go to streamline in the home setting. And that has greatly improved the time efficiency in the home setting. We have another nurse practitioner that's with us and our collaborating physicians on here today. We range anywhere from 35 to 45 patients a week in my area versus my other nurse practitioners, 45 to 90. Well that tells you he's in a city setting because he's closer to a lot of patients. So that's what he sees anywhere in a day. Outstanding. Thank you very much. Next, Sarah. Dave, if you could please unmute yourself and introduce yourself to the group. Hey, I'm Dave Rader. I'm the medical director for Premier Medical House. Chris just gave a outstanding overview of the program. I'm also a general surgeon. I'm a provider for the Ascension Health System in Birmingham. And the two things I'd like to get out of this program is I'm new to the field, less than a year. And I'd like to become more conversant with it and learn more about the billing and the reimbursement and how all that works. Thank you. All right. Thank you. All right, next. Josh Pope, if we could have you unmute yourself and introduce yourself to the group. Hey guys, I'm Josh Pope. I actually work with Chris and Dr. Rader. And, you know, basically what Chris said, we, you know, provide home-based primary care. We also take care of a bunch of folks in assisted living facilities, memory care, independent living facilities, and really kind of all over. So Chris, he is kind of more in the rural area of our state and I'm in Birmingham, the biggest city in Alabama. So typically, you know, I do see a little bit more people just because there's more people here to see. But, you know, as Chris said, we're able to really do, you know, most things your typical primary care doctor's office can do. We can do it in the home setting, which has been very beneficial with, you know, all of our patients because those people that are truly homebound are homebound for a reason. They've got a lot of medical issues that need, you know, good management. So, you know, hoping to, you know, take away from this just more, you know, practice skills and, you know, more ways to do things. But yeah, really looking forward to it. Thank you. All right, Sarah, who's next? Julianne Guy, if we could have you unmute yourself, please. Good morning. I'm Julianne and I'm with Geriatric Solutions. I'm the office manager here. And I also have the practice manager, Mary Lynn, here as well. We're having a little bit of technical difficulties getting online this morning. So we are a fairly large practice. We have about 1600 patients currently. And we're covering the entire Maricopa County area, which is quite significant. We are we have about 13 providers on staff currently, and we are hoping to get some tips on scheduling and productivity for our crew. Looking forward to learning and sharing with you guys. Fantastic. Thank you. And I do love hearing about, you know, people who are here with their teams. I think that's going to be very helpful for you as you go back to implement some of the things that we're going to be talking about. Sarah, who's next? Laura Walker, if we could have you unmute yourself and introduce yourself to the group. Good morning, everyone. My name is Laura. I am a family physician with about 25 years experience in health care. I've done a lot of different things along the way, including rural family practice. I worked as a hospitalist for a while. I did various administrative things in leadership, clinical informatics, quality and population health for a while. And then I returned to clinical practice a couple of years ago. And I currently work for Carolina Caring with Patrick. And my first role with our organization is I'm a staff physician at the hospice houses and help a little bit with the palliative care program. But as our organization is launching our home based primary care program, Patrick and I will be working together on that initiative. And so we have a lot to learn just starting at the beginning, our building blocks and just really looking to learn how to bring up a program in terms of our staffing, our training, our program development and excited to learn from all of the other people in the group, as well as the expert people that we'll be learning from. So nice to meet everybody. Thank you, Laura. Sarah, who's next? Talisa Atkinson. I know you do not currently have your screen on, but if you could unmute yourself, introduce yourself to the group. Absolutely. I'm Talisa Atkinson. I am one of the medical directors at Geriatric Solutions. And Julianne had already introduced our group. I have been with the practice for about 10 years, trained internal medicine and geriatrics at Boston Medical Center, so very familiar with home-based primary care there. And I am excited to learn more about how I can get more acute fit-in visits in during my very busy day. Very good, thank you. And who's next? Valerie Safar, if you could do the same and unmute yourself and introduce yourself to the group. I've already gone, but I'll go again if you like. I'm sorry, my mistake. Forgive me. Veronica Torella, if you could go next then. Hello, my name is Veronica Torella. I've been in healthcare for 26 years, mainly as a nurse. I've been a nurse practitioner for 20, excuse me, for 20 and a half years at Palos Health. And I work for the community-based medicine palliative care. I started in palliative care, but went to the SNFs and then slowly transitioned into the community. And so I'm here to learn as much as I can to maximize what I do for those patients in the home and learn as much as I can. That's all. All right, thank you. Sarah, I don't know if we have any other learners, but maybe we could circle back to Bruce. I don't know, Bruce, we weren't able to hear you before. Do you want to try again? Hi, is it Bruce Bender you're asking? Okay. Yeah, we can hear you. First, I'm sorry I wasn't there. Second, I have difficulty hearing, so things like calling out my name could be problematic. Nonetheless, I'm here and I want to learn. I'm from Home Instead Senior Care, actually recently rebranded Home Instead. My background is as a physician and a medical administrator. I spent five years in Canada in New Brunswick, seeing a different system. And 23 years ago, my wife and I bought among the first franchises of Home Instead. We've been taking care of seniors in their homes ever since. It's kind of a big change for us. But one thing that we're very interested in is that the evolution of the healthcare system seems to be, at least to a certain extent, finally happening through efforts to create a more integrated care system. I think we definitely need that. And I think for us, we're looking at how can we match the support that we provide to seniors in their home with the healthcare system, discharges, support, keeping people as well in their lives and their families' lives as as optimized as possible. And that means building a more integrated system. We need to know how the information is going to go back and forth. We often get people with being discharged with little or no information. And we often have difficulty accessing their actual providers when things start to go bad. So we want to discuss how do we fix that. And we're overwhelmed by the payment mechanisms for private pay. All this stuff is a little bit daunting. Well, you have named some of the very real barriers that our field encounters. And so, I mean, yes, we try to start talking about some strategies that can help practices like yours and others to overcome until we can get the policy and payment situation rectified. So thank you very much. And is there anybody else who's registered as a learner whose name we haven't called? According to what I have in the list that I have in front of me, I think we've gone through everyone. Okay. Yeah. I know that some of the folks from Palos, they were going to not be able to be on the whole time. So our Palos friends, when Tony Noonan, is she going to be able to join today at all or sometime tomorrow? I was asking if any of the Palos people know, so that we can just make sure to greet her when she comes. I am not aware of Tammy's schedule. Okay. All right. Well, no worries. We'll just watch for her. And so we have a few other staff that I just want to make sure we get to highlight some staff who are newer to our organization. And so this is the first time they're going through this workshop as well. So is Rachel Jankowski there? Hello, I'm here. Good morning, everybody. I am new to HCCI and I am the Manager of Outreach and Engagement, primarily focusing on our Chicagoland area. Thanks to meet everybody. Okay, real good. And Dana, how about you? Hi, everyone. I'm the Senior Director of Engagement and Practice Development here. I provide leadership over our consulting services, as well as engagement in those teams. And I am excited to get to know you all and also your perspective and what you're experiencing every day as boots on the ground. So thank you for letting me join. All right. And I don't think Betsy, I don't know that Betsy's on right now. I had to step off for just a second. Okay. Okay. So Betsy is our Manager of Practice Improvement. I'm sorry, Manager of Provider Engagement, excuse me. And so you may have actually spoken with her in the past as well. So and then, of course, you know, our other team, Sarah and Janine and myself. And why don't we advance to the next slide and we can introduce our faculty. Do you want to go ahead and do that, Janine? Certainly. And faculty, please, pause after I say your name and please jump on and say hello. So first, we've got Dr. Paul Chang. He is our Senior Medical and Practice Advisor for the Home Centered Care Institute. He's also the Medical Director of Northwestern Medicine Home Care Physicians. Dr. Chang, do you want to say hello quickly? Good morning, everybody. I'm really excited to be here with you. Again, as before, with the previous group of learners, I wish, you know, we could meet face to face. It's just so much more interactive, but we will harness technology the best as we can. I'm hoping, along with the rest of the HCCI team, over the next two days to really share with you. I've heard the comments about efficiency, about staffing, about travel, and so on. I hope we can help you with some of the questions that you have. So I'm looking forward to talking with you all and sharing ideas with each other. Thank you, Paul. Next, we've got Dr. Costa Deleginitis. He is the Director of Education and Director of Quality at Northwell House Calls Program. He's also the Assistant Professor at Donald and Barbara Zucker School of Medicine at Hofstra-Northwell. Dr. Deleginitis? Hi, everyone. Good morning. It's a pleasure seeing you all, you know, virtually. You know, it would be great, just as Dr. Chang said, you know, to be there in person, but, you know, having a Zoom conference is still nonetheless great, and we're going to have an exciting next couple of days where we're going to go over a lot of material and hopefully address, you know, the questions that you have answered. And also, I just wanted to say, you know, as I was listening to the participants, I heard there was a lot of shared experiences. So, for example, Laura, I'm also a family physician, and I've been, I used to do small town rural practice, and I did that for 12 years, and I did full spectrum family medicine and joined home-based primary care, and I've loved it. You know, this is, you know, it's professionally fulfilling, and I'm happy you all have joined this field. It's really exciting. Excellent. Thank you so much. Also joining us today is Breanna Plentschner. She is our senior consultant and manager of practice development at the Home Centered Care Institute. Breanna's been a certified coder since 2014 and a certified medical auditor since 2018. Breanna, could you introduce yourself? Good morning, everyone. I'm really excited to be here with you all today. It's nice to see a few familiar faces. My background is in operations and practice management, as well as billing and coding, like Janine mentioned, and I just have the absolute privilege of getting to work with so many amazing house call providers and different types of practices. So, just excited to be here with you and just wanted to say thank you for all that you're doing, you know, now more than ever, and making the time to sneak away with us the next two days. Thank you, Breanna. Amanda Tufano is also joining us today as part of your faculty team. She is the chief executive officer of Genevieve. She is also a board member of the Minnesota American College of Healthcare Executives and the Minnesota Association of Geriatric Inspired Clinicians. Amanda? Hi, y'all. My name is Amanda Tufano. I'm the CEO of Genevieve. We're the largest geriatric practice in the state of Minnesota. We do a lot of geriatric work, so we're in over, I think, 100 or 110 campuses, senior campuses, so nursing home, transitional care, independent living, and assisted living, and we have a small home-based medical practice. That home-based medical practice is varied in size. A lot of our work today is in assisted living or independent living, and so I'm excited to be here, excited always to be on faculty. I think we'll have a fun day, so I have a lot of your names, and it's, hopefully, you're experiencing slightly better weather than me, but I think it's gonna be a real fun two days, so nice to meet y'all. Thank you, Amanda, and finally, as part of your faculty team today, we have Megan Verdoni, who she is the Chief Executive Officer of ER Liaison and the Associate Clinical Education Director at the Florida State University Physician Assistant Program. Megan? Good morning, everybody, so I'm Megan Verdoni. My background is in emergency medicine as a physician assistant, as well as internal medicine. I have almost 20 years of doing that. I still work full-time in the ER, but about five years ago, I really began to see a need here in Florida for patients who weren't getting the follow-up and who couldn't get out of the home, and that's how I segued into doing home-based primary care at that time, and now I have a real focus in medical education, so that's how this all ties together, so I take all those experiences and try to let you know how we've had things happen to us and what we found successful down here, and hopefully that translates to your practices. Welcome, and I'm so glad to see you all. Thank you, Megan. So our agenda for today, it's changed very slightly. Lunch is happening a little bit sooner. We wanted to let you know so you could plan accordingly, so after this session, we'll be moving into foundational principles, and then we will have some clinical care cases. At that time, there will be non-clinical track running as well, so Melissa, do you want to take a moment to talk about that opportunity for those joining us today? Yeah, so we're going to ask you to kind of let us know your plans for that session starting at 10.50 and then going through 3.15 this afternoon. Can you go to the next slide, Janine, please? All right, so I just want to kind of give you an overview, and this is really the first time we're doing this. Again, trying to meet people where they're at and make sure we're addressing their needs for coming to this workshop. You'll see on the left-hand side the clinical care topics that we'll be covering in one Zoom room. We'll be doing a lot of case-based education. We'll be looking at some patients that are very typical for home-based primary care, Ralph, Betty, and Christina, and we're going to be interspersing some mini-lectures on the topics you see there, prognostication, managing multi- complexities, so how to prioritize those patients who have so many chronic conditions and still account for their goals of care, medication management, acute and urgent care, infection control, and then rounding out at the end of the day and the afternoon there, cultural competence, medical decision-making capacity, and quality. So that's a very rich session, primarily appropriate for anyone who's a clinician, but we do have a non-clinical track too. So Brianna and Amanda will be meeting in a different Zoom room to talk about considerations for starting a practice, so if that's where you're at, kind of the very beginning of identifying your business model, your clinical model, determining service area, that kind of thing, but then also the next session starting in with structuring your home-based primary care team and how to demonstrate value to payers and others, so beginning with who to hire, roles and responsibilities for each of the team members, what are some of the options for staffing models, and then talking a little bit about key quality metrics and patient stories, and then and using patient stories to demonstrate value, and then finally in the last session really kind of zoning in on marketing and branding and, you know, identifying your unique value proposition, identifying and recruiting patients and key partners. So what I really do recommend is that if you are here with others from your practice, try to have a presence in each of these tracks, and then you can compare notes when you get back together later on, but it will be helpful for you if you, you know, if you can let us know in the chat sometime before 10 45 a.m central which one you think you'd like to be in, and you can swap in and out, you know, if desired, just kind of chat with us and let us know. So, you know, if there's, you know, between 10 50 and 11 55, if you wanted to be non-clinical but clinical the rest of the time, you know, that's doable too. I saw Bruce asked a question about whether the recording, we would be recording both tracks. That is our intention. That said, you know, I believe that that will happen, but we've had some challenges with recording breakouts in the past. I think we've overcome that, but I just want to give that caveat, and thank you for going ahead and putting into the chat what you think you'd like to be in. I think no matter where you go, you're going to get some great education, but we did, we do recognize that people are coming for different reasons, and so we wanted to offer that option. All right, so we can go to the next slide. I think we're reasonably on time. I'm going to turn it over to Dr. Chang to talk about foundational principles. Great, everybody. Janine, can I have the next slide, please? Well, just to go over the objective for this session, I want to help assess some of the perceptions of home-based primary care and dispel myths or clarify misunderstanding about HPPC. Ten days ago, I was at a patient's house. I think we spent a good amount of time just trying to explain to the husband of the patient the difference between us and home health. He was really having a hard time understanding that, and even within our health system, we're referred to as home health, and I'm in the process of trying to educate those in our EHR, so when the referral is made, it's not referred to home health. It's actually to home-based primary care, and I want to talk about some of the fundamentals of HPPC, not only to help you run your practice more efficiently, but also to equip you so you can do your job better taking care of some of our sickest of the sick patients in the country. I want to discuss the various characteristics and competency that I think is required to be a successful house call provider. We're going to talk about the four Ms in caring for older adults and how we can apply that as in our day-to-day work and to begin our HCCI learning plan, and I'll just take a moment here. I just want to say I really love teaching essential elements because it gives me an opportunity to share with you all something I'm really passionate about. I love my job, and people who are with HCCI, you've heard me say this before, and I've been doing this for 21 years, and I stepped through a lot of doors, and I met and greeted a lot of people. I love this work, and 24 hours ago, I was at a patient's house. I was lying on my back on the floor looking up at a terrible pressure ulcer on the heel. Because of the patient's size and her mobility, her arthritis, her pain, she could not maneuver to a place where I could debride that wound in any other way other than being on my back looking up. I'm geared up, you know, debriding upside down. It was interesting. You know, my arms got tired doing this because I was holding my arm up and trying to debride, but when the procedure was done, the patient and the family, they were just so grateful that I took the time. I made the effort in taking care of their loved ones. I just felt great that I had the opportunity to serve this patient in this way. You get to be part, as Dr. Cuomo said in the video, you get to be part of this amazing movement, not only providing care to these complex sick patients who otherwise have really no access or very little access to care, and also take part in the transformation of healthcare in America. So I'm excited. I know we have a smaller group of learners this time, and I hope that we can use that to our advantage, that our conversation will be more intense and more intimate, and we can share ideas with one another more easily. Next slide, please. Now, I want you all to go to I think workbook, I think it's page 12, and take a look at this particular exercise. There are three questions we want you to think about, and I want all of you just to take a couple of minutes to write down in your book, and then later on, we can unmute your microphone, and you can share with us what comes to your mind when you think of home-based primary care, both the positive and maybe not so glamorous, right? What do you think are some of the greatest opportunities and joys in home-based primary care, and then also what are some of the greatest challenges and barriers to care in HBPC? So why don't we take a couple of minutes and just jot down some of your thoughts, and then I want to hear from the audience your responses. Does anybody want to share what comes to mind first when you think of home-based primary care? I think of just filling a gap or a void in health care with patients being able to get good care because of various situations and limitations. Instead, I think we're just kind of filling that gap and meeting that need. I'll say evolving. I agree that health care is evolving into a transitional base to where we try to attack it at the home before it ever gets to the hospital. What is the group, what do you think are the greatest opportunities and joys in home based primary care. I'd say for me, it's kind of an honor to be able to enter the home and kind of become part of the family almost, you know, most of the patients I've taken care of I've taken care of some for, you know, upwards of 10 years or more. You know, I really become part of the family someone that the family knows and trust differently than the provider that they see intermittently in a white coat in the office, really, you know, knowing, you know, getting on your back. Like the doctor just just described, you know, being very vulnerable to patients not being that, you know, straight laced suit that you know patients, you know, kind of revere, but really a human being, and then being able to be with them, usually till the end of their life. And so I think it's an honor to be able to do that. I think one of the greatest opportunities from the patient perspective is, you know, the ability to have care. Otherwise, you know, there's a lot of people that cannot make it to the doctor's office, for whatever reason. So, people are happy to have care at home. Yes, thank you. Those are powerful testimonies. What about the greatest challenges or barriers to home based primary care. Well, I think, you know, kind of like what Chris talked about is just the geographical challenges. You know, we, we foresee we're launching our program at the end of June, you know, in North Carolina and our service areas, a ton of rural area. So we foresee a similar challenge with getting to patients, and when we get to those patients, what those situations are like, and the resources in the time it's going to take to give them the best care and get them, you know, turned around, so to speak, it's going to be very challenging. So I think the geography is a big challenge with these folks. To add on top of that, while you say and also interpersonal relationships that we build with the other family network physicians in the area where we not only come across as a some might be as a competitor, but they also need to look at us as a