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Essential Elements of Home-Based Primary Care-Virt ...
Main Session / Clinical Break Out Day 1 Video 2
Main Session / Clinical Break Out Day 1 Video 2
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I'm not that pregnant. Well, anyways, if the example would be, if you're pregnant. And you've never have Aracela, and you're seeing somebody with with an infection, a rash might have shingles. And supporting your staff in these decisions can help with morale, increase the quality of care and mitigate risk of infection. Summary. A multidrug resistant are particularly organism, particularly risky, sorry, for, for home based patients with immune system, and they are in and out of hospital a lot, they get treated with different antibiotics. So we encountered them frequently. Bedbugs could be anywhere, any home. All right, keep that in mind. And, and there may be situation when you should not go into the house, either because of your condition, or perhaps the patient's illness. And a effective infection control program includes good leadership, good policy procedures, good communication, and ongoing dialogue of monitoring and evaluation. That's it. Phenomenal. Thank you so much for bringing us through that amount of content in that amount of time. That was incredible. So I'm going to stop screen sharing for a moment as I queue up our next case. And we're going to make sure that everybody is in the right breakout group group for the track that they chose. So that'll take just a minute or two hang tight. Okay. Okay, I'm going to screen share like this since we're going to move over to our workbook in a moment. But you should be able to see and if Dr. Deleginitis would lead us in this clinical case study and then we will discuss it as a large group, followed by a couple more mini lectures on cultural competence, medical decision making capacity, and quality. So Dr. Deleginitis, whenever you're ready. All right, how's everyone doing? All right, excellent, I see a thumbs up, good. So the case begins on page 41 and I'm just going to go over the summary here and then we'll launch into it. So we're asked to see Christina by Home Health Agency that's been in the home since the patient's hospital discharge. So Christina is a 68-year-old Romanian woman who lives with her 50-year-old daughter Veronica, whom you see there. Over three years ago, Veronica brought Christina, who's the patient, into the emergency department with significant belly pain, nausea, and obstipation. Christina had been ill for several months in Romania and couldn't get what Veronica considered adequate care. So at the time, her abdomen was firmly distended with protruding embolicus. She had prominent lymph nodes and then was found to have ascites and was diagnosed with stage three ovarian cancer. She underwent debulking surgery and then had chemo for about six months. She did well for many months, but then tumor markers lately began to increase. And she had a recent surgery for an SBO, which was caused by some adhesions and now is home after three weeks after her operation with home health in place. So let's go into the casebook. And I'm just going to go over her... Well, we won't go into her demographic intake form because it basically goes into her patient information, emergency contact, and she's Medicare Part B and Blue Cross for her secondary insurance. So let's go straight into the assessment form on the following page. So the chief complaint for today is that she's having increasing weakness and fatigue. And like we mentioned earlier, she's three weeks after surgery. She also has a rash that started yesterday. There's a language translator that's being used during the entire visit because the patient, Christina, only speaks Romanian. Her history of present illness shows that she has stage three ovarian cancer after debulking surgery and chemo. She's been complaining of exhaustion and fatigue, rash that started yesterday. She also has a history of hypothyroidism, hypertension, and hyperlipidemia. In terms of her past medical history, there's just limited information as she grew up in Romania, and the daughter doesn't know much about her past medical history. Her immunizations, she hasn't had any flu shots or any pneumonia shots. She had a Tdap before she turned 40. And we talked about the past surgical history with debulking surgery. She also had a transabdominal hysterectomy with BSO three years ago. Family history, significant. Her parents died. Her sister is alive and well, and she's 72 years old. Daughter Veronica is a lab tech, and she's 50 years old, and a patient lives with Veronica. And her son Constantine is 48 and lives out of state. She's a nonsmoker, no alcohol, worked as a secretary. And then review systems. Let me just hit the major ones. So we talked about her lethargy. She spends more than half of her time in a chair, and she's been increasingly spending more time in bed. She has some trace edema at the end of the day of her legs, but no chest pain or orthopnea. She does have some dyspnea on exertion, especially when she goes from kitchen to bedroom. GI has constipation. Now it goes every three days, and she used to go every day. She has some residual pain from her scar. And she's eating less, and she's nauseated. She has some incontinence. She has trouble getting out of the chair, and she's fatigued with walking. She has a rash on the right side of her chest that appeared yesterday, and there's some blistering, and it's very painful to touch, and we'll see the rash a little bit later. Her PHQ-2 was negative. She denies depression. She worries, and the daughter chimes in that she's a fighter. She's very strong. And we talked about her ... Oh, we didn't talk about her legs. She has some swelling in her legs, and she was told that she's anemic. So let's go into her medications. She finished a course of chemo 12 months ago, and was taking dexamethasone with chemo. She's on Coldase BID. She's on a statin. She's on esomeprazole, 20 milligrams daily. She's on hydrocodone with Tylenol, 5,3,25 as needed, and she's usually taking two a day. Thyroid, 125 micrograms a day, Deltiazem, and Lorazepam as needed. In terms of her screenings, her timed get-up-and-go test was 19 seconds, and her gait is unsteady. She needs help in the shower because she feels unsteady, and everything else that she does, she does slowly. And she needs help with her instrumental activities of daily living. She no longer cooks, and primarily because of her lethargy. We talked about her PHQ-2 was negative. We don't have, as you can see in the screening section, we don't have a cognitive assessment. Environmental survey shows that she has some DME, like bedside commode, walker, and a wheelchair. There aren't any grab bars in the bathroom and no bath bench. There's some throw rugs in the hallway. And she feels safe. The abuse screen is negative. She is part of an orthodox community, and her faith is important to her. And her caregiver, Veronica, her daughter, shows mild to moderate burden, caregiver burden. So and we talked about how Veronica is her, she lives with her, and she's her emergency contact, but Veronica works as a lab tech in the local hospital for the past 15 years. The financial status, as you can see, because Christina is dependent on Veronica, sorry, she's dependent on Veronica's income, and Veronica needs to work at least part time to keep health insurance because she's exhausted FMLA, and the daughter is not, feels she can't take care of the patient. But she's kind of like stuck that she has to work full time and in order to keep her health insurance. So let's go into the physical exam. The, you know, the things here to make a note of is that her weight has gone down. She's lost about six pounds over the past month, and about 20 pounds over the past six months. She looks fatigued. She has a slightly protuberant belly. She has normal to slightly diminished bowel sounds, but non-tender, no palpable masses. She has no hypothalamic spondylomegaly. She has that rash that you see there on her TA dermatome, hint, hint. And we talked about her time to get up and go test, which was 19 seconds or so. She has a decreased strength. Neurological exam was performed, and she did have a five out of five mini-cog test during the physical exam. It wasn't performed on the screening earlier, but during the neuro exam, it was checked. So, and then at the very end, her goals of care, she doesn't have any formal advanced directives. Veronica has been making the decisions and signing consents for Christina. Christina doesn't understand English, but Veronica, you know, has been making all these has been making all the decisions for Christina and has been fluent in English and is fluent in English. She, Veronica hopes that her mom will have more energy and her functionality will improve. She needs, Veronica right now works part-time. She needs to return to work full-time. So that's kind of a goal for her. And Veronica chimes in and says that she wants to restart chemo as soon as possible because her tumor marker isn't as low as it used to be. So let's pause and focus on the problem-based assessment and plan, and then we'll go into the 4Ms. So what problems can we identify for, for Christina and the treatment plan for that? Good point. Yep. So we have, ask daughter what she knows about the prognosis. So advanced care planning. Another problem is shingles. Yep. So let's, let's go into advanced care planning. Yep. Yep. What, do you think they, based on what Veronica said about starting chemo as soon as possible, do you think she'd be amenable to having kind of a discussion of most in advanced care planning? Get the five wishes in Romanian. Good. Really good point. Yep. I think that that's probably the first important thing is to actually find out what the patient wants versus just what the daughter wants. So having the patient complete the five wishes in Romanian, go from there. There's a lot of truth in that because sometimes, We run into this a lot in the emergency department where you, the, the family will pick and choose what they're translating. And I speak enough Spanish, I've read it well to, to know when this is happening. And so then we'll call in for a formal translator at that point, because that's what we're going to be doing. And then we're going to have to figure out what the patient wants and what the family wants. And so then we'll call in for a formal translator at that point because, and sometimes the, the family member may not know the words. They're fluent, but they don't know the medical terminology in the language. Yeah, and, and to, and to that point, so if, if I have a family that's speaking French or speaking Creole, I know French and, and there's, there's similarities also with Creole, but if I asked some questions and I hear only like part of the question asked, I'm, I chime in and I say, why don't you ask about, you know, blank. And sometimes it catches people really off guard. Yes, it does. Um, yeah, uh, so, um, so, but, um, but I, I think that's, that's important. We, and especially important because from a dementia screening, she's, you know, she has no cognitive deficit, right. And so it's important to not have language be, be a barrier, um, to, to addressing, uh, um, addressing, you know, uh, goals of care and, uh, and, and, um, and the five wishes specifically. Um, okay. So let's go into the next, uh, the next one shingles. So what would we do for that? anti-viral? Yep. Let's see, other problems that we would add? I think that we could certainly get the team involved and solve two issues by home health having therapy for the weakness, at the same time getting the social worker involved because the daughter's exhausted her FMLA and may need additional resources and the social worker can kind of help work on that to get the team back in play. Well said. Labs for thyroid, excellent. Yep, making sure that she's taking her medications appropriately for her hypothyroidism. Great. Yeah, med review and checking labs, yeah. Now here's a, what's your feeling on deprescribing in this case? Does she really need to be back on the lipid medications or would you tend to pull the plug on that at this point for a cost savings and is it really going to give her benefit if she has ovarian cancer potentially? How do you guys feel about that? I'll leave it up to the group. Talisa? Yeah, I agree. I mean I always like getting rid of statins but again it comes back to the goals and what the prognosis is. I mean obviously if this is something curable you know I would say okay she's a young person so maybe consider it but again if goals are aggressive treatment and I would say okay let's keep that for the moment but I agree I always like getting rid of excess medicines. It definitely changes based upon the