way of, we work with them. If it's just temporary, such as in gap care, when we can get to those patients and we work with them almost as a hand in hand, even though we're not, you know, employed together, but we'll say, hey, we take care of your patients for you until they can get back to you and report to you, you know, work as a team. Other thing to grow those relationships. I agree with both Patrick and Chris. Another thing that comes to mind is just the is the fragmentation of just basic healthcare information. It reminds me of. I've been waiting for a urine culture to come back from a big health system, all week long, and this morning one of the first emails I got is, you know, we're still having a hard time tracking down that urine culture result. Think about how that should be such a basic request has healthcare so fragmented, and our, our electronic health records are fragmented and information just is not readily available, something that is, is just so it feels like it should be so easy becomes I think that's another piece with this additional layer of home based primary care is, how do we get our providers and patients, the information in front of them they need to make good decisions. I think the big challenge I have is the, the EMR, you know, obviously having access to it in the home with the new technology but, you know, just all the layers that you have to go through and sometimes the firewalls break down and you lose contact and, you know, I look at my colleagues, because I come out of a primary care office and they all now have computers in the rooms and computers on their carts and computers in their offices and I'm struggling to just look a urine culture up, or, you know, be able to, you know, document all the time and it's, you know, they're long days with documentation, because most of the documentation for me gets done at the end of the day, you know, I've got my notes I've got my information I've got everything but to be able to keep moving. I have to, you know, finish it up later. And so that makes the days extremely long. Anybody else? Yes. Can you hear me? This is Chris Bender. I think primary care is being very different from specialist care for the most part. We've got so many people, particularly in the senior population now, who have multiple ongoing issues that I think the focus of primary care, particularly home-based, is much more longitudinal than the kind of care that you get in a hospital. And you were talking about debriding an ulcer for somebody at home, and I was thinking, you know, in a perfect world, we would have been on top of it, and perhaps we wouldn't have the ulcer. And I really think that's a big part of the goal. And it's really difficult in the current payment structures to get credit for keeping that ulcer from happening. So I think it's very different. We need to be aware of it. Well, thank you, everybody, for your comments, and can I have the next slide, please? As I'm listening to all of your great words and concerns and so on, and I hope that over the next, like I said, the next two days, we'll be able to help you with, I think there's talk about technology, geographic scheduling, electronic health records, about relationships, and so on. And I hope we'll be able to answer some of those questions in our time together. But if you have a specific question that's not addressed, please let us know, and we'll do our best to get back to you with some comments and suggestions. So quickly, what is home-based primary care? It's a model of care that brings providers and modern technology to patients so we can care for them in the comforts of their home. We want to improve the quality of life for the medically complex patients and their caregivers. I tell my residents when they rotate with me here, it's always a pair. It's always the patient and the caregiver. We've got to take care of both of them because if the caregiver doesn't do well, the caregiver panics and so on, the caregiver doesn't have the information or feel equipped to take care of the patient, they may panic and call 911 where they don't want to go. We want to prevent hospitalizations, ER visits, and nursing home placements, if at all possible, and we want to dramatically reduce health care costs. So the next couple of slides, as I think about the next 30 minutes or so, I'm going to give you really an overarching view of home-based primary care. I'm going to talk about structure, finance, about the value, about competency of a provider, and about how to approach a multi-complex patient at home. I hope you can take some of the information, whether you're new to the field or maybe you're seasoned in the field, that you can apply this to your practice, to encourage your providers as you're recruiting, or maybe have some bullet points for an elevator speech as you are talking with the C-suite people about the value of HPPC. Next slide, please. Well, home-based care really fits in very nicely with a quadruple aim. As you know, it started with a triple aim, the top three, and then that was in 2008, and then the last bullet point about recognizing, hey, you know, we need to acknowledge the importance of workforce in this whole health care transformation. If they're not happy, if they are retiring early and so on, the triple aim is going to have a difficult time to come to life. So I think HPPC, we know this, and we have data now to show from different studies that we meet all the quadruple aim in terms of outcome, whether you're talking about independence at home or the VA data, improving health care patient experience, lower cost, and great job satisfaction for provider and their staff. So this really fits nicely with the transformation aspect of health care here in America. Next slide, please. So HPPC comes in many different forms. It's not like a one-size-fits-all. Just listen to your fellow learners here. We come from different backgrounds, whether you're an academic medical center that's involved with education and research and teaching residents or fellows, whether you are an independent group practice that tends to reflect the local culture and the passion of the entrepreneurial founding provider, perhaps. Or maybe you are a community-based hospice and palliative organization adding home-based primary care to their hospice and palliative care services in a way to close the gap in care among those who are seriously sick but doesn't quite want or qualify for hospice care. Or maybe you are part of a value-based managed care organization that is realizing that, hey, you know, what you guys are doing can really not only help the patient but reduce cost. So it comes in many different forms in terms of just overarching structure. Next slide. But also it can differ in clinical care models in HPPC. There are two broad categories of that. One is transitional care, where you provide care at home to a patient for a defined period of time. For example, we're seeing a patient who is otherwise reasonably healthy but who is involved in this terrible motorcycle accident and is really in a bad shape. So the anticipation is to take care of this patient during that recovery period of time, manages diabetes, heart, lung condition, and so on, and get him better to the point that he can be transitioned back to his primary care provider. So that's one model of care. The other is more of a longitudinal care. That's what I do for a living, for the most part for a living, where I become the PCP for the patient. Because these patients, as you know, they can't get out to the PCP, to their specialist, because they have multi-complexity. They have mobility issues and so on. And often these people are older. They get the fragmented care in the ER, which we all know is not great. They have very limited contact with their PCP. And that's where we come in, and we become the PCP. We become the coordinators, helping them with counseling or social services. We collaborate with hospitalists. We collaborate with specialists to really bring as much care to these patients as possible, so that they keep on living and thriving where they are. And they don't want to go to the ER or the hospital. We're going to do our best to help them achieve those goals. Next slide, please. Again, in terms of administration of a house call program, you can be part of an academic department. You can be part of a hospital medical group. You can form your own professional corporation or LLC. Your operation could be supported by a health system or academic department. You can have staff that's directly employed under your department, or your staff could be outsourced or contracted. Or you can have any of the above combination. So I hope that next slide, please. I hope that you can get a feel that practices are very different across the country, and that we get support and vision and energy in different fashions as we carry out our work. As I look at, you know, what makes a practice successful in doing house call medicine? Number one, I think you have to have great clinical leadership, somebody who's energetic, who's a visionary, who truly believes in this model of care. Number two, this is very obvious, I should say. You should be providing great, outstanding medical care to some of the sickest of our patients. Number three is efficient scheduling. And we talk about minimizing windshield time, especially if you're in a service type of arrangement, trying to get to see as many patients as you can. You need to have a protocol for handling calls and triages so that you can not only respond to the calls in an efficient manner. So to, say, keep them out of the hospital, the emergency room, as well as to minimize the interruption and the flow to the provider's day. Care coordination and social services are huge aspects to what we do, because as you know, our patients are complex medically, they're complex socially. And I tell my patients, I'm only a doctor, I cannot fix all of the problems. I need help, I need professionals like a social worker or a counselor to help you work through some of the issues that you're having with mom. I have a patient who called yesterday about needing some resources to help her cope with taking care of mom who's got advanced dementia. We need to make sure our visit follow-up orders are executed and are clear. And also to have a unified team in the office. This is hard enough work as it is to have a team that's a little dysfunctional, maybe doesn't share in the vision of the practice, can add additional challenge. Efficient revenue cycle management support to make sure you get paid in a timely way for the work that you do. Again, having resources, either internal or outsourced or handouts that you can provide to patient and family so they can feel supported and be educated. And finally, data is so important as we're talking about. Somebody mentioned about the reduction in ER hospitalization and so on. It's important for us to have that information, not only for quality, to demonstrate our value to those in management and show them that we may not make money in a traditional fee-for-service way, but we certainly can reduce costs for the system through a different mechanism. Next slide, please. This is kind of a duplication of the previous slide we talked about. You need to understand your market and the demographics, who are you hopefully hoping to serve, whether it's a transitional care model, whether it's a longitudinal care model. And the other, I think I do a fair amount of assisted living care as well in several facilities here in our service area. Is that an eligible patient population? Is that a target that you want to go after in terms of what you can do with the staff? And maybe to balance out the long travels that you have with your other rural patients, you can pick up more facility patients and you can see more patients on those days and balance out your revenue when you need to travel and see less patients on those rural travel days. Next slide, please. It's important to have some basic understanding of how your practice is doing financially to understand the revenue side and then the expense side. Who are your payers? What are your percentage of your payers? Are you able to get any additional sources of income through philanthropy or direct contracting with a payer? And then understand the expenses, the direct expense of such as staff salary and benefits and drugs and supplies and equipment and rent and travel. And also your provider expenses, your physician provider and your APP and your malpractice. And then finally, the indirect expense, such as your overhead and other taxes you have to pay. Speaking of compensation, providers are compensated very differently. As you know, compensation for a provider is the single largest expense of a of a house call practice. Some practices pay their providers on a base salary with a bonus or per visit completed or base salary tied to an RBU or some hybrid or some combination of the above. So, again, it's not a one size fits all kind of thing in terms of looking at payment for the provider. Next slide, please. I think it's important to have an understanding of the value that you bring not only to to the patients, but also to a health care in general. I think it's important for two reasons. One is, you know, to help your staff to stay focused and passionate about what they do. So that's an internal thing. And the other thing is I talked about is I think it's really important to have this elevator speech ready. Whether you're talking to media, whether you're talking to the C-suite, you can quickly show them that, you know, we do great work. We do we help you keep out of the penalty for the 30 day readmission. We help take care of our patients who are the sickest of the sick in a more cost competitive fashion. We help cut down costs of ERs and hospitalization. We have great patient satisfaction scores. We have great high quality care, whether you're talking about vaccinations, whether you're talking about, say, an advanced care discussion and so forth. It's good to have this information as you talk with the community, as you talk with people who are in market relations and say, hey, you know, we're taking care of our neighbors. These are people who live in our backyard and we're here to help serve them and philanthropically help people recognize that there's a huge need for this. And we are really in a unique position to fill that need. Next slide, please. So why the interest in home based care? This is a white paper that Dr. Cuomo put together a few years back. I encourage you to take a look at the paper when you have a moment. Basically, there are four main driving forces. The main driving force is the aging of our of our society. And the second would be the advancing of excuse me, advancing of our technology. I have a this is a remote stethoscope that we use in our practice. We have a mobile six lead EKG. Some practices are now using POCUS or point of care ultrasound at home to help take care of our patients with heart failure, with COPD. When we're not quite sure, you know, is he short of breath because because of A or B. So having POCUS can give us some additional information in managing our patients. And of course, many of our patients and families have wearable devices now to help track their multitude and multiple different biometrics. Whether you're talking about heart rate, your weight, your sugar and so on. Next will be payment reform. And finally, the lowering of of hospital mortality rate through good end of life care. Next slide, please. You know, I've been asked, you know, what are some of the successful what does it take to be a successful house call provider? This is not your this is not your everyday office office job. It isn't. Somebody mentioned earlier about, you know, it is a honor and privilege to step into the patient's homes. But we're we're. How can I say this? It is. We're under turf. And each home is different. And it is very unstructured. Right. So you got to you can't have the mindset, you know, every exam room is the same and so on. So you need to have a little bit of flexibility. So and and and and charisma to do this kind of work. So here's what I call the eight C's in terms of being a successful house call provider. One is being competent with complexity. I've already said these patients are complex medically, socially and many other ways. Right. We need to be able to handle this complexity without feeling overwhelmed or frustrated. Number two, we need to be able to communicate comprehensively by that. We need to talk about all their conditions. We need to talk to the family members if necessary about their conditions or the specialists about the conditions of the home health people that's involved. So we need to be able to talk with various individuals involved in the care of this patient. We need to have a certain degree of character and composure. Character is key. You know, we are in the patient's home. We have to be honorable. We have to be good individuals to take care of them in the privacy of their home. And we need to have some composure. Those of you have made house calls before, as you know, not every house is a clean house. Some have clutter, some have strong odor that even when you open the door, you're just hit with that that fragrance. And you need to maintain your composure as you go about taking care of this medically complex patient. And lastly, you need to be considerate and compassionate. You need to be considerate in a sense that these again, you're stepping into the house and you're a guest, whether you are putting down a plastic barrier for your bags or putting on shoe covers over your shoes. You need to be considerate of what they want from a guest that that's walking into the into the home and compassionate and in caring for these patients and their loved ones. That's I think it's it's so important to reassure the patient and the family through very difficult times, as well as to inspire others to do this kind of work and share with them the important part of what you do. Next slide, please. It's important to have a mission, and it's important to periodically remind myself, remind my staff, you know, what are we doing for our patients? We're managing their complex medical conditions. We need to exquisitely manage their medication. We have a lecture later today on medication management. We need to be able to balance multiple laboratory abnormalities and diagnostic testing findings and put forth a plan that's really optimized for this particular patient. And then understand the psychosocial and the family dynamics that's involved in the care of these complex patient. As I've stated before, if we neglect to take care of the family or if we don't address this patient's depression, his condition may not improve. Next slide. Yep. So again, just quickly, some key competencies for a household provider. And I think there is a link to the American Academy of Home Care Medicine. There's a list of competencies that they have listed. Here's just something I put together, advanced clinical skills and knowledge. Again, I'll talk more about this later on in the multi-complexity talk. These patients have, they don't have just a little COPD, right? They have advanced COPD. How do you manage that? Advanced heart failure, advanced CKD, you get the idea. You have to be competent in diagnosis and treatment of those advanced illnesses as well as some of the procedures. I talked about debridement in the advanced application course. We talk about, we can teach, we do teach learners about joint injections, wound care and tracheostomy tube changes and G-tube changes and so forth. Next is a commitment to the integrity in order to provide safe and quality care for the patients within the home setting. The provider, you know, when we go out and see patients, we are alone. And I think that's on the first exercise that we did, one of the greatest challenges. You know, again, after all these years of doing this, it is still being out in the home alone. I really need to know my stuff. I need to have some composure. I don't quite know what to do next. So I have to be able to work independently, but I cannot be just a silo, right? This is teamwork. You know, home-based care is never just about Paul Chang. It's never just about me. It's about relationship, having a team help me to do the work that I need to do, having good interpersonal communication skills with my staff, with the family, with other providers and so on. The provider needs to have good time management, good organizational abilities and be able to handle multiple priorities. And again, you know, our work is complex. Our lab values are complex. Our phone calls are complex, right? So you have to be able to manage these different demands and keep track of your time so that you can not only see the patients that you need to see, but also get back in terms of a response to a patient or family who might be wondering what to do next. And finally, I think the provider needs to have great written and verbal communication skills. Again, you know, a lot of what we do is talking and sharing information and guiding patients in terms of, you know, finding goals to care, optimizing the medication and so on, or getting hospice or telling them the difference between hospice and palliative medicine, right? So having those skills and being able to communicate is really important. Quickly here, the four Ms of caring for older adults. This is the approach when residents rotate through with me, I had one here on Tuesday. I have a resident rotating with me every month. The four Ms, these are, I'll just quickly go through them. The first M is what matters most. Next slide, please. That's the first M, understanding the healthcare goal and preferences of our patients. Do they want to pursue curative care? Do they want to follow up with their specialist? Or are they looking at more palliative and hospice care? Understanding their goals and preferences in applying prognosis and medical decision-making in the context of risk, benefit, functional status, and overall quality of life, and helping patients and family clarify for them and for us, you know, what we should do in terms of next step in their care. And making sure that the patient's goals and care preferences are reflected in the treatment plan and then it's being honored. And that's important, for example, to have advanced directives placed in an EHR so that everybody's aware, especially the emergency room, if the patient does show up unexpectedly. Coordinating advanced care planning and communication of this clearly, which I spoke about just a bullet point here ago. And then adjusting, it's not a static thing, right? It's adjusting and updating the goals and preferences with health changes. You know, people ask me, you know, when do you talk to patients about advanced care planning? One of the opportunities for that conversation is when they come back from the hospital or when they come back from the nursing home and you just revisit with them, you know, say, you know, how was your stay? Have you thought any more about your advanced directives? Has the hospital stay changed your perspective on that at all? So that might be an opportunity for you to update the care plan. So that's the first M is what matters most. Next slide. Is meditation or mind. Finding ways to help our patients maintain their mental activity, whether it's through a puzzle work, puzzle book or electronic versions of that, encouraging them to stay mentally active, identifying, addressing social isolations and stressors. You know, COVID has been so hard as many of you know, for our seniors when there was a lockdown, right? You can't visit, no family, you're locked in your room, you ate in your room and if you are hospitalized, nobody can visit you. And just the catastrophic outcome that has been, that I've seen in our patients, you know, how do we address social isolation and those stressors? Monitor mental and cognitive wellbeing, whether it's through blood testing or optimizing the medication, identifying, addressing cognitive impairment, you know, considering their goals of care and changing your care plan to support their needs over time. Don't forget the caregiver, that theme is gonna come up over and over again, right? Help identify, treat and prevent patients with delirium and I wanna add their depression as well, working, whether it's testing or medication or both. Next M is mobility. We wanna be able to help our patients maintain their ability to walk or to be as mobile as they can, to support them in their ability to be independent in their ADLs. We wanna help minimize their falls by addressing risk factors and optimizing the home environment. That is such a huge opportunity for us, that office doctors, they don't have that chance. So, you know, at the end of my visit, I do what in real estate is called a walkthrough, right? I say, you know, show me how, you know, mom's day, you know, this is mom's breakfast area, this is where mom sits, show me how does mom get to the bathroom, get into the bathroom and so on and so forth. The walkthrough really helped me identify, hey, there could be potential risk factors in terms of falls and also, hey, you know, I think a grab bar here would be good, getting rid of some of these rugs here might prevent falls, having a nightlight here and so on, you get the idea. Being at the home, you really have an opportunity to see the home environment and optimize your treatment plan, especially related to mobility and get the team involved. Some of the areas, some of the practices, some of the cities have these volunteer carpenters and whatnot, they donate their time and material to help, say, build a ramp or put in a grab bar to help patients with mobility and safety. Remember, you know, get a team involved, social services or these volunteer services. Next is medication, reducing polypharmacy. We did a research study here in our practice, the average number of medications our patients take, 18, one eight, that's way too many, you know, one of our goals here is going to reduce polypharmacy, realigning medication dosing with a patient's need and their safety, their grant and clearance, de-prescribing medication, optimizing medication at geriatric friendly dosing, whether it's like a kidney function or a liver function that needs to be dosed more appropriately. Utilize the opportunity to review the medications in the home. Again, this is something unique to home-based care, like show me how you inject your insulin, show me how you use your inhaler, where is your spacer for your inhaler that I prescribed last time I was here? You can not only identify, hey, there's a gap here, or perhaps a patient simply is not using the medication that you imagined that should be used, right? And finally, educate the patient and the caregiver on the benefits and the side effects of medication. Next slide. So those are the four M's. The fifth M is bringing kind of all together. It's about multi-complexity. It's about helping older patients manage their multiple conditions. It's about assessing living conditions impacted by social determinants of health, optimizing therapy and care plans, choosing therapy to maximize the benefit, and to enhance function and the quality of life, to really pull in care partners to support the function of the patient, and to talk about different philosophy of care as appropriate. Again, whether it's curative care or palliative care or hospice care, depending on the stages of the patient's condition. And also coordinate and integrate the recommendation from specialists, weighing the risk and benefits. Somebody talked about being at the home, having that relationship, having that trust, right? You're a part of the family. I think that was the word. You become part of the family. They really depend on you. They talk with a specialist, but they want to hear your opinion, whether it's about going for the next round of chemo or getting a TAVR procedure done and so on. They look to you to guide them through some of these difficult decisions. Next slide. This is just a slide about multi-complexity. It's not a, I do it once and that's it. No, it's about this constant cycle of, I plan, I do, I check, and I adjust, and I keep going depending on the condition of the patient, the lab value, their goals of care, and so on. Next slide, please. This is just to introduce the idea of, choices can have dramatically different outcome. This is a movie by Gwyneth Paltrow. It's called Sliding Doors. Basically, it's about her missing her subway ride. And one storyline, when she did get on the subway, what happened? And the other storyline is when she missed the subway, and then what happened? All that is to say is to demonstrate that our choices, our recommendation, our treatment of our patients can have dramatically different outcome. Next slide. And we'll take the opportunity to show this little video, and then think about the outcome. Think about the four Ms that you've heard, and how it applies to the story of Fred. Next slide, please. Thank you for watching! So, the key takeaways, the perception of home-based care can vary significantly among clinical providers, healthcare managers, administrators, as well as the general public. Home-based care is not a one-size-fits-all program. The decision you make will impact your ability to achieve the goals that you desire, and regarding operational efficiency as well. Don't forget the four M's in terms of having a framework that helps focus in some of the top areas in caring for the older patient. And just remember this cute little video about the tail of two treatment pathways that minor recommendations and decision changes and so on can have a dramatic impact in the lives of your patients. Next slide, please. I just want to remind you that this workshop is just one component of a broader comprehensive educational program for house call providers. We have essential elements, as I already talked about. There's advanced applications of home-based primary care. We have a very large online course library. There's a house call practicum that Dr. Cornwall talked about, as well as webinars of virtual office hours talking about topics that's important in home-based care. And finally, there's the ACCI tools and tip sheet where you can get a lot of helpful information to help with your day-to-day practice and operations. Next. And this is your learning plan. And this is intended to help guide your thinking and your development. And think about the session, the objective, and to review them. And I won't talk too much about this for the sake of time, but just take a look at that and fill it out. Especially, I should say, about, you know, what do I still need to learn more about? Were there additional topics about the session that stimulated your interest or revealed that you may have some additional learning need? All right, that is it. And Melissa or Janine? Just a note about the learning plan. Thank you so much, Dr. Chang, for that session. A note about the learning plan, a copy of that was sent to you via email this morning. So that is something, it is a fillable form. And we do ask that you write your thoughts in that today and save it. And then within the form, there's an email address to send it back to. It will guide the conversations over the next couple of days. So thank you. If you haven't received that, just let us know and we'll make sure you get a copy. Up next, we have Dr. Dela Giannidis, and he will be going through the house call simulation and patient assessment. Let me know when you're ready and I'll advance your slides. Hi, everyone. And I just wanted to say, first of all, thank you to Dr. Chang for his presentation. And I just wanted to also mention that there are components to that presentation that's going to be repeated in future presentations. So kind of like foreshadowing the particularly the quality presentation at the end of the towards the end of the day. There are going to be some components that Dr. Chang had mentioned that will be repeated then as well. So just stay tuned for that. So if we can have the next slide. So this presentation is going to be a house call simulation and patient assessment, and we're going to review the essential elements of an HBPC assessment and care plan. We're going to view and discuss afterwards a simulated house call. And we're going to describe some recommended approaches to just different aspects of clinical care for homebound patients, including med management and prognostication and acute urgent care in kind of future mini lectures. And after this, after this presentation, we're going to have three clinical cases, three different HBPC clinical cases for those doing the clinical track. And we'll be applying the four M's in the care of older adults when we review those cases. So next slide. So I know these are in your workbook. I believe there are pages 14 in your workbook. But I wanted to ask, you know, when you have, before we go into this example of an HBPC assessment, when you are doing an intake for a patient before you see them, and when you're getting information about them to, you know, to enroll them into your program, what information would you like to know about them? And this is just a question for anybody. We usually take in a home health referral form that is either a HPI from a previous provider or discharge note from the hospital, say if they weren't attached to a primary care provider. And we use that information there and also discuss with the home health program company who's already set up with them. Social determinants of health, yep. Thanks, Laura. Any other information? Chris, I think what you said was right on target with when you have referrals from a certain referral source like home health, having the background information, the HPI, having hospital discharge paperwork, I think that's really critical. Yes, Veronica mentioned why are we needed in the home? Yep, excellent point. And what makes them homebound, right? Anything else people would like to know before, you know, when people do an intake? Kind of anticipate people's needs. One thing we always found that was really important was to see if there were other providers that might be going out to the home as well. We ran into some times where the home health company had also called another home physician and that made it kind of awkward if we both got called out but didn't know it. So always make sure that you're the only one that's going to the patient's house or they're not expecting anybody else. That's true. And I see here also if it's appropriate to obtain a med list prior to the visit and pre-populate to the EHR. I agree. I think it's important to have, just as HPIs and discharge paperwork from the emergency department, I think it's important to also have a med list as well. These are great, great points. And I also, Megan, I just wanted to also say I had also been caught in an awkward situation when I went to see a patient and actually when I was there, the other provider came into the room and we were looking at each other like, what are you doing here? Yeah, I bring it up because I hate, I mean, we talk about geography, we talk about efficiency and there's nothing that just makes your heart sing faster than realizing I didn't ask that question. So that's a priority as long as I get all the other medications and everything else. Right, right. So excellent points. You know, I wanted to call your attention to that and to just an example of an HBPC demographic intake form on page 14. And the, you know, it's kind of one of the routine things that our practice does. And, you know, and I'm happy to see this as an example, also that HCCI provides. You know, you get, you know, patient information, you get emergency contact information. I think it's important to have that, you know, right off the bat. Obviously responsible financial party and primary insurance and secondary insurance information. The current or the previous PCP, I think is really important just to get, you know, charts or get, you know, a discharge summary, you know, just get some medical records from those providers. And, you know, to Chris's point, I think it's really important to have that. When Chris and Laura brought up the fact, I think it's important to have both and to have the medical records and to have med list and problem list kind of ahead of time. Because it helps you anticipate people's needs. The, you know, there's also, you know, other information. Do you have home health? Do you have other agencies that are coming into the home? And then the, actually another really important thing is look, asking about durable medical equipment. Because if there's, for example, I don't know if this happens to everyone, but if we get someone from hospice and they have, you know, durable medical equipment through hospice and hospice has to take it, we have to, and if it's needed, we have to arrange for a transfer of that durable medical equipment to, you know, to another agency. So it's, so DME is also a key. And then when we do, when we do the intake and we go to see a patient, and we'll see this in the video in a little bit, an example of a HBPC assessment form is shown there on page 15, I think 15 through 16 here. Actually, yeah, 15 through 17. So some of the components and, you know, for those, for our clinicians and the audience, you know, this is going to be kind of, you know, obvious, but you're going to ask, you know, chief complaint, HPI, past medical family, social history, you're going to perform a review of systems. And then the medication management, having that list of medications, I think as Megan had mentioned in the chat, having it ahead of time is really going to save you a lot of time because you can simply review it and determine their understanding of medications. So for example, oh, you're taking this medication. Tell me what, why you're taking this medication. So, and then for new or even established patient screenings, it's helpful to, you know, according to the clinical scenario, you might want to go through a certain screening test. So for example, cognitive assessment, depression assessment, PHQ-2 or PHQ-9, you know, opioid risk, like the ORT assessment, the OTP assessment, and then going into a spiritual assessment, safety abuse assessment, caregiver assessment, and social determinants of health assessment, as Laura had mentioned in the chat earlier. And then you'll go into the physical exam and patient and talk about patient preferences and goals of care, and then come up with a problem-based assessment and plan. As it'll be mentioned in the video, I think, and I kind of want to underscore this point is that when you do your first patient visit, I find it really critical to have that advanced care planning discussion right off the bat. It's, if people are kind of on the fence, you've at least started that discussion. And then at a subsequent visit, you can say, remember that discussion we started having at the first visit, let's go back to talking about that. It's better to have a discussion about advanced care planning when things are not in crisis mode than when they are, because emotions flare up and misunderstandings amongst caregivers and family members happen. And it gets away from care that matters. So I try at the end of every visit, to have a conversation with patients on advanced care planning. Yep, exactly as Chris said, prevent the sudden decision scenario. Yep, exactly. So let's go to the next slide and start the video. Thanks. Thank you so much for joining us today. We hope you have a great day and we'll see you next time. Okay, Rebecca, so I just went through Brianna's morning email, and there are a few changes to our schedule. Hmm, cancellations aren't ideal, but in this case, it's a good thing. It's Betty Connolly, and she's going with her sister to visit her new great-niece. Remember when we first started seeing her? The only time she ever left the house was when she was being transported to the ER. Oh, and we're seeing John this afternoon. His mom says that he's really congested, so I grabbed a Leukin's tube. So our first appointment for the day is a new patient visit, which is always nice. Her name is Sharon May. Her chart says she's a 72-year-old widowed white female with congestive heart failure, hypertension, and arthritis. I'm going to finish reviewing the chart and the rest of today's patients. Let me know as soon as you're finished restocking the bag and mapping our route, and we'll head out for the day. When you arrive at the house call, it's important to keep your own safety in mind. Always carry a charged cell phone, have accurate directions, and always make sure someone knows your exact schedule and the addresses of where you will be going. While you're out, periodically check in with your office. And if you're delayed, let someone know. When you arrive at your call, survey the surrounding area for any dangers, unsecured pets, or conditions that may impact your patient's quality of life. Ah, right on time! Great! I am Dr. Hoffman, and this is Rebecca. Hi! Come on in! Thank you so much! Sharon, is it okay if we set our stuff down over here? That would be fine. Okay, great. So it was fun reading about you. Thank you for submitting your information. I understand that you've got some grandchildren? I do. Eight of them. Eight of them! Oh my gosh, that's a blessing! I'm just going to have a seat next to you over here. Okay. So Sharon, how are you feeling today? Not much better, really. About the same. Okay, I'm sorry to hear that. I've got all of your information in front of me, but I'm going to go ahead and ask you some questions just so I make sure that it's all the right information. Okay. Okay, and then while you're talking, is it okay if Rebecca takes some of your vitals? She'll just check your temperature and take your blood pressure. It's fine. Okay, great. I can see here that it says you were diagnosed with congestive heart failure in 2015. That's correct. Correct? Okay, and you've been taking medication for that? Yes. Okay. You've also got arthritis in your knees, and I see that you've got your walker. You weren't using it when you answered the door. Why is that? When I'm in the living room like this, I can kind of hang on to the furniture, and it's awkward to try to get the walker in between the sofas. But when I'm walking down the hall or in an area with more space, I do use the walker. Okay. Do you have somebody who checks in on you? My sister's daughter, Isabella, comes by maybe every other week or so. That's a beautiful name. Do you guys ever get a chance to go out of the house and do things? We can't really because my wheelchair is so heavy and so bulky, and to get it in the trunk, it's just really difficult. I see that you are taking amlodipine for your blood pressure. That's correct. Okay, and you talked a little bit about being unsteady and feeling a little dizzy. Right. When I stand up, especially from a sitting down position, I get a vertigo type of sensation. Okay, and when you're standing? Lightheaded. Okay, lightheaded. Do you feel like you might pass out? At times, I do, right. Okay. The arthritis in your knees, are you taking anything for the arthritis? I do take some medication for the arthritis. Okay. Do you feel like that's helping? It does. Okay, we'll take a look at that when we go through your med reviews as well. There's also some exercises that we can show you to do with your walker that just might help with some strength as you're moving around. Okay, so why don't I take a look at you? Okay. Before you finish the call, there are several important things that you must do. The first is to discuss advanced care planning with your patient. This can occur at any time during the visit, especially if the opportunity presents itself naturally. If not, it is important that before you leave, you discuss and document next steps with the patient and any family who may be present. You may need to revisit these steps on a return visit. Second, be sure to schedule a follow-up visit. Third, answer any questions the patient may have. Fourth, remind them how and when to call your office if they need anything. And last, thank them for their time. So your heart's pumping your blood down, right? And what we want to do, and that puts all of the liquid and the fluid down around your legs and your ankles, which is where you're experiencing your swelling. So what we want to do is we want to increase your circulation. So one of the things that you can do really easily is just walk in place, and you don't have to do it for very long. Absolutely do it while you're in your walker, and you can do that while you're watching TV. Okay, so what we're going to do is we are going to drop your amlodipine from 10 milligrams to 5 milligrams, and we'll see if that helps with the dizziness. We talked about switching you from the Advil to Tylenol, because the Advil is something that we think is probably blocking your water pill, which is kind of making the swelling a little worse. And then things that you can do, right? So we'll move your pillows to this side of the couch before we go. If you are going to sit on the couch, maybe have a pillow under your legs, keep them elevated. That should help. Some of the exercises that we showed you where you can start moving your feet while you're watching TV, maybe five minutes as you're watching your favorite show, and that'll just help with your circulation. So there's some other things on here, we talked about walking in place, and then your medication changes is right up here, and then we're going to move your furniture. If you could, maybe talk to your family over the 4th of July weekend and see if they could help you get a smaller coffee table, and that way you can get your walker around so it's more accessible for you. So I'm going to leave this here with you. If you have any questions, Sharon, call us, okay? It is never a bother. It bothers us when we don't hear from you, okay? We want to know. We want to be able to answer your questions. Is there anything else that I can do for you before we go? I think this is great. Thank you. You're welcome. If you think of anything, give us a call. I will. I will. Okay, great. The home visit isn't finished until all charting has been completed and any calls to family, power of attorney, and other caregivers have been made. Properly dispose of all medical waste, restock standard supplies, sterilize all equipment, and recharge your electronics so you can be ready for the next day's visits. Remember, a successful house call begins outside the home. All right. So, I think, I think that was just an excellent demonstration of just a coordinated and efficient visit. Obviously, taped up pre-pandemic. But I wanted to, I wanted to just go around and, and kind of like debrief, debrief the simulation. And, and, and I'll go into each question, one by one. So what did you observe about how the care team prepared for the visit? I see teamwork. Yep. It reviewed the schedule. Focused on the patient's concerns, yeah. And like more specifically, before they even got to the home, yeah. Love to have a scribe, yeah. Anticipated needs, supplies, yep. Organized, ready for the day with supplies, yeah. Yeah, I mean, I think that's, yeah, a scribe would be very beneficial and allow for increased productivity. Yep, absolutely. I mean, I think the really important part, and reviewed the chart in pertinent information, thanks. I think really important was that anticipation of needs. I mean, how disruptive would it be for you to go to a patient's home and say, and they'll say, oh, they need their Foley changed, and oh, shoot, you don't have a Foley. And so now you have to go back to the office and then, or arrange for a Foley to be brought to the home. That makes the visit really inefficient. So anticipating all the different needs, having the supplies is really important. Sometimes what I do, especially for some unanticipated needs, like for example, a PEG tube, because I change PEG tubes in the home, I'll have three different sizes of PEG tubes in my car. And so that I'm, in case of a patient that needs a PEG tube change that they haven't talked about already ahead of time, I'll be able to just change it right then and there. The other thing I just wanted to mention is that they kind of like planned out their day. They talked about the travel route and they also called to confirm the visits. I think that's also really important because if patients for whatever reason are not at home, maybe they're at, maybe they're even at the emergency department from overnight, the previous night. It's important to call ahead of time and confirm the visit. Okay, so the next question is, what did you notice about the start of the patient visit? Shoe covers, yep. Intro to the practice. You put a chuck down on the couch before she put her bag on it. Yep. Asking a medical question about, you know, to establish caring, to establish rapport, right? And in some, oh, Megan, I think you had said that they put the, you know, the cover of the chucks on the, yep, the shoe covers. And, you know, I mean, they were aware of their settings and it was like, it was a pair that had gone into the home. Sometimes I'll go to the patient's home alone. And other times when I feel like either I need, kind of, for lack of a better word, a chaperone, you know, I'll have one of, I'll have a, you know, one of my staff members with me. Or if I feel like there's, I need help, like, you know, a second pair of hands for, you know, a procedure, I'll have someone go to the home with me. All right. So the third question, during the first part of the visit, what were some of the things that the physician said and did that's a little bit different than the traditional office visit? Well, I think she made some comments about, you know, her utilizing or not utilizing our Walker. You know, which in her home, which would be obviously not the same in the, in the physical practice. So, yeah, and she kind of called her out on it too right. Yeah, and, and honestly I think that's the, that's one of the great things about home based primary care said settings, is that you see the environment in real time in real life, not an artificial facade in the doctor's office. You know you see any environmental challenges that patients have to negotiate. All right, so how about, how about the physical exam. How is that different than a typical office visit. No gown. being flexible to the surroundings. Yep. Yeah. And, you know, I, one of the things that in this demonstration was, might be different for your practices is that they did vitals, they did the exam, and they did blood work at that visit. Our, for example, our practice, we don't do our own phlebotomy. We have a home draw lab that goes out to do the blood work for patients. But obviously, if you have to draw blood, making sure that you have the right equipment and the biohazard bags, vacutainers, all that stuff at the visit. So, I'm just taking a look at the chat here. First visit, I always make notes of the home, especially if another provider has to cover for me. Yep, that's a great point. So, how did the physician handle the different dimensions of the patient assessment? So, for example, we talked about that, they introduced the program, but how about the environmental, social, medication, functional, psychological, like those assessments? How did those happen? So Veronica mentioned the physician asked about the family and it wasn't just the grandkids, but also checked in. She mentioned that her neighbors check in on her. Yeah. Laura mentioned thinking of the contrast to the traditional office that the dynamic is different. The team is a guest in the patient's home rather than vice versa, that's true. And Bruce mentioned that the physician wanted to know the patient goals and obstacles to achieving them, right? Yeah, and one of the things I did wanna mention was that she was able to demonstrate some exercises as part of the care plan with the equipment that she already had. And she was able to talk about how they were going to need to arrange the furniture so that she was safe at home and she could take care of the walking with the walker, which kind of goes into the next question, what patient safety issues did she address? Great, excellent. So Chris mentioned, and Laura mentioned polypharmacy, adverse effect of the medications, falls risk, walkway clearance, social interaction. Yeah, I mean, she mentioned that she was getting lightheaded. She has osteoarthritis. She sometimes uses the walker, sometimes doesn't. And so those are, you put her at a high risk for falls. So by addressing those things, like adjusting her amlodipine dosage, changing her Advil to Tylenol, like those things are going to help. And obviously the walker and the furniture rearrangement, those are going to help with her safety. And just for the sake of time, I'm just going to go into number seven. The physician sat next to the patient at the end to go over the care plan, and she handed her a hard copy. Sometimes people hand a hard copy at that visit. Sometimes it gets mailed afterwards. I tend to like having a small plan actually handed to the patient at the end of the visit. And also I kind of ask the patient not to do a teach-back, but to kind of give me the rundown of what we talked about, of what we were going to do before the next visit. It's kind of a teach-back, but it also helps solidify understanding. And then what are some things that need to happen after the visit? Bruce mentioned charting, restocking, care plan, communication to other providers. I think it's also, in addition to that, communication to caregivers or family members. Yep, Laura mentioned that. You know, for example, with helping with home safety of patient consents, review and complete note optimal billing. And then follow up soon from office staff. And Chris mentioned follow up soon from office staff discussing pros and cons of visit with patient. Yep, that's that's excellent. And, you know, and also, you know, just really important. Bruce had mentioned about restocking supplies. Really important charging electronics that that as well. You know, it's it's it's challenging, especially if there's a lot of distance between between homes. You know, to make sure that you have like a portable battery pack to charge up a computer or or or a phone or a tablet, whatever you have. You know, in case, you know, because I think one of the things that is really challenging is going into a home and all of a sudden, especially in an EMR, your electronics don't work anymore. I mean, I've been in a paper, you know, paper based system for four years before I went into an EHR. But I mean, sometimes it's it's just really inefficient to have to write things down and then transfer it over to an EMR system afterwards. So just making sure that your EMR, that your electronics are working for the next patient is is important. So that's it. I think we're going to go into a break next. Yes, we are. We're going to go into a break. And thank you so much, Dr. Deljanitis. That was fantastic overview and debrief. When you get back from your break, we're only going to take about five minutes, everyone. So when you get back, we you you will be placed into your breakout room. You've been communicating with Melissa about your preference, whether you'd like to be on the clinical or nonclinical track for session three. I've got that info and I will sort you accordingly. We remain available by chat as well. Hi, is somebody able to throw up the revised agenda for the day, just so I can take a peek at that again and plan? Sure, I can do that. All right, thank you. Patrick, this is how comfortable I am with all of you. I'm gonna share our internal agenda cause that's where we made the changes. Okay, thank you. Sorry to be, I just got to make a couple of phone calls this afternoon. So just trying to see when the breaks are and. Okay. Perfect. Okay, so we're so we're on break until 1235. Uh, no, no, no, I'm sorry. Um, no, we're, we just have 5 minutes and we're going to start the session 3, which is, oh, I see. I see. And this is central time. Okay. Got it. So that's 1255 my time. Got it. Exactly. Lunch is at 1255 to 135 Eastern. Yeah. Then there's another short break at 415 your time. Gotcha. 1255 to 135. And then we're done at 545 your time. Okay. There is another I can I realize there's another thing I could show so I'll put that up. All right. Thank you. Hello, it's Janine. If you have opted into the non-clinical track, you should have an invite waiting for you to join that breakout room. If not, just let us know in the chat and I will resend you an invite. The main room is going to be the clinical track, so we will have... Okay, good. I see that everybody is heading over into the breakout room for non-clinical, and then I will be staying here in the main room, but we will be available by chat. So just to reiterate, if you are hearing me now, this will be the clinical session. So Talisa, you're in the right place. Bruce is in the right place. Millicent... Millicent, did you want to be in clinical or non-clinical? I don't know if she can hear me. I think she wanted to be a non-clinical. That's what I thought, but we can move people around if they're not in the right place. Millicent has not yet joined the breakout group, but I have pushed an invite her way. Okay, super. Yeah, people may just not be coming back from break yet. I know this is a short break and this is a full day, so thank you, everybody. We'll get started here in just a couple minutes. Janine, would you like me to do the slides this time? Sure, that would be great if you could pull those up and then I will be mindful along with Sarah of chat and if anybody needs to move in and out of the breakout groups, I would appreciate that. All right, I'd be happy to. Talisa, are you going to for our next session, session four, are you going to join us here in clinical as well? Did you have a preference? I think clinical is probably better. Perfect, no problem. Also, just FYI, I keep getting a message saying my internet connection is unstable, so if I drop off or I can't, or I'm not responding, that would be why. Thank you. That struggle is real across the United States. I'm in Phoenix, we've heard it in Chicago, we've heard it, I mean everyone it seems is, so we've got a plan, B, C, D, E, we will find a way to get to you, okay? Thanks for letting us know. Okay, they're doing great in the other room, we should probably get started in here. If you're within distance of my voice and you are on your break, please come back and join us. We're going to be getting started. Okay, Melissa. Well, I'm actually just going to drive the slides for Megan. All right, great. Perfect. All right. So we'll go ahead. This is the clinical care portion and what we're going to do is take three cases, we're going to start with the first one. But this is really to build upon the walkthrough of a, of a visit from the earlier session. And here's an opportunity to see how I would conduct a visit as well as Dr. DelGenetes and Dr. Chang. So we're really just trying to put that perspective of how it is from a home visit. We're going to start off with our first case. This is Ralph. And you'll want to try to keep Ralph in mind as we go through the next two days, because he will come back and we'll see him again. But Ralph is a 76-year-old African-American man with oxygen-dependent chronic obstructive pulmonary disease. He's got pulmonary hypertension and heart failure, he's got a reduced ejection fraction as well. And you've been seeing him, this is not your first visit, so you've been seeing him the past few months. Before he got involved, Ralph was frequently admitted to the hospital for shortness of breath. So you, Ralph, and his nephew, Reggie, have been working on a care plan so that hospitalizations and EV trips have stopped, but he recently had some increased shortness of breath and he called an ambulance three days ago. He was kept in observation overnight and came home two days ago, and now it's a routine post-discharge visit with Ralph today. So we're going to take this information and keep in mind the four Ms, you know, mobility, mentation, medication, multi-complexity, and we're going to try to apply it. Next slide. All right, so here's the official form from him. Again, this is a hospital discharge two days ago. He was admitted for shortness of breath. And we've got his diagnosis list. I always try to make sure I review that just to remind myself, even though I've seen him before, COPD, history of CVA, the leg edema, AFib, hypertension, BPH, his EF is actually 40%. And then his pulmonary hypertension, anemia, chronic kidney disease, which always makes it a little bit more interesting too, and osteoarthritis and vitamin D deficiency, hyponatremia. Next slide. All right, so now that we know a bit of his past medical history, what's going to matter for Ralph? What's going to be some of the goals when you come up with a care plan? That's something we want to make sure we keep in mind here. And what else will we need to know? What's our sense of Ralph's prognosis to make sure he remains independent? It's important to know Ralph doesn't want to be a burden. He really is trying to be independent. Okay? And then when it comes to mentation, you have to ask, was a mental status exam completed? And in the workbook on his, when we take a look at it, he's had a mini-COG done, and he got us, he had a score of five, if I recall correctly. Just going to scroll down, there we go. So we've got a mini-COG of five. Does anybody else have any other kind of apps that they're using for those evaluations of their mental status? Or do you have any kind of thing that you find is easy for you to use? Does anybody use the Mocha real easily on their phone or have an app that they like to pull it up from? Yeah. Mocha for me, it's a little too long, plus the mini-COG is built into our EHR. So mini-COG is the one that I've been using to screen for cognitive assessment. I know some of my APNs, they also use the Full Steam Mini Mental Status Exam as well. Yes. So it's something that's easy that you're able to use on your phone to get that formulation quick so you can move on. And if, of course, if they score low in the short term, then that means that you've got to do a little bit more thorough exam on it later, so that way you've got the documentation for it. All right. And then going back, we've got mobility. And we're going to move the workbook here a little bit out of the way so I can see this. Just a comment about the mini mental status thing. I think it's really important because often we are asked by family members to write that letter, right? Write the letter that says Reggie cannot handle his finances and so on and so forth. So that family members can go ahead and start managing his 401k or whatever it is. So having that information in there can be helpful to you so you don't have to go back and make another trip simply just to do the mental status exam. That's exactly right. Yes. And you've got to, you have to have that formal documentation to back it up. So later on, if another family member claims that no, that they are competent and they could have managed their own finances and that somebody may have had access to things they shouldn't have, it helps from your standpoint and documentation. Mobility. Does Ralph need help with ADLs? Is he a fall risk? How can you help facilitate his mobility and safety? Does he need a walker? What do we have or not have? Of course, on the medication. How complex is Ralph's plan of treatment? How feasible will it be for him to follow? If he has a lot of medications he's taking, would you consider making changes in Ralph's medications? If yes, why? So these are the questions that we definitely would want to go over. And the multi-complexity, what makes Ralph a complex patient? Is he complex just because of the medications? Is it his medical conditions, the family factors? We have to look at all of that together. And then how complex is your plan and is Ralph going to even be able to follow it? And that's another issue too. What concerns do you have? And you ask, what resources could be helpful for Ralph? All right. Next slide. Oh, so let's go back to the, my apologies, let's go back to the workbook so we can start from there. So, and like Dr. Della Giannina said, he uses the Mini-Cog first and then the Mocha. So if they score low. All right. So in reviewing Ralph again, so we went through his chief complaint. He came out of the hospital, you know, two days ago, he was admitted for the shortness of breath. He's got his history of his COPD, CHF, and hypertension. And then going down, we have to look at the course of past family and social history. What are the three things that really jump out to you when you're reviewing his past medical? And then even down when we get to his medications, the things that, that I look at and that always really make me pay attention, of course, is that, you know, his COPD, he's oxygen dependent. You know, we've got to make sure we have a plan for if his oxygen runs out or if they lose power, particularly where I'm at here in Florida. He has a history of AFib. And I believe he's on anticoagulation as well, if I recall. And then let's scroll down some more. All right, now the social history, again, going back to multi-complexity. Ralph's wife died five years ago. He lives alone in his home. And he has a nephew, Reggie, Reggie was, you know, 10 minutes away, checks on him daily. Reggie's an integral part of Ralph's life. Ralph has a sister, Jessica, she helps with grocery shopping, you know. And then, of course, we've got this 40-year pack history. No alcohol or drugs, but again, the smoking. And Reggie doesn't always pick up his medications from the pharmacy because of cost. We go down to review of systems. Hey, Megan, if I could just make a comment, going back to the, his past medical history. I think the three things that I find most challenging are his conditions of COPD, CHF, and CKD. And if you want to put in there, it's his history of hyponatremia, right? Because we all know, we all know Reggie's phone call to us is going to be about, or Ralph's phone call to us is going to be about what? He's going to be short of breath. And how are we going to manage that shortness of breath? And we can talk about acute urgent visits and so on, and testing, what testing is available, how much diuretics to give, given his CKD and his hyponatremia. I think I still get a little anxious when I see that creatinine go up and that sodium go down. Like, how much more can I push on the bumetanide or whatever diuretics that you're using before you really get into trouble? So I think those three are like some of the most daunting patients that I face in the practice. He's a real balancing act, for sure. Yeah. And I wanted to just chime in, in terms of the atrial fibrillation, whenever I see that, I mean, here, Ralph is on Warfarin, but I'm seeing more and more patients be on the newer meds. And the last time they've had a creatinine check was a long time ago. And one of the things that I get increasingly nervous about is when people have had that, you know, they have had one of the newer meds prescribed when their GFR was greater than 80. And lo and behold, now they're 30. And so I think, you know, making sure that the labs are being checked and especially with Warfarin, making sure that the INR, like there's a routine follow up schedule, you know, like however, however the routine is for your practice, making sure that the INR is being checked regularly. And also false risk, you know, on an anticoagulant, does the risk outweigh the benefit for the med, even, you know, even starting off with med? Agreed. Yeah. You know, especially with him being on Warfarin, if we have to at some point put him on antibiotics because of his COPD and he develops an infection, that's a whole nother set of issues too for him. Make it more complicated. Yeah. The other thing about the multi-complexity and it's related to his COPD and also the Warfarin thing, and, you know, should we consider using a DOAC in this gentleman instead? But then I see the comment about Reggie doesn't always pick up his medication because of cost, right? So we all know there are good medicines our patient should be on or may be on. But because of cost issue, for example, especially those these fancy inhalers, right? We all know that Lama Lava inhaler should be used in patients with advanced COPD, but they are terribly expensive and they simply can't afford them. So that adds to the challenge for us as we're trying to take care of these sick, sick patients who may benefit from these newer fancy drugs, but they can't afford them. Exactly. Yes. So we do. We do find that that's all those layers come together and certainly can make it very limiting and challenging at the same time. And so going back to Ralph, when we look at those review of systems, of course, sure enough, what is he called back for? He's still having problems with blurred vision because he's been on steroids. I still have shortness of breath. It's worse with walking exertion. He's sleeping in his lift chair at night because he's been short of breath for three days, even before he called 911. He's constipated. It's been more than four days without a bowel movement. He's still having intermittent urgency. Of course, he's on diuretics and he's got, you know, all these things that are certainly setting him up to end up back in the emergency department again. And the question really is going to be is what what can we look at or what can we do to try to limit that? Let's scroll down. All right, so he's already on ferosamine twice a day. That is warfarin. He's on his oxygen, you know, his inhalers, you know, and then he was sent home with some razopam, of course, probably to help with some of the anxiety in case he does get short of breath. And now they've put him on metropolol and you see ibuprofen, which is a little concerning considering kidney function as well. Let's scroll down. And then, you know, talking about the four M's, talking about our mobility, he's walking with a cane, he's unsteady, you know, needs assistance for the grocery shopping and gets around slowly in the house. He has to use the furniture to help with support. And let's go down. All right, and his unit is clean. So from an environmental standpoint, that's good. His family's helping with it. So it's really important that he has a sister and his nephew to be able to help him. He's got his oxygen concentrator and he's got two portable oxygen tanks in the closet. So that's good, too. So he's got some backup. And then his diet, nutrition, important to double check. He's somewhat compliant with the low sodium diet. He's got access to nutritional food because of his sister doing the grocery shopping. So it's real important that we keep track of the sister and the nephew to make sure that they're able to help. And go down. All right, so we know that he's had some issues, vital signs. We walked in, noticed how he was breathing, but, you know, again, got a blood pressure 170 over 88, pulse of 78 irregular, his AFib and pulse ox is 76 percent initially with the oxygen not working. So always check that oxygen, make sure it's even on. And then it was turned on. And now those three liters, he's popped back up to 92 percent. So you would think he would have noticed it wasn't on, but he didn't. And sometimes they just turn it off because for whatever reason, they think they're doing OK. All right. And then his repeat blood pressure, because he's not struggling to breathe, is 140 over 76. So it's improved as well. Respiratory wise, he's got some dyspnea when he talks. Better after oxygen. We gave him a neb treatment. His wheezing's improved after that. So he's doing better. Otherwise, the rest of the exam, for the most part, he's got no pressure sores. You know, neurologic exam is good, no focal deficits, but he's got some more extremity edema, two plus. That's worrisome. And then we'll scroll on down. He's a full code and full treatment, including feeding tube. That's important to note. We have a health care power attorney, which is Reggie. You know who's going to help him in case things start to go badly for him. And scroll down past the DNR. OK, so that takes us. So we have what we would look at as our big concerns here, which. But does anybody have anything that they automatically pop out in their minds with how he's symptomatic and what concerns them about when they walked into a visit like this? Because these are not uncommon, unfortunately. They may not call and tell you that they're feeling sick or they can't breathe. You walk in the house and what becomes a regular visit becomes suddenly more of an acute visit. So we've got the fact that with the COPD, his shortness of breath, that's the first big symptom that we had to work with. And what we did is we gave him a nebulizer treatment that helped to improve. We made sure his oxygen was working. Make sure he's sitting up. Any other thoughts that might be helpful in this in Rob's case? And making sure he's taking his medications at all, right? That gets back to the cost issue. If Reggie's not picking up his nebulizer treatment, just like, oh, dear. Maybe that's why he is. He is having an exacerbation because he's simply not taking his pills. Well, especially if he doesn't even remember to turn on his oxygen. And of course, then we have just on the heels of a COPD is his CHF, which is probably pushing him into that a little bit as well. So he's got a CHF. He had two plus pitting edema. So what do we want to do to work with this CHF? Yeah, we can increase his diuretics to help him with his shortness of breath and leg swelling. And I don't know if Ralph is steady enough to stand and be balanced on a scale. That's how we instruct our patients to monitor their volume status is to weigh every day and call us if you gain three pounds a day or five pounds a week. But some of our patients can't do that because of their mobility, their weight issues, and so on. Right. And then, now, do you usually find, Dr. Cheng, that you have them recheck their lab, like a BMP, in about three days and just do the increased Lasix for three days? Yeah, certainly. That's certainly a concern, right? He's got CKD. He's got a history of hyponatremia, right? So there's always a concern about driving him too much the other way. So yeah, follow-up blood tests is important, especially if he already has underlying electrolyte disturbance. I think it's really important. Now, so those are the two, the COPD and the CHF. I mean, those are the two driving forces besides the hyponatremia and his renal function. But what matters to Ralph, the biggest thing to me that also I have to worry about with a patient, when somebody tells me they haven't had a bowel movement in four days, sometimes then that'll be the next problem because they're very uncomfortable. For an older person, they are fixated on when they last had a bowel movement, not understandable. So from the constipation standpoint, sometimes just making him immediately feel better from that, that can also be a source of improved mood for him if they're going to the bathroom. That's a great point. Yeah, they're very concerned about their BMs. Many of my seniors are. Yes, that's like, you know, that's their number one worry. And you're right that if he's constipated, he might be short of breath from that, just feeling so bloated and being uncomfortable. And you as a provider, if you feel that there's a clinical need, doing like a disinfection at the bedside can really bring a lot of relief to your patient. And I know it's not the most pleasant thing, but it's an acute intervention that you can make with a dramatic response. And it certainly reminds them to take their Miralax then the next time. So, you know, in his case, like a cap full of Miralax, you know, that may it's not going to work right away, but it certainly gets things moving, hopefully, before he ends up back in the hospital from that, because then he's just bought himself without a CAT scan of his abdomen. If you don't ask for the, you know, then weakness, getting around the house, that may be part of it with the shortness of breath. And those are things that you could always talk about doing physical therapy later with home health. And keep in mind, and then hypertension that was noted when we first arrived, that his blood pressure was pretty elevated, but it did improve a bit after he was on oxygen. And you could certainly make changes to it, but I usually find it, and this might be different from your perspective, Dr. Chang and Dr. Villaginidis, but I try to limit the amount of changes I do in a visit, because if I get too many going on, I find it overwhelming for the patient. So you got to prioritize. He's acutely, in this case, he's acutely short of breath, and I have two real strong causes with his COP and THF. Try to make sure that I can make him feel better with something that's important, with having a bowel movement. Hypertension, I would keep an eye on it and certainly recheck that back in the next visit to try to see if he's feeling better. Then I would probably try to address it more so then. Oh, absolutely. Absolutely. Talissa also had a comment about he may not eat well either, no bowel movement, and worry about renal function and dehydration and coumadin level. Great points. Absolutely. I think that just highlights that it's not just one, and I'll talk about this in multi-complexity in a little bit. It's not just the medication, right? It's not, oh, I just change your meds and everything will be good. I wish it was that simple. And your comments are right on. It is not. It is, as they say, it is complicated, right? Regarding the constipation, hypertension thing, I think, Megan, yeah, he's on Carvedilol, but then he had a bag of Metoprolol as well. I just want to make sure he's not taking two beta blockers, right? Right. So that's a good point too, because we've had that several times where we've walked in the home, and even though their medications are changed at discharge, they are not stopping the whole medicine. So sometimes they end up taking both of them when maybe they weren't quite taking what they were supposed to even before they went in the hospital. So then I end up with a duplication process. And so it's really important to make sure that they're following the correct instructions and not duplicating. It's all about prioritizing, you know, make sure you've answered what matters to the patient from the mentation standpoint, by fixing his oxygen status. Sometimes that makes a huge, also, improvement in how he's thinking. As for the depression, that'll also definitely have to be addressed. If we can try to make him feel better, a lot of times that's going to help with mood, and we can always look at it from there. The mobility, if he's pain, having a lot of pain and discomfort, that comes into play too, that may be why he's not mobile. What can we do to help with those ADLs? We talked about, you know, physical therapy, and that's where home health really, don't be shy about putting in home health orders for the physical therapy, because that's another set of eyes to make sure that Ralph is taking his medications, that he's actually on his oxygen when they arrive, because they'll call you and let you know that he is not doing that, or they showed up and he was hypoxic. They'll call you real quick on those. Overall, it's just all that complexity together, but prioritize the symptoms and try to do what matters most, and then you can take that and kind of start making a plan of how you're going to approach Ralph and schedule visits going forward. I would definitely do more visits sooner. Oh yeah, yeah, Dr. Bender, we would keep track, almost every single visit that's a transitional care, we would find medication errors between the hospital and the home meds, and so that routinely was a big part of the problem, you know, why people were bouncing back in the hospital, why they didn't do well for quite a while. So I agree, you really have to do the medication reconciliation. Yeah, even with our practice, I'm still baffled. Even when we make follow-up visits, there are still some discrepancies between what they're taking and what's in the EHR. So it's a constant struggle, it's a constant process improvement project that we can do for our patients. So even as meticulous as we are with their pills, when we do follow-up, just like, where did this come from, you know? Yes, it migrates in somehow, I don't know, but it does. All right, I think then we're going to be, are we, Janine, are we heading to the next? Yeah, all right. Yes, so we, I think we did the debrief for the most part. You want to take a minute, everybody, to look at this screen. I think it was already covered in the conversation for the most part, but let's just take a moment to see if anybody has any questions before we transition to prognostication. Does anybody have any questions about what's on screen and how the 5Ms apply here? Nope, we're good. Thank you so much, Megan, and let's get ready for prognostication. Thanks, Megan, and thanks, everyone. I just wanted to just take a moment and discuss about prognostication. So for the next few minutes, we're going to go over elements of prognostication, including its role in caring for complex patients and their families, describe and discuss functional patterns of life-limiting illness, and then identify barriers to accurate clinical prognostication and use effective tools to overcome those barriers. So if we could do the next slide. So one of the important things is the definition of prognostication. So prognostication, first, let me start off with what it isn't. It's not fortune-telling. It's not playing God. It's rather a science of estimation. It's the science of estimating the likelihood of an outcome due to a medical condition. Very often, it's the estimation of death due to, let's say, COPD, five-year mortality rate for cancer, for a particular cancer. But it could be other outcomes as well. And those outcomes, some outcomes might be death, but some outcomes might be just functional decline, which is important to patients and their families. And most patients with serious illness want discussions about this. They want to know what they have in store, but it often doesn't occur. So if we can go forward one more slide. So first of all, it's important to recognize certain patterns of functional decline. So the patterns or the clinical trajectories can help inform prognostication. And if you recognize these patterns, it can help with care delivery and help anticipate patient and family resource needs. So it's important for not just patients and not just family members. It's also important for providers. So for example, it helps with visit plans. So for example, if you're seeing someone, let's say every three months, if you see the clinical trajectory, you might say, okay, you know, I anticipate the patient needing, you know, monthly visits, or, you know, maybe I'm going to need to have in the back of my mind hospice discussion sometime soon. You know, it's important to have a plan so that it informs the discussion with patients and their caregivers and their family members sooner than later. So we're going to go over the four major trajectories of a functional decline, and we'll go over each of these individually. So if we can go forward one slide. So the first one is the obvious, you know, sudden death. You know, patients are at a certain functional status, and then they suddenly die. Now, if we can go forward another slide, yeah. So then there's kind of the cancer death trajectory. So patient has been diagnosed with an incurable cancer, and at the very beginning, they might have a certain, you know, higher level of functionality that may slowly decline over time. And then there's usually a rapid decline over the span of four months before death, and that's usually when specialist palliative care, like hospice care, is recruited. If we can go to the next slide. And then there's another pattern with organ failure, like heart or lung disease. You know, patients have, you know, have a certain level of functionality, and then they begin to use the hospital often. So you see these little dips, and then they, you know, get out of the hospital, they rebound, but sometimes their rebound isn't to the same level where it was before the hospitalization. And then they slowly decline, and then they have another hospitalization, and then another rebound. And this can go on for years, like, you know, two to five years, but then there's this sudden dip where they might be in the hospital, or they might have a lot of services that they need, and then they don't rebound, and then they die. And it's because of that lack of rebound that family members might say, oh, it was a sudden death. But looking back in time over the past, you know, two to five years, people say, well, actually, they've been declining gradually over time, but it just felt all of a sudden because they didn't rebound as they had in the past. If we can go over another slide. And then there's another pattern with dementia or frailty, sometimes it's called the dwindles, where the onset could be just some small deficits of activities of daily living. And, you know, many years will pass with some small dips of decline, maybe even some plateaus, maybe even some, you know, brief moments of improvement followed by decline. And it's an overall downward trajectory with kind of like these little blips, you know, downwards and upwards. Now, if we can go over one more slide, yep. So the problem with prognostication is that there are insufficient evidence-based guidelines. And also, you know, we talked, actually, we talked about this with Ralph, it's, we're not dealing with one disease process, right? It's very unusual for us to deal with the one disease process. There, people have multiple conditions. So, you know, COPD, CKD, and, you know, frailty or, and dementia. And so the trajectory is harder to kind of like map out. And sometimes you have to like mesh the trajectories. Also acute hospitalization makes prognostication hard because acute hospitalization, you know, is very important in this disabling process. So often we hear patients who, you know, with dementia, who go into the hospital for, let's say urinary tract infection, and very often we hear that they've come out much worse than when they went in, even though the UTI has been treated. And so it's, hospitalization is disabling. But one of the things that has been shown is that a prognostic tool with clinical judgment is better than simply using one alone. So if we can go over to the next slide. Now, in addition to having, you know, limitations of prognostication, there's also clinician barriers. So we, as clinicians have, you know, have a concern about removing hope, especially when patients have been dealing with chronic medical issues and they want to, you know, they have certain goals, like they want to be around for, you know, something in the medium future. It's, you don't want to remove that hope, you know, for them to, you know, be able to make it. There's, you know, and that can stress the therapeutic relationship, that can stress a family dynamic, that can stress the relationship between the clinician and not just the patient, but also the family members. There's also giving information that's not requested. So sometimes, you know, patients don't want to hear it, but we as clinicians think it's really important that they hear this. And how do you kind of like negotiate that conflict? And there are also cultural issues. You know, I'm just going to give an example just from my background. I'm Greek and my, you know, one of the things that, you know, we had, well, and particularly in, from where my family came up, they came over in the Northern part of Greece, it was the cultural norm for prognosis not to be shared with, especially, you know, bad prognosis, not to be shared with a patient, but to be shared with a family. And obviously, you know, if there's, if you're practicing here in the U.S., you have to negotiate those cultural issues and respect the patient's autonomy. There's also, you know, physicians, you know, clinicians being concerned about being wrong. Clinicians consistently overestimate survival and sometimes are overly enthusiastic about new treatments. If clinicians have had a bad experience in sharing bad news with previous, you know, patients or family members, and, you know, repeating that process might be even more difficult. And so that's another barrier. And also there's a limited formal training in doing this. You know, in residency, in medical school, we don't often talk about, you know, the science of estimation and even communicating bad news. So if we can go forward one slide. And, you know, this is just a quote about, you know, that management should reflect an older person's own preferences and goals in the context of his or her own combination of diseases and conditions, prognosis, and the feasibility of its implementation. Let's go forward one more slide. So I wanted to share a lot of different resources, and these will be in your packet. There are, so for example, for Ralph with COPD, there's the, I'm gonna call it the Bode Index, or it might be the Bode Index. You can find this online, and you can plug in certain numbers of, for example, for Ralph dyspnea, how much he can walk, and you can see what his four-year survival rate is going to be. There's heart failure, CKD, brain mets. Next slide. There's, you know, for advanced cancer, Calculate by QXMD is actually a pretty neat app. That you can use. It has multiple calculators in there. E-prognosis is also really neat, and I'm gonna show you some screenshots in the upcoming slides. So E-prognosis has some calculators. It also has some patient-oriented cancer screening imaging. So for example, you know, if out of 100 people, you know, breast cancer screening had this positive impact for, you know, this number of patients, you know, for example. If we can go up one slide. But MTCalc, this is actually an app. It's a desktop app and a smartphone app that I personally use three times, at least three times a week. And, you know, on average, sometimes I even use it daily. Obviously I have no, you know, conflicts of interest with these. I just like this, you know, this website. It has the Bode index. It has calculators to determine if someone has sepsis. It has the CHADS-Basc score for, you know, AFib stroke risk. You know, there are multiple calculators and it's really helpful. So I'd encourage you to use that if you can go forward one slide. So just in summary, the prognostication is an essential tool in caring for patients, but also in helping drive advanced care planning discussions, which helps care for patients. There are four major trajectories like we talked about. And sometimes the, you know, patients won't fall into one trajectory, but we'll have kind of like a mesh of both. And there are a number of different tools that are available, but tools are just that. They're best used in concert with clinical judgment. And we have some references. And I just wanted to, if we can go forward one more slide, just wanted to bring up another website. It's called the nnt.com, which is number needed to treat. And sometimes patients will request certain medications and, or will question certain medications. And that website is helpful to kind of drive and inform discussion with patients. So for example, bisphosphonates, should my patient have a, be on Fosamax or not. Having, you know, having a discussion of, well, out of, you know, you would need 110 patients with your condition for one person to have a hip fracture prevented. That discussion, that information is important for patients and caregivers to say, you know what? If it's only one in 110, forget it. I'm not going to do it. Versus, you know, versus other interventions. There are, I think, 250 different interventions that are listed on that website. So take a look at that as well. It's a neat resource. And that's it. Now we'll go with Dr. Chang. Thank you so much. Those were fantastic resources. Dr. Chang, whenever you're ready, just let us know. Well, thank you, Costa. That was a great information. To have those tools to help us with those difficult discussions, I think is really important. I'm reminded that it's always dangerous to be the presenter that's standing between the learners and the lunch. So I will try to make this presentation on time and hopefully helpful to you. The objective of this section is to help recognize the challenges of treating homebound patients with multiple chronic illnesses and to apply a management model, which I'll talk about at the end, for treating patients with multi-complexity. And just briefly describe treatment medication management for four of the commonly found geriatric homebound patient populations, such as diabetes, congestive heart failure, CKD, COPD, which we talked about with Ralph's case. Next slide, please. Now, this is a tough talk, and it's also tough in life in terms of what we do, right? We take care of patients with multiple conditions, not uncommon to have 10 or more. They take a lot of pills. They're a high risk for hospital readmission and ER visits. They have multiple comorbidities that can contribute to their decline and their impairment. And support from the caregivers is required to help these patients with medication management and other activities. Even something simple as picking up the medication, which our patients often cannot do. Next slide, please. I think this is just a reminder to all of us that to help take care of a complex patient, it is, we need to take some time. I think Megan talked about trying not to make too many adjustments at one time with your medication. It's gonna be, unless it's some really urgent or critical issue, multi-complexity, it's probably best addressed by this circular plan here or plan do, check and adjust, right? We are going to need to take a couple of visits to kind of sort out all of their problems rather than say, well, I'm gonna fix all of your problem in one visit. I think that's very challenging if you went in with that particular mindset, I'm just gonna do it one time here rather than sequentially and trying to figure out as you do your checking and adjusting and optimizing your medication and your care plan according to the patient's symptoms and goals of care. Next slide, please. Just quickly, again, prioritizing treatment. What are your goals? Remember the four Ms, right? What are your most distressing symptoms? Could it be the constipation issue for Ralph or is it the shortness of breath? The impact on the patient's mobility and safety. We're always worried about our patients falling, right? Traumatic injury is still a huge problem for our patients. We need to not forget preventative care and also consider other obstacles that may be involved in achieving the patient's goal. Next slide. We need to, after we take a look at our patient, do the assessment, think about what testing is needed, what can be done here at the home, EKG, chest x-ray, ultrasound, lab work, and so on, and maybe some tests that really are not plausible at home and the patient is, you really are concerned for the patient's shortness of breath and you think that Ralph may be having a PE, so maybe he should go to the hospital and have a CAT scan instead. There are things that you can do at home and then there are other testing that needs to be done at the hospital. Don't forget mental illness. Anxiety, depression plays a huge impact in terms of how our patient is feeling and their compliance with their medication. Remember, one of the beauties of what we do in home care medicine is being at the home and seeing the surrounding, the living condition and so on that may be adding to the patient's decline. Real quick here, just highlighting some things. Think about lifestyle modifications, diet modification, and so on. Don't always just look to medication as an intervention. For example, there's a patient of mine who was Southeast Asian. She's on four or five different hypertensive medication. I just can't get her pressure down. We went through the kitchen, looked at her cooking stuff, and we found out that her fish sauce that she cooks with, I think one tablespoon has, I think, 1,500 milligrams. I'm not exaggerating things, 1,500 milligrams of sodium. So don't forget looking around. Get as many clues as you can to help your patients. Think about your medical interventions, the benefits, the adverse events that may happen. If you use a LAMA on a patient with BPH, you might wanna tell them that, hey, call me if you have difficulty urinating. Reduce, deprescribe, reduce, deprescribe. Always have that mindset when you go and see your patient rather than just adding to their extensive list of medication already. Remember, think broadly. Think about your team, PT, OT. Get them the equipment that they need to help them to be safe and mobile. Next slide, please. And always check and adjust, whether you're using a home health agency or using electronics to help you through a remote patient monitoring, which now you can get paid for. Brianna will talk about that tomorrow. And again, be on the lookout for adverse effect of your intervention. Always, always check to make sure they're taking their medication correctly and using them as you think they should be using. And of course, always be there to assess how they're doing. And if they're not doing well, to have that conversation about goals of care again. I'm just gonna briefly talk about the big four categories of diseases. Obviously, this is not meant to be an extensive discussion on management of diabetes, COPD, and CHF, and so on. Just quickly, as you think about managing your patients with diabetes, talk about the frequency of blood sugar testing and your blood sugar goals within the context of their use. The context of their age, their condition, and so on. I already talked a lot about medication compliance, modifying diet that's appropriate for the patient's condition and goals. Exercise, exercise, exercise has so many benefits. Don't forget that. Also, if it's available to the patient, make sure a podiatrist sees the patient and an ophthalmologist or optometrist that can do good eye exam. And be judicious regarding what test to order and so on. If you're not gonna treat the cholesterol, if you're not gonna treat the microalbumin with medication, then probably testing is not needed. An appropriate A1C goal should be kept in mind. We're not going for A1C of six, maybe seven and a half or eight is more reasonable for older complex patients. Real quick here, this is just a list of commonly used medications from Metformin, sulfonylurea, your DPP-4, your GLP-1s were injectable except one oral one, the SGLT-2. They've been getting a lot of press about that in terms of both the GLP-1, helping those patients with CAD, SGLT-2 being helpful in patients with HEF-REF as well. Thiazolidinediones, I don't use that as much because of the leg swelling. And then insulin can be used, but cost sometimes can be a barrier. Next slide, please. CHF, salt and fluid restriction within the patient's goals of care. We talked about monitoring the weight. Again, make sure the patient is taking the medication as prescribed and not double dosing, right? You know, metoprolol, carbadolol and so on. Always have the patient call us, have an action plan. You know, call me, call me, call me when this happens. Leg swell, you can't sleep flat, you're short of breath, you can't put your shoes on, et cetera. So that they will be able to reach out to you before they get into trouble. Next slide, please. Again, these are the medications that we use to manage HEF-REF in this particular talk here, a lube, you got your thiazides. For additional benefit to your lubes, we use MRAs, aplerinone or spironolactone, ACEs or ARBs. And now we have these ARNI agents, sucupitrovalsartan, brand name Entresto. That's now probably, that is recommended over ACEs and ARBs, but this gets back to the issue about cost for our patients. Next slide. COPD, goals of care. Talk about smoking, about using oxygen, have a backup plan for their O2 in case of emergency. Megan talked about power outages. It's important to make sure they have backup equipment. Make sure you see your patients quickly after discharge. And also if it's appropriate, get patients into hospice care. Without going to all the details about management of COPD, I think we all know the alphabet soup pretty well. Your SAMA, SABA, your LABA, LAMA, your X, and then the triple therapy that can be used, but it does increase your risk of pneumonias when you add the X on board here. Next slide, please. And these are just some other interventions. One to highlight is we do use pulse azithromycin, which has an anti-inflammatory effect that can reduce the exacerbation of COPD in studies. And also perhaps to have an emergency bottle of prednisone for the patient at home in case they really get into trouble and the pharmacy is closed and so on, that they have something that's available to them to get them over the immediate crisis. Next slide, please. Other ways to help with shortness of breath and COPD, talk about repositioning, make sure the oxygen is working, make sure there's airflow in the room, cough medicine for your cough, benzodiazepine appropriately used for anxiety, and morphine for dyspnea. And as in Ralph's case, if you think he's overloaded, you know, diuresis. Management of CKD. Again, within the context of the patient, treat their hypertension, get them to stop smoking, weight loss and cell restriction if at all possible, treat hyperlipidemia with a statin if it's consistent with their goals of care. Again, managing metabolic bone disease related to CKD, hyperphosphatemia, hyperparathyroidism, appropriately acidosis with bicarb, ACEs and ARB if appropriate. We talked about microalbuminuria if it's appropriate for the patient. And again, we had a discussion with a patient who's relatively young, but she wants to forego dialysis. And what is the implication regarding that? Next slide, please. And I've been working with the family practice residents here as they come and rotate with me here. And one of the most common comment is, you know, help me take care of these multi-complex patient. I feel overwhelmed, I feel a little paralyzed. I don't know what other comments they have shared. And I thought about, you know, how can I help them and help the learners overcome these challenges? And I thought about these are the five things and I'll make it quick. One, I think it's really important to have a good working knowledge base of these common conditions that we face, right? We talked about COPD, CKDs, et cetera, AFib, diabetes, and the other would be like dementia with behavioral disturbance. Good working knowledge of what you need to do in terms of management. It's also important to have preparation, going into the visit, having reviewed the chart, review lab work and so on, so that you don't feel unprepared when you are faced with a patient condition or complaint. It is important to have good software and computer hardware that allows you maybe to pre-chart, that allows multiple, a widescreen view, for example, on your computer that you can see past medical history, medical medication, and so on, a document on the same page without having to go back and forth between the pages, which is time consuming and dizzying. Having smart phrases and voice recognition stays on typing time because, you know, I'm not the fastest typer that takes me a long time to type up a note. So having phrases or using voice can really help. And the final thing is I feel bad for these residents. Sometimes they really, you know, they have 20 minutes for these really sick and complex patients and all their issues. Make sure you block enough time for your visit so that you can address all of the complexities that they will likely present. So nobody likes to feel rushed. The patients don't, you don't. So make sure you have enough time. And this kind of segues into what Brianna will talk about tomorrow, and that's billing and coding to make sure you get the proper reimbursement for the time that you spent. Here are some references. And I think here's the summary. You know, again, don't try to do everything at once. Go back and adjust. And it's a challenge for me. It continues to be a challenge for me trying to balance all of these diseases, but it's really important to have a good working knowledge of commonly encountered conditions in home-based patient. Focus on the patients and their goals, and not necessarily just talk about, you know, diabetes, diabetes in a silo. Try to put it within the context of patient's goal, reducing symptom burden, and not prescribing medication that costs a lot of money. Think about interventions that can optimize function, and also not stress out the caregivers with non-necessary complexity. Again, I wanna remind you, you know, go back to your learning plan as you are taking some time for lunch. Fill in some of the blanks here. Think about what you have learned this morning. Again, what would you like to learn in the future? Thank you so much, Dr. Chang. We're actually gonna break for about 30 minutes. This still says 45. That was from our original agenda, but we're packing in a lot of learning. So thank you. Please go take a breath and refresh and get yourself something to eat. And we will see you back at 1235 p.m. Central Time. So you'll have to adjust that wherever you're calling from. We'll see you soon. Thank you. And no need to disconnect. Just mute your audio, stop your video, and we'll see you in 30 minutes. Yes. Thank you, Melissa. Hello everyone, if you are near the sound of my voice, we are soon going to start sharing materials for session four. Just as soon as I get my slides to cooperate, bear with me for just a moment. It wants to kick us back to the beginning. Okay, it still wants to kick us back to the beginning. So we're going to do a quick review, super quick, lightning fast as I go through these and get us to our correct slide. Don't let it make you dizzy. Feel free to look away. Here we are, we are ready. When you are, Megan, just let me know. I will be advancing your slides for this session. Sounds good. All right. Well, welcome back, everybody, from lunch. I hope that you had a moment to refresh. We're going to start our next section here with piece number two. This is Betty. So we'll advance the slide. And as I get through, this time I'm going to go through Betty's chart. And we'll keep in mind, in the back of your mind, what matters, mentation, mobility, and medication. Those are the four M's. But Betty is a 60-year-old, morbidly obese, Caucasian woman who you're seeing for the very first time. She's got multiple medical problems, severe physical limitations, depression, anxiety. She hasn't left her basement for several months, and she cannot make it up the stairs due to weakness, pain, and fear. She has not been able to leave home to see her primary care provider. Next slide. So this is not an uncommon situation that you walk in, and you've got multiple issues kind of all at once. All right. So first thing is, I look at the intake form. And actually, let's pull up the workbook, because I'm going to kind of start with that, and we'll go through her chart at the same time. We're going to introduce Betty, because one of the big things, and you're off, if you have an office staff, they may do this for you. But I really wanted to stress, make sure that you get the right insurance. Even if you're getting referrals from a home health company, and they're sending over the paperwork, and you, if you don't check the Medicare number to make sure that they're good to go, and they're actually on Medicare Part B. We used to find sometimes out the hard way that they actually weren't covered, and that just became either a free visit, because they may not be able to come up with the money on their own. So when you look at their demographic intake form, for example, they've got Medicare Part B. It says, and their supplemental is Blue Cross Blue Shield. You want to make sure that you double check that and get those numbers and copies of the cards. That's key to making sure that you're getting paid for all of this. And so again, I would look through it, make sure I've got the right address. Sometimes I've also been sent the wrong address by the home health company, which is where a lot of our referrals would come from. And notice that she's got the oxygen concentrator. She's supposed to have a walker somewhere and a nebulizer. That's the equipment listed, but I keep that in the back of my mind, so I can make sure it's there, because we've also found that sometimes it's not there. And then let's scroll down on the workbook. All right. So knowing what I should be finding, that she should have that equipment, I come in, and the chief complaint from Betty is that she is being seen for follow-up depression, anxiety, weakness, pain, and that she's extremely depressed and down lately, which is understandable, considering that she's very limited with her mobility, living in her downstairs apartment, and having chronic pain. Her HPI, she's depressed, again, has little pleasure during daily activities. She's got COPD. She's had increased wheezing and coughing, she's stating. And she's got a new abscess under the right axilla. Noted a week ago, it's draining, but she has not done anything to treat this, because she can't leave her home. And, of course, she's got weakness, pain, and reports that it's a six out of 10. Let's scroll down to her past medical history. Things to keep in mind, she has extensive history, hypertension, stage 3 COPD. She is oxygen-dependent, chronic pain, diabetes type 2. She's insulin-dependent. She has peripheral neuropathy, making life difficult, history of CBA, recurrent fungal and rash going on in her skin folds, of course, obstructive sleep apnea, osteoarthritis, hemorrhage, lower extremity DMS, stasis, dermatitis, recurrent cellulitis. So, and the, you know, the list goes on. She's got a lot of different issues. Looks like she's had some of her immunizations, missing some others, and, of course, her surgical history is pretty minimal, so that's good. And scrolling down, social history is key for her. She is married. Her husband's the longest in this truck driver, and he's pretty much gone a lot. Three grandchildren, one's in Chicago, another one lives with Betty, has a mood disorder. Betty's son, Joe, he's incarcerated for his fourth DUI, and Allison, who lives with Betty, is reportedly verbally abusive towards Betty, but she does help out with pill management and picking up the medications. Betty's an ex-smoker of 20 years, otherwise no alcohol or illicit drugs. Let's scroll down. On her review of systems, she doesn't appear to be in any acute distress, but she's got the occasional cough, some wheeze, shortness of breath, her recliner, which she sleeps in is at 45 degrees, and, of course, she gets shorter breath than whenever she tries to get up out of the chair. When she reclines the chair, of course, then she gets heartburn as well, so that's another reason why it's not able to go all the way back. Blood sugars can be anywhere from 40 to 400. No specific diet, she just eats what they bring her, and that's not uncommon either in these homes. So her sugar is kind of more consistent in the 300 range. She has diffused pain, a lot of muscle spasms, and difficulty getting out of the chair. She has to use her walkers for short distances, and her legs are swollen and discolored. And as for her XLS, she's got a swollen and tender lump in the armpit. Overall, she's depressed about her overall condition, both physically and socially. She's been seeing her mother, or visions of her mother, who recently died with visual hallucinations, and, again, swelling. So let's scroll down on our chart here. Her home medications, big one is, you know, she's on furosemide, but it's just 20 milligrams daily. Of course, she's got kidney disease. There's the tetrahydrocorticoid, you know, and tryptophan. Metformin, 1,000 milligrams twice a day, rather unusual considering her kidney disease. So that's interesting. Insulin, floxetine, and, of course, she's got inhalers. She's got more hypertensive medications. And we'll scroll down. And keep going to the next one. And these are screening exams. Although this is our first visit, so I don't, typically, I wouldn't expect to have much of this information unless they got it from other chart work. But, again, it just kind of helps in this situation. She can't really get out of the chair without assistance. She uses her walker. They did, you know, a tug test on her. Her PHQ-9, she's got a total score of 15 with, you know, positive depression. The house is cluttered. She lives in the basement. The staircase, so checking the environmental aspects. The staircase leading up to the basement, from the basement, is narrow and steep. She's obese. She uses a walker and oxygen. How she gets up and down that would be almost impossible. The kitchen's messy. 30 dishes in the sink. Ants on the counter. Leftover food out. I mean, it's stuff everywhere. The food is fairly fresh, but, again, a lot of frozen dinner, pizza, ice cream, all the stuff that we wouldn't want for her diet. And she says she feels safe at home now. And she says, although, but then she says, has anyone ever been physically or emotionally threatened to you? And she checked yes. But there's no signs of physical abuse present. All right, we'll scroll down. So she's really dependent upon her family members, and her husband and daughter aren't involved. And she rarely leaves home. So I'll scroll down some more. Physical exam. Blood pressure 135 over 72. Respiration rate listed at 17, pulse 78. Those are reasonable. Temperature's fine. That's good with that questionable abscess. Her weight at 465 pounds, and she's got a pulse ox of 96% on room air. All right, so she's obese, poor hygiene noted. And then her respiratory, coarse bronchi throughout the lung fields with scattered wheezing, poor respiratory effort, otherwise belly soft. Nothing too significant with her MSK. The skin, she's considered to have some redness, maceration, and satellite pustules in the right axilla with a two-centimeter abscess. Draining fluid, and it's noted to be fluctuant. She's got that going actively. And then she appears to stress and anxious, but even though she mentioned she's seeing her mother, she's not having any active visual or auditory hallucinations. And then she has the two plus lower extremity pancreas edema with associated stasis dermatitis changes. Let's scroll down. All right, she feels powerless. And when you ask her what her goals of care are or what matters to her, she wants to improve, she wants to be able to manage her conditions and try to get some help. Her husband is the health care power of attorney, but remember, he's gone a lot, interestingly. So that can be a whole different problem in itself. But they also, Bill and Betty, rarely speak to each other. So that's going to be a problem. Scroll down some more. So based upon that history and keeping in mind the 4Ms, let's talk about what things from her symptom-wise do we need to treat or manage first? What do you see as the priority if you walked in and this is your first time walking in this home? What makes you nervous if you didn't address it? You know, I think the first thing, I remember meeting Betty in the basement. I think the first thing I needed to do was take a deep breath because she's just so complex and sometimes it's dizzying for me even to know, like, where do I begin with this? And, you know, her basement is so messy, the carpet was really sticky. And in having that composure just to say, all right, you know, I'm here, I'm going to do my best. So I think that was just a reminder for myself, even years after years of doing this, just, you know, take a breath, reorient yourself and take care of the issue at hand. I think I remember trying to come up with one or two things like, you know, and help having the patient define, you know, what should we talk about? What is the most urgent thing? So it's like, you know, Betty, can you share with me what's like one or two things that we could really try to fix today or address? If it's, for example, if it's her shortness of breath or maybe it's her uncontrolled blood sugar, maybe we can get a dietician involved. Maybe we could adjust her insulin to get her sugars better controlled. And as much as possible, involve the family and say, hey, you know, she's kind of a captive audience and it's not good for her to be eating all the ice cream that you bring home and all the McDonald's or whatever else that they were bringing home and giving to Betty. So maybe getting a dietician, adjusting the insulin and trying to engage the family the best as possible. But, you know, despite the dysfunctionality that was present in the family. I think that's a really good point. Again, even if whether it's the emergency room, whether it's somebody's home, wherever, you cannot address all of these issues in one visit. That is it's just not possible. And you have to set up a thought that I'm going to have to come back and I can address these if I need to, two by two, whatever works or whatever, whatever you find the most reasonable and whatever works for the patient. And that's a really good point is to say what matters most to Betty, you know, and then at the same time asking what would be the most likely thing to send Betty, you know, calling 911, which how they're going to get her out of that basement, who knows? Because that's going to be a real problem. So and she had mentioned I'm going to go back and take a quick peek. You don't have to do that to her goals of care where she wanted to be able to manage her conditions and try to get some help. That was one of the things that was mentioned as a patient preference was that in her living conditions, she feels powerless. And so she does have a lot of things that that we do need to address medically. But the. Getting a social worker in there certainly would help to empower her, make her maybe feel like she could get some control back in her life by solving some of the problems from that standpoint. Figuring out how to work with it and then the dietitian. So that way, she feels like she's a priority, what what her needs are with the social worker, and then the dietitian is a is a great point to you, Dr. Chang, because it's going to take more than just us as a provider going in and working on that blood sugar and those visits is going to take probably some phone calls. Now, has anybody had to consult a dietitian in the past or tried that before or had success with it if it wasn't available in your immediate practice? Any other solutions to bringing a dietitian on board? We usually try to get home health, some kind of nurse from home health to help with the dietary stuff. A lot of times insurance doesn't cover anything else. Exactly. So that's another reason where get home health out there. And then if you put that in your order, sometimes they they may not have a dietitian either, but the nurse can go out there and certainly take a look at what's in the refrigerator. Are they following the diet? How their blood sugars and kind of be those eyes and ears for you. So that would make a big difference. And then now. A key thing that would make her feel better right away, I always try to make sure I ask that of a patient that maybe the patient doesn't realize we can fix instantly. What's something that we can fix instantly for Betty that would make a big improvement and maybe how she feels? What about that abscess? That's a that's an easy one. If she doesn't have a stinky abscess under there. Yeah, exactly, Dr. Bender. I mean, you know, it's already draining. So, you know, the gloves on and you try to get out as much as possible. And if you need to put because she's diabetic or on antibiotics, that'll keep her from having that worsen to a point or developing further cellulitis. And again, ending up in the hospital. So that would be something that would be a nice immediate goal to make her feel better. Just like with Ralph, we address this constipation right away. Try to address the abscess right away. Absolutely. I think that's a that's a that's an easy fix. Right. Betty doesn't have any easy fixes. The abscess, I think, provides two opportunities. One is one is an easy fix. The other, it helps you establish your credibility and your care. You came in, you did something for Betty. You didn't just, you know, throw your arms up and say, I don't know what to do with you. Although maybe deep down inside you're thinking maybe some of that, like, I don't know what to do. But that helps you establish that relationship, providing the care and also help you get the foot in the door in terms of a relationship standpoint that, you know, she may say, yeah, I can trust I can trust you. I can trust Megan. I can trust Bruce or Dr. Chang and whatnot, because he did this for me. Again, it's going to be a long road for Betty in terms of trying to get all of her condition managed. And I think Bruce had another comment earlier about access. Right. You know, she just feels trapped. She just felt hopeless. Now, is the hopelessness from or I think maybe access or maybe that was access. But anyways, in terms of feeling hopeless, is that depression hopeless or is that physical weakness that she can't go up the stairs hopeless? So I think it's important to tackle maybe both of those aspects, the psychosocial aspect of depression and also the physical weakness part. I think somebody already mentioned, you know, getting home health in there, getting a nurse follow up on the meds, you know, abscess and getting PT, OT involved and trying to improve her condition. Again, being reminded that it's a team. It Betty will take a team to fix. You cannot fix her on your own. And the final comment I'll make is the final comment I'll make is when I take learners out of the residence and so on, I say, you know, resist the temptation to add more pills. Look at her pills. What can you prescribe? What can you cut down? Look at her creatinine clearance and so on. Are any of those medications, are they appropriately those she's is she having side effects from her meds that's making her sick? The gabapentin dose and so on in her kidney, is she at the right dosing? Is that why she feels loopy and her legs are all swollen? Now, can we cut back on the medication she's on and actually make her feel better? Well, and the metformin, I mean, she's on a high dose of metformin for somebody with stage four kidney disease. So that may be making her nauseous and not feel well either. So there's a lot of things that we need to probably cut back on. Yeah, I just wanted to just piggyback on something that Dr. Cheng had mentioned when, you know, just going back a few, you know, a few presentations ago, you know, when we were doing the introductory visit, you know, and we were talking about supplies, you know, things, supplies that you're going to need, but also having, you know, some supplies like in case something comes up. So I think, you know, and in this case, you know, having some supplies to IND that abscess already in like in maybe in the second bag that you keep in the trunk of the car so that if you see it, you can treat it right, right there at the first visit. And then and then that by doing that at the first visit, you're building trust. You know, you're the patient, as Dr. Cheng had said, you know, the patient is seeing you and saying, oh, this doctor can at least do something for me as opposed to referring me out or just throwing their hands up in the air. And to piggyback off the on the home health, another thought, too, is we're talking about somebody who's depressed. And one of the things I run into time and time again, you know, she's got a husband who's not present. Very rare. Nobody's coming to visit her. The home health, even though that's not really the purpose of them is for social visits, but it is social visits. It's activity, it's interaction with other people. And I find that that makes a real big difference in how they're feeling all around by having people come in and check on them and ask them, how are you doing today? So, you know, don't underestimate the power of having people just come in even for simple things. Sometimes that's really what a person like this who's been trapped down in the basement is looking for. And then you can bring a social worker in there and say, what are we going to do if a true emergency arises? How are we going to get this person out of here? Because we really need to work on the goal of getting them up and down the stairs. Definitely. So we've talked about the kidney disease, trying to eliminate some of these extra medications. What that would probably help from a cost standpoint, because then she's not having to buy as many things. This all ties together, you know, then using the physical therapy to help with the weakness, the social worker, you know, try to look at what can we do to get her in and out of the apartment if it comes down to it. We're working on her depression and mood disorder by having increased activity go on and and people talking with her and checking on her. And what one and we know she's got the uncontrolled blood sugar. We talked about the dietician. But what about her shortness of breath? You know, that's the other day, too. We've talked about this before, making sure that she's using her inhalers the right way. So lots of things. But what matters is that Betty wanted to have some improved control. Of her situation. Yeah, I remember, yeah. And then her mentation, we certainly want to make sure we grab that that many cogs. We've got something in the event that we can document her cognition status, particularly since she did mention she's been seeing her mom come to visit her. I want to make sure that we address that in addition to having increased personnel out to the house. And we mentioned on the mobility, working with therapy. Working with therapy and then the medications, of course, looking at with her kidney disease. What are some other suggestions or situations that you've run into that might be similar to this that you found were helpful? In addition, is there anything that comes to mind? Melissa or if that's something that you've run up against already or. Yeah, I'm just and it might not be appropriate for the first visit, but I frequently involve adult protective services when there's concerns for safety or neglect and maybe not at this visit, because I don't know that there's an imminent like an immediate threat, but, you know, just resources. I think that's a really excellent point. Often we're afraid of getting adult protection services involved because we don't want to be wrong. What if it's the wrong? And I think there needs to be a change in that thought process to what if I am right? And I don't want to miss it, number one, if there is a problem here. But, you know, getting getting them involved sometimes helps with documentation so they can get additional services, they can get additional accommodations that might be available for them. And by having them come out and take a look and say, hey, what can we do to help this? That might be what the social worker needs to put those things in place that would help her versus us just saying, I don't know, I don't want to call and rock the boat because I don't see any definite evidence. That's for them to decide. That's that's for adult protective services to come out and do the interview. So let them let them be the police. Our job is just to say, hey, we've got a question. It's worthwhile to give a call and let let them figure it out. I agree with you. Especially because, you know, the husband's not there. If the daughter, you know, is is a role, it's not. It's how she may be helpful when when you're there, but that may be the only time she shows up to come down and help out mom. We wouldn't know. The other comment I was going to make is that, again, it depends on your practice and your access and so forth. Having a pharmacist work with these complex patients, either indirectly or working through you, having them review the medication of somebody like Betty and say, you know, please help me. I don't know where to go with this with this lady. Having an expert like that to help you with managing her multiple medications in the light of I think Megan mentioned, you know, CKD and whatnot, appropriate dosing and so on and so forth. I think that could be something for for you to consider in terms of, you know, maybe networking with with a pharmacist that that's maybe within your health system that can help support you as you try to your best to take care of somebody like Betty. You can also certainly call her pharmacist. I mean, that's what they're they're they have additional resources besides just counting the pros out. They can a lot of times be very helpful in our area to see what's going on, who else is prescribing in case you want to identify if there's any other prescribers that might be contributing to this. But call her, you know, if you call Walgreens or who are your CVS or whoever her pharmacist is, that's a good point, too, is that you can also kind of put them on to review those medications and say, what's going on here? Do we have some that aren't aren't appropriate for her to help give me a heads up here so we can start making these changes? I think that's a really good idea. And that's speaking outside the box. So if you're if you're a one man shop or even two or three woman shop, you got to use resources that that are available, but just not in your immediate office. And the pharmacist is one of them. Good point. Let's see, what what else? I feel like there's other things that we could try to set in motion to get to get involved for Betty, but that we might miss, you know, the pharmacist, you know, reviewing those medications, home health or therapy, PT, OT and the social worker, adult protective services. What about from the mental health standpoint, you know, do you how successful have some of you been with getting whether it's a psychologist or psychiatrist that we might do a telehealth visit for her? Yeah, Betty. Yeah, Betty happened before COVID, right. And COVID has changed the landscape of televisit and access in a dramatic way. So post COVID, there are a lot more psychologists, even psychiatrists who are doing televisits. So that's a great point, Megan. Don't forget, post COVID using that, you know, if you want to call it a benefit from COVID, if there's such a thing in the sense that it has really opened up telemedicine for our patients. Veronica, on the mental health nurse, do they do visits to the home or are they doing it still by telemed? Both, but mainly at home. Good, that's pretty good. Excellent. Yes. And is that something that you have? Is that a whole separate business or is that something within your organization? Within our organization. So it's part of our group of interdisciplinary group. Yes. Okay. And there are, I know in our area, there's a couple of nurse practitioners that strictly do mental health and do mental health visits. So and then as Dr. King was saying, we have even more options now because, you know, with telehealth. Now, again, I do tend to find that many of our patients like Betty, I'm lucky if she's got a flip phone. I mean, that's so it is still tough to just say telehealth. I know that sounds great. And for some of them, it is an excellent option. But if they don't have the electronic ability, there are other ways around it. So with some of the mental health nurses that are out there. So some of our patients that have like a psychiatrist and they do virtual meetings, we still use our mental health nurse because it's very different to have somebody in the house. It's like you say, it's a social visit. It is a game changer. So absolutely, absolutely. And sometimes people I find they they get better a whole lot faster because they're getting a lot of people in the home. And that kind of prompts them to say, OK, I I got to get better so I can get some of these people out of my home with too many visits. I've had that be a complaint before, too. Absolutely, you know, I think we've all seen this, what we'll call the hospice rally, right? When patients are declining and then all of a sudden you bring in all this support, all the social worker, the chaplain and the nurse and the aide. And all of a sudden your patient is is improving. So, again, I think just a reminder to all of us that taking care of Betty like patients, it will be beyond us. It will be beyond us. And just recognize you have your limitation as a provider that you really need. One of your job is to kind of assemble the team, right? As we're talking about, look at look at the list here. We got dietician, we got APS, we got pharmacy and so on. So one of your role is to be assembler of a team to to bring in to help Betty. Well, I hope that helps. I mean, it's just all about trying to find those resources outside of your network sometimes and bringing them in and just tackling it. Like, what's the problem that you can do right away instantly that makes them feel better? But at the same time, what's the problem that will keep them out of the hospital if I solve that? And that that makes all the difference in the world. OK. I think from that note, we're going to go into our next talk. Yes, we will. Give me just one moment. I'm going to queue up the slides and we will be ready in one minute. We recently just on a side note, there are some dentists that are doing home visits. I don't know if anybody else has run into that Yeah, we we have Dentists and podiatrists doing home visits in our area. Yeah Yeah, likewise with us dentists and podiatry we had a Optometry group that was making house call Our house visits on our patients with especially with diabetes and so on very helpful But he moved away to to North Carolina. So we lost we lost him to geography. So That was sad Well, thank you all For your contributions to that session everybody in chat and and then if you do you want to speak up, please don't hesitate Our learners can just jump in any time next up we've got medication management and If you are ready, let me know and I will go ahead and start advancing slides Yeah, I'm ready and I just wanted to just mention that though this This like mini lecture flows nicely from from the previous case and and especially Some of the comments that dr. Chang had made are going to be woven into this So the objectives of this mini lecture are just to review and discuss the essential steps in medication management and Namely to reconcile justify optimize and demonstrate Medications discuss some mitigation strategies for challenges in management and med management of Home based primary care patients and to ID some assessment tools to help with this. So next slide um, so when when I First saw these stats, I remember like doing a mental pause and just letting this soak in and I just wanted to like Assess people just to give it some time to sink into for these stats to sink in so nearly a fifth of community dwelling adults over 65 Take ten or more medications nearly a fifth, right and almost 40% of seniors are unable to read prescription labels and 67% are unable to understand the information that's given to them. That's That's some really remarkable stats there Next next step next slide and You know, I I know this this picture comes from one of dr. Chang's Patients but I wanted to ask you know ask you all What are your impressions as to what's wrong with this picture and and also kind of share at the end Some of my interpretations of what I saw in this picture as well. So the floor is open Meds outside the box. Yep So what does I'm gonna ask a follow-up question to that to Lisa What does that signify Oh meds meds miss? Okay some missed doses But what? In terms of the meds outside the box What's your interpretation of that? can't see the the boxes the single boxes themselves You know tipping them over missing meds can't feel the meds in their hands can't pick up meds out of the holes lots of Vision, you know all different sensory issues And and because they also look like the meds that are inside the boxes as well Another thought that had come to mind when I first saw this was You know, could these be quote-unquote PRN meds? It's it's possible but the other thing in addition to what you're describing is also maybe art some arthritis And she's unable to physically manipulate the the boxes Let's see here. I Dr. Bender Mentioned skip doses Valerie mentioned missed doses and Veronica mentioned small print Yeah, has anybody had any experience with using the pill pack where it comes packaged whether it's the pharmacy did it or they ordered it that way curious Yeah, I I have some of my patients do that, but It becomes a little bit challenging when I have patients stop medicines and they say oh Which ones do I stop and sometimes they don't have the description in the pack? and you just have to Go through the the pills inside the little the little containers that come in the pill pack Yeah, I think the challenge with the pill packing with my patients number one They have if they have arthritis or vision issues to tear open the packet sometimes could be difficult They end up spilling it. So I have I'll have a you know, hold a large bowl under under them as they're opening the packet And and the other is as Costa said sometimes we need to change a dose for example We're changing coumadin and we're changing, you know lasix because you're all swollen and all that pill package does not offer That that flexibility and it can cause confusion so when I take the learner out when I When I show the residents say, you know, what do you think about this as you look at the the pillbox here? The same exercise that we're doing. I think one of the things that we're all looking for Like, you know, we're all looking for a quick fix. We're looking for a quick fix like somebody like Betty Whatever just And sometimes we just say just get a pill box as if that will fixed That will fix everything and as you see here that doesn't fix it, right? It actually it might be causing even more problems That's true and and I know this is you know, this is You know a pill box per week But when I first saw this I thought well is This actually not a one month or four week supply But rather a week supply and the yellow is the morning meds The pink is the you know, noontime meds, etc and You know, so they need some clarification there but also You know the The meds there they're all together and so which medicines does she take in the morning which medicines does she take in the afternoon and will Does she know or does she she sometimes makes up? Oh I took my morning man in the afternoon, you know, etc I to your point. Dr. Cheng be you know a pillbox doesn't solve Isn't the cure-all? Yeah, so that that yeah, it's it's morning afternoon to top so The yellow one and the blue ones are morning pills and the pink one and purple ones are afternoon pills And and then you guys can just figure out, you know, what is wrong with this picture after I give you that information Like, you know, what is this, you know? And anything else that you bring up with To bring up with a picture What are the stickies for Week one and week two now that even asked you know that begs a question Why is week two on top of week one? Week one and week two now that even asked you know, that begs a question. Why is week two on top of week one, right? So again, this just creates so many puzzling You know, what can you draw? What conclusions can you draw from this? It's just so perplexing and it can be frustrating but also it really gives you an opportunity because an Office doctor doesn't get to see this This is the beauty of house call medicine Okay, we have an advantage here. If you're in the office, she'll probably say yeah, I got a pillbox. Are you using it? Oh, yeah, you know, I put in the pillbox and you know, I take it according to the pillbox and you would be thinking great She's got a pillbox She's taking her pills and the and the meds are matching up in my EHR and all that kind of stuff When in reality when we're home, we see this, right? So use your position literally be next to the patient as an advantage to provide better care for our patients Yeah, that's that's well said and and actually I've got another Example to illustrate a little bit later on but let's go to the next slide So just and just to go over some Some Some kind of like key tenants to medication management The first thing is to do is to reconcile meds Now in order to reconcile meds, you have to have an accurate list, but it's not just The patient having an accurate list. It's the provider having an accurate list as well And making sure that both of them are aligned You might have it in the EHR They might have something folded over from a year ago in their wallet. That is not accurate But that's what that's what they carry. So it's important that they have That that both parties have an accurate list The next thing is justification so Whenever Medication is prescribed there. There should be a documented medical condition that requires the medications not to say that all Conditions require medications, but for those for them each medication. There should be a documented medical condition The third thing is optimization So having proper dosing of medication based on kidney function liver function Considering drug-drug interactions, and I also might add not and not just drug-drug interactions, but drug meal or drug food interactions Because if and also and also timing so sometimes For example, you know people take levothyroxine too close to Some of the other meds or even something close to the some sometimes their meals so best to optimize the medication dosing and timing and Then the fourth key tenant is demonstrating You know having the ability to properly administer medications like we saw there and Possibly using teach-back methods, you know show me so for example Ralph's case Show me how you're using your inhalers Well, if they're breathing in and then pressing the you know, inhaler canister They're not getting the full dosage You know just just as an example for that So having teach-back is is is important next line So med management is You know Reviewing medications in the home as dr. Chang had said it offers a unique opportunity for us to assess med adherence completeness and barriers to use so for example, I had a patient who had Uncontrolled diabetes a1c is greater than 12 She was and this was in my my previous clinic practice. I was dutifully prescribing She was dutifully picking up because I was checking with the pharmacy and there were a couple of days that she missed them Appointments and we were worried about her. So I did a home visit with my student and we go in and we do You know amongst other things we do a refrigerator, you know, what we call a refrigerator biopsy we take a look and she was stockpiling all her insulin and for when things got bad and So She was dutifully picking up the pharmacy, but not using it. Sorry dutifully using the Picking up the insulin from the pharmacy not using it and we would not have known it had have we not done a home visit so Reducing med burden can you know can create success for adherence? And it's it's good to review medications to see if they're appropriate for For their conditions to see if they're beneficial and effective and if they're if they're in alignment with With their goals of care so The if we can go to the next slide What we'll do is We're going to skip this patient case, but what I'd like to do is Have have you at the end of the day? Take a look at this in your workbook and And kind of like over this it's just a mini case it's just a one-page case Where it goes it goes into these tenants and how she how mrs. Smith misunderstood the instructions for For her medications So if we can go to the next slide So some some med management tools The beers criteria we have some websites here about deep prescribing as well Including some tools to assess, you know self administration of medications and And so these will be in your packet and you can Look them up online Just wanted to also go over the this equation for drug dosing You know to use the estimated creatinine clearance that remember those Prognostication tools we talked about earlier the QX MD and the sorry Kind of the calculate app by QX MD and the MD calc that calculator is is in there as well so If you want to look up creatinine clearance Online you can you can take a look at it and then Take a look at it in the apps and then adjust medications So next slide so just in summary We should consider physiologic changes Associated with aging and the risks associated with polypharmacy and at a minimum with every change Clinically or a change in setting It's important to do a medication reconciliation and to see if certain medications should be stopped and then Use some evidence-based tools like we talked about in the previous slide and that's it Thank you so much and in record time too so as mentioned that case for mrs. Smith is in your workbook We are going to go over tomorrow how to access the workbook if for some reason you weren't able to get to that and next We've got acute and urgent care with Megan Megan. Let me know when you're ready and I'll start advancing Yeah, go ahead. Let's do this All right, so our objectives in the acute and urgent care portion We're going to review the common urgent medical issues that arise when you're doing home-based primary care Discuss the approaches to planning and preparing for those urgent scenarios as well as how do you implement and evaluate your strategies? We also need to describe how to use those acute and urgent issues for continuous quality improvement Okay, so an urgent call from your patient what kind of questions or concerns it'll be They have chest pain shortness of breath fever valerium Other mental status change fall with injury These are all just some of the the things that they'll call you and say I need to I need to have somebody come see me today right away And you've got to make a decision. Is that something that you're going to be able to go see or How are you going to handle that? Next slide All right, then the other side of that coin is that you were scheduled for a routine visit and you Arrive at the routine visit and you find they've got abnormal vital signs. You're confused and unaware of their sudden illness Kind of like how we had Ralph in the first case. He's totally unaware that his oxygen is off and he's not meditating So then you've got to make the decision is it so bad that I need to call 9-1-1 Is it something that family can help they want to transport the patient to the ER or is it something I can fix? And it's really important to keep in mind you know if If this is something where you think that they are septic or they might really be having true chest pain Stemming and strokes or their time protocols in the hospital. So you you wouldn't want to sit on it You need to make sure that that's something you call the ambulance for Unless you have a pre-arranged agreement with that patient and the family and they've said no that that's not what they want And that may be reasonable too Next slide Okay Now what if the urgency is related to the caregiver so you get out there the patient is fine, but they say, oh, by the way you know Like in the case of ralph, let's say something he's really dependent upon those two family members Let's say his son suddenly goes in the hospital or the daughter There's a progressive illness and they can't function Sometimes you have the alzheimer's patient who the caregiver the functioning spouse suddenly develops cancer and dies These things happen Sometimes it's just a stressful nursing task of taking care of somebody with a chronic illness And then of course you've got the psychosocial issues like in the case of betty where the daughter isn't Physically equipped or mentally equipped to be able to take care of a mom with all those kind of needs We walk in and we have to take a deep breath because we find it overwhelming but for the daughter you know if they don't have the Capacity that we have imagine how that's got to be for her on an everyday basis to face that Next slide All right, so operational strategies So, you know these things do happen and first and foremost scheduling. This is how you kind of have to keep it in mind How are you going to get through or how are you going to maintain it? Some practices will maintain a certain number of open slots per provider or have an on-call provider You'll have to figure out what works best for you If you've got more than one provider in your shop Then sometimes this is a method where it works for you if you're doing this on your own and you're one person you'll have to be Cognizant of how you're going to handle those phone calls if they say they suddenly need to see you And realize you can only do so much But make a decision so you have that plan ahead of time The other way you can manage urgent calls is by using telehealth have them call in That way you and you can of course As Brianna has said you can go for that now. That's a real big change. You know, the value of that billing Episode is a lot better than it used to be Other places they use a paramedic the paramedic would actually go out and triage that that urgent call and or Sometimes i've even had the home health company. I know that there's going to be a home health visit And the home health nurse, I will call the nurse and say look here's the situation. I we need to get eyes on this person Uh, you know, I is it reasonable for them to wait for the nurse to come see them? Then you have to consider payment arrangements you know if if your practice is fee for service, it's One of those where sometimes you've got to consider you can't just leave openings if you've got to see five to seven patients a day To be viable It's pretty hard to leave those open slots And when you're hiring providers Consider the service area needs and how close is your provider to be able to do an urgent call? you know if The provider that's on call that day or working that day If their area is, you know, 45 minutes away from where the urgent call is It's very difficult to say that you're going to be able to have that provider come see them without Sacrificing the care of the five people that they were scheduled to see after that patient So you do you do want to keep that all in mind? Next slide All right, and then Don't forget you've got the different point of care technology and services you can use now or try to set up ahead of time Now there's the ecgs and rhythm strips There's even some of the technologies available that the patient could keep for them, you know at home themselves and utilize Pulse oximetry I think now after covid most people have a pulse oximeter or Recognize what that is. So if that's something that they need to have they can do it Of course knowing what labs can get out there and how quickly and x-ray In our area Because it gets so hot in in a car when you're going in and out of these house calls you can't really keep the supplies nor can you keep blood in the car for any length of time clearly because It just won't last So you really need to know which mobile service might be able to help out most of our home health companies in this area They need at least about a day and a half lead time to go out and to do Labs on a patient because they have to schedule their own And We're lucky we have x-ray portable doppler And they're they're very responsive And again telemedicine make sure that if you can handle it over the phone or by video You know that certainly is a very helpful tool and don't pass it by and then spend a lot of time trying to drive out To somebody's house just to get out there and say I think we need to call an ambulance A lot of times that decision could have been made By phone Next So create a create the workflow, you know, what is your office triage procedure when somebody calls in or the caregiver and says They have an urgent situation Make sure you think about how are you going to handle that? And then what are going to be your scheduling strategies? are you going to be able to handle those kind of urgent calls that can't be done over the phone or What can you do to Try to accommodate as best as possible And are there any other team members such as the home health nursing staff that might be able to assist with the assessment care? Is it reasonable for you to have a paramedic or somebody else that might be on staff as well? and ultimately Really need to to know what you're going to do when they say I must Have a visit today Is that going to be something that you can reasonably do or not? Without again, you got to remember sacrificing the care of the patients that you may have had scheduled already Next slide Uh keep them, you know, another thing to to do is to assign different acuity levels low acuity stable medical conditions Stable medical conditions. There's no acute exacerbations hospice or nursing home patients Theoretically the hospice patient doesn't plan on going to the emergency room Medium acuity, of course beginning to decline. They've been having some exacerbations or Potentially new diagnosis And then a high acuity if they're unstable medically or psychosocial issues So that may be something from the very beginning in your EMR is that you identify where they fall on the spectrum Next slide So that way the goal is you're anticipating what their needs are going to be Review their charts in advance Consider what equipment supplies to bring Especially if you are going to go do that urgent call Assess potential decline in a patient status, you know have those early discussions with the patient and family Ideally, we we would have already made sure that they've got Uh the competency to make these decisions and we'll talk about that later But make sure that that you've kind of considered this ahead Are they going to be competent to have this kind of discussion if they're going in the ambulance or not or? If they decide to stay home and not go for further treatment, what does that plan before you get in that crisis situation? Uh, and sometimes it changes, you know, just because you have that conversation uh You know the when you first meet the patient a year later, you may find it's a whole different conversation with them So educate the patients and caregivers to communicate when they have further symptoms or worsening side effects particularly for medication And encourage them to practice those contingency plans, you know, what if the oxygen's not working? What are you going to do? How are you going to can they even set up the portable tank? Are they strong enough to get those tanks out of wherever they've been put in storage? Are they able to make the connections and get it all put together? Sometimes they're not um but uh You know and what and ask the question What are you going to do if the caregiver is not able to take care of you and suddenly has to go in the hospital? Uh, and also if they have pets that comes up too uh next slide Once you go through uh urgent visits It's important to sit back And you want to document how often are these calls happening? um for a couple reasons one So you can get an idea as to who might be kind of continually decompensating The other one is that this is all data that helps you When you know how many times you might be able to avoid having something go to the hospital this can be data that's helpful to share and uh with other Potential business partners in the community. They're really looking at how can we best fulfill? uh A quality of life for these patients and avoid unnecessary visits and if you're able to document Opportunities where you made that successful That's really what some of these You know businesses you're looking for in different health care organizations And review it as a team. Sometimes the the patient family sometimes they can also provide insight to how they thought about the process Uh that that you may not realize how did it go? What did we learn? How can we improve? The family may say, you know, we had no idea and hadn't really considered this Uh, you know as a possibility and now that we've gone through it You know other families ought to be aware of this is a problem Uh, you know around here in our area it's hurricane planning and Don't forget to bill for extended time visits You know, I know that's been asked before. How can you maximize? Uh, or make sure you're getting paid for what you do And this is one example of it really make sure that if you are spending extra time for an early care visit that you are Documenting for it and making sure to put on the billing. That's really key this is the new patient codes because you've got A change in the amount that pays out versus an established patient the next slide Oh the established patient visit And It's all about again that whole time is the whole time you spend counseling and coordinating their care now in addition to If you spend so let's say this was a a new patient visit You were referred to by like a home health company And you've spent a whole lot of time reviewing the hospital documentation the home health documentation And getting all that in order before you can go out to do the visit Then you go out to the visit and let's say you find that their vital signs They were tachycardic 120 and their adamin was tense and painful Which i've walked into that before you would have thought they just came into the hospital. The problem had been solved Unfortunately, we ended up having to send that person back to the hospital to find out their pancreas was necrotic And they had just gone also and done a follow-up visit with the gastroenterologist But the point being is is on a visit like that Don't forget to do the uh, the non face-to-face time as well. That's an additional code that you can use to help kind of Make sure that you're getting paid for the time you're spending because you just spend a lot of time with that type of patient Next and in summary Um, this is going to happen. You're going to have patients they experience sudden changes in their condition Make sure if you plan ahead and how what What your Framework is going to be for when that call comes in You may find some days you can you can take urgent calls and other days Unfortunately, it may not be realistic and you may need to say look based upon what you're telling me. You're going to have to You know go to an emergency room And sometimes that's totally reasonable. Uh, so don't be afraid of it Uh, you can't always see everything but certainly if you can make sure to document and take advantage of that so you can use it to Demonstrate how you are a help to all of the different providers and health care organizations in your area Make sure that way we can always learn how to improve Thank you very much Dr. Chang, let me know when you're ready to advance. All right, next slide, please. So the objectives for this section is to recognize the infection risks providers may encounter in the home and to describe infection risks that require special considerations, such as dealing with multi-drug resistant organisms or bedbugs, and to apply some strategies to minimize infection risk, including provider's behavior. One is probably not a good time to make a house call, as well as discuss a little bit about infection control programs. Next slide, please. Just quickly, for your practice within your organization, I think it's really important as we're talking about infection control to have good leadership. Somebody who oversees the program, can make decisions regarding protocols and so forth. It's important to have adequate resources. I think infection control might not have been a real hot topic, perhaps in home-based care before, but with COVID, that certainly has changed many things, including infection control, having adequate resources like PPEs and N95s and so on. It is also important to have written procedures. All your providers are following the same protocol and provider A is not telling the family to do this and the provider C is, ah, don't worry about that. I think having a written protocol is important, and have a reporting and communication structure, whether we're talking about state policies, about which infections need to be reported to the health department, or communicating with your colleagues or say a home health agency about a potential multi-drug resistant patient that they'll be seeing at home. And then ongoing monitoring and evaluation, obviously they're important. We're always on this journey to better ourselves and better in terms of improving our care of our patient, which includes managing infection. Next slide, please. As we talked about before, I think planning, whether you're talking about handling multi-complex patient or not having to dash back to your office to pick up something, planning and chart review and chart prep is really important as you are looking at your day, going out and take care of your patients. That might include, there might be a little comment section in your EHR about a particular cultural practice or religious practice that they want you to wear shoes or something upon entering the home. And also about a packing, I think Casa's talked about packing the necessary equipment for the anticipated procedure or encounter that day. Consider wearing appropriate clothing that includes, we talk about scarves that are not too long or coats that are not too long. They're less likely to get contaminated being dragged on the floor, that's an example. And also review, as I said, review the records and see if the patient has a history of infection related to a multi-drug resistant or if the patient has an acute infection such as influenza or nowadays, if the patient is struggling with COVID. Next slide, please. You need to think about the bag that you pack as you go from house to house. There's not, no pun intended, there's not one size that fits all. In terms of bag selection, whether it's a roller bag or a bag that's maybe leather or as a canvas and whatnot. But when we talk about dividing the bag into section in terms of organizations, I like to look at it in three buckets, if you will. There's a clean section, there's gloves, swabs, things that just never returned to the bag. And then there is the dirty section, such as needles and forceps that need to be sterilized and so on. And then there's a reusable section, such as pulse oximeter, blood pressure machines, thermometer and so on that they are placed in that section after being cleaned and used on our patient. And then you can have a personal section for your keys and wallet as well. It's also important to have a container. If you do procedures, if you draw blood, like my practice does, to have a container specifically for biohazard, for sharps, syringes, scalpels, and needles, and so on. And stock your bag, not bad, with disposable gloves, shoe covers, gowns, and masks, and so on, so that you're not scrambling to find the appropriate PPE as you go into a patient's home. It's important to keep hand hygiene product, such as a hand gel. I like to keep it on the outer pocket of the medical bag. In our particular setup, it has a little pump action, so that little, I don't know, a little pump thing hangs out of the bag so I can clean my hands without necessarily have to unzip sections and so on, and potentially contaminate the bag that way. It's important to pack soap and carry paper towels. Do not use the patient's, especially don't use their bar soap, don't use their towels. It's just not a wise thing to do, especially when we're talking about infection control. Next slide, please. Some of us who travel in private vehicles should be placed, your bag should be placed in a large plastic container with high size. If you're taking a ride share, or if you're on public transit, it's important to keep the bag next to you. Don't put it in a trunk because we have no idea where that trunk has been, and where it could pick up potential contamination. Next slide, please. You know, when we visit a patient's home, obviously that's one of the challenges of doing house call medicine, right? It's not an office, not everything's the same. You know, there's not like a cleaning crew that comes and clean up after the visit and so on. Each house is different, each family's different. So you have to be prepared and have kind of a protocol as you go in and make your visits at home. Finding a smooth surface before you put your items down or using a barrier, such as a plastic garbage bag or chucks to put your bag on, to put your laptop on. And make sure your bag is on a clean surface high enough so that, you know, dogs and cats and small children are not, you know, getting around and getting their hands in there. Place your laptop, a tablet on a clean surface or on your lap, and then hang your coats on. If you have a rolling bag handle, put it on there rather than, you know, putting it on their sofa or couch because you're not sure if there's a bed bug possibility there. Next slide, please. It's important, I know this is like, oh, this is so basic, but I think we all need, I need to be reminded that, you know, before we enter into the clean section of the medical bag, especially, you know, wash your hands, sanitize your hands, and make sure hazardous material disposed of in the proper container. And place your blood collection tube in a plastic, appropriate plastic bag. You know, we have these big Ziploc bags that says, you know, biohazard on there so that your blood samples or your samples are appropriately placed. And again, you know, don't drag your clothes on the ground because of potential contamination risk. When you're ending the visit, make sure you count the sharps and put it in the container on the dirty side of the medical bag and things that are used and contaminated, you know, bandages and gloves. We usually dispose that in the patient's family, in their trash. The non-reusable equipment in the dirty side, such as, you know, tweezers and forceps and so on, they're put into the dirty side inside a biohazard bag, brought back to the office to be sterilized. Next. And definitely, especially with us going to, from house to house, meeting different kinds of people, make sure you wipe down your electronics, your blood pressure cuff, your thermometer, your pulse oximeter with a appropriate cleaning bag. Make sure you wear gloves. Some of those cleaning solution can be pretty harsh on skin. So wipe that down and put it on the appropriate section of your bag. And I think it's important to document in the patient's chart if the patient has a history of multidrug-resistant organism, MRSA, C. diff and whatnot. So other providers can be alerted to that and also communicate that with home health nurses that might be going in there, taking care of a mutual patient. And finally, clean your hands with sanitizing gel or wash your hands with soap and water using the supply that you brought from the office. Next slide. Just at the end of the day, when your sharps container is getting full, obviously get a new one. And if you have other specialized equipment, cleaning them with appropriate wipes, make sure you restock the items that you need, like gloves, mask, and so on. Clean the medical bag on a regular basis. There's not a specific guideline that says you should be clean every four hours and whatnot. There's not a standardization regarding that. And then wipe down the exterior surface of the bag with disinfectant wipes, again, using gloved hands. Next slide, please. For the sake of time, just the whole COVID thing has really highlighted the need for us to do a better, to think differently, perhaps, about infection control. You know, social determinants of health, which we knew was important. It's even more important now in the era of COVID. We do, in our office, we do pre-visit telephone screening. You know, how are you doing? Do you have symptoms of COVID? And so on. And determine if the patient has a preference for inpatient visit, or perhaps they're more happy with a televisit, again, in the era of COVID-19. And you can find a lot of resources at acci.org and the COVID information hub. And there's the link there. Next slide, please. Also something to keep in mind, infection control with COVID on top. Look out for your staff. How's the morale? Are they ready? Do they feel educated, equipped? Do they feel supported by you? What testing capacity, what testing equipment do you have? What additional information and resources do you need to help take care of our patients during a pandemic? Work with your local health department in terms of getting supplies, possibly getting vaccines for our homebound patients. And obviously maintaining workplace safety. That's before COVID and post-COVID. An example is how to put on a PPE. And we have a link here to, I believe it's UCSF, that teaches you how to put on and take off a PPE. You could certainly use this to educate yourself and also help your staff so that they feel like they have the necessary information they need to take great care of their patient. And that link will be included in the slides that you'll all get post-workshop. So yeah, it's donning and doffing, and it's a good- Thank you. Next slide, please. Just some strategies regarding dealing with these really tough bugs that are out there. One example is the pack-only essential items. Perhaps you don't need to bring the entire medical bag into the patient's home, only what is really necessary. And then of course, you need to make sure you have appropriate cleaning supplies to wipe down your instrument, if at all possible. If the patient has a thermometer, they have a pulse oximeter, blood pressure machine, go ahead and use their equipment rather than risk the possible contamination of using the equipment that you're bringing in. And again, having a system for indicating a patient who may be contaminated with a multi-drug-resistant organism. Next slide, please. Yes, we do run into bed bugs. We often think of bed bugs are only involved in patients who's got socially compromised condition and whatnot, but obviously it can affect any patient from any socioeconomic status. Just some strategies related to, if you know that there's a bed bug infestation, don't sit on the bed, don't sit on the sofa. Ideally, if there's like a smooth surface you can sit on, such as a metal chair or a plastic chair that you can sit on, that would be more ideal. Again, review the chart in advance and pack only essential items. Again, you can put what you need in a plastic bag and schedule patient visits who's got bed bug infestation to be the last patient of the day. That's obvious to all of us why that should be. And wear clothing that can be washed and dry at high heat, such as your scrubs and so on. And when you return to the office, you change into a new clothing place to potentially contaminate a set of clothing in a plastic bag and seal it and carry it out for laundry and cleaning. And have a social worker. Remember, it's a team, it's a team. Work with the family to help eradicate the pest infestation, possibly handing out eradication services. There's some consideration when you, maybe you shouldn't make a house call, such as when you're sick, that's obvious. Or if you're immunocompromised.

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