patient in each scenario. I agree it's certainly tough because there's no clear answer to when can we get rid of a statin or when can we get rid of some of these other medications. You know when does that when is the benefit gone? You know what at what point is it not going to be effective? Yeah, Veronica's recommending stopping the statin. I agree. So let me add this along. Colace. Okay, great. Talisa's shaking her head. I see her response. I personally don't like colace and I know it's kind of like basically just give some mineral oil instead. There's really no indication for it. If you want to treat constipation there are other medications to prescribe or rather over-the-counter modalities to use. So I'm not a fan of colace just as an aside. I usually use Miralax or even well actually more likely it's you know more of the preventative measures. So fluids, fiber, and the three F's fluids, fiber, and footwork or physical activity. All right, so we talked about caregiver burden. We talked about weakness, rash. How about her ovarian cancer? I would hope we'd be able to access some records, maybe. Oncology, they might also have discussed prognosis in their notes, so. Well said, yeah. Yeah, Veronica's in prognosis, yeah. Okay. So, how would you approach the request from Veronica? Oh, actually, Veronica, the other Veronica said, said, you know, what does the patient know, understand about the ovarian cancer, right? So I was gonna say, how would you negotiate that request to, you know, restart the chemo as soon as possible? And it's about discussing goals of care and discussing prognosis, so good. So this is actually very interesting because this actually segues into the next talk about cross-cultural competence and communicating with family members who might wanna shield their loved ones from the diagnosis of cancer and so on. So this is perfect. I think it's difficult terrain for us to navigate, right? We wanna have a great relationship with a daughter because we know how important she is to the care of the patient. At the same time, we have this duty to our patient to honor truth-telling, correct? If the patient asks us, you know, why is my belly so big, for example? So there's that real tension for us. So I'm glad we're working through this case that we could pick up on some of the ideas on the next session as well. Thank you. Excellent. And I wanted to, before we, you know, just being mindful of the time, wanted to go into the five, one of the four M's, five M's, and the discussion questions below. So let's talk about the what matters. So, you know, preferences for care, goals of care, shorter-term goals. I think we talked about this, right? What else do you need to know? And we talked about kind of like the five wishes in Romanian or, you know, having that discussion with the patient and in her language with a, you know, with an interpreter, you know, sometimes, you know, those mobile. We have our mobile interpreter services that we dialed into and use for each patient. But let's talk about mentation. So we talked about MINICOG that was performed during the neuro exam. That was a five out of five. And I think we talked about PHQ-2 and it was negative. How, what do people use? I think we talked about this earlier. What do people use for cognitive assessments? You're using MMSE or MOCA, okay. Anyone else? Does anyone else use anything different? Yeah, Minicog, okay. Yeah, I use Minicog. I used to use Mocha, but then I heard that there's a training that you have to go through in order to use Mocha. And like you have to, I don't know how much it costs. I think it's like $100 for the training. I know there's another one called RUDAS, R-U-D-A-S, that other people have been using internationally with good sensitivity. We lost the presentation. It's okay. How about her mobility, the patient's mobility? How would you facilitate getting mobility and safety for her? PT eval with health home. Yep. Okay. And we talked about medications and I think the last thing is about multi-complexity. And I think we talked about this as well. You know, what makes Christina a complex patient? And someone had mentioned, it was Veronica had mentioned that we have two patients, the patient and the patient's daughter. And, you know, enlisting the help of social workers and home health, you know, to address the, to be resources for the patient and the patient's daughter, I think would be really helpful. So I think I'll leave it at that. And I think we can go into the next presentation with Dr. Chang and cross-cultural competence. Thank you so much. Great segue into our next topic, whether Romanian, whether it is Asian, as in the case that we'll talk about later in Mrs. Chang. I think it's important to talk about culture and in terms of what we're doing, shared decision-making with a patient and family. Kind of think about culture and their biases and the impact that it has on the healthcare of the patient and review our role in terms of what we can do to enhance cultural awareness, to facilitate shared decision-making and really doing good medicine in a culturally sensitive way. Next paragraph, next paragraph. It sounds like I'm dictating. Thanks. We've all heard of the golden rule, right? Do unto others as you would have them do unto you. But there's the platinum rule, which states that, you know, treat others the way they want to be treated, right? So it's a different perspective in terms of having the golden rule and the platinum rule. The platinum rule kind of takes on the view that, hey, you know, what would you think if you're the patient from that particular culture? How would you like to be treated as a patient by a provider? Next slide, please. So, you know, as I'm reflecting here about, you know, multi-complexity, all that kind of stuff and what we're doing, talking about Christina, she's got cancer, you know, what about her future and that kind of stuff? You know, doing medical care at home is not just about medical, their medical conditions, as many as they have, right? But it's also about how patients make the decisions and who they want to be involved in the day-to-day decision-making process, as well as, you know, future planning for their care. You know, having these discussions early on, then reviewing them periodically will help us craft a plan and communicate the plan in a culturally sensitive way. So that when, let's say an emergency happens or the illness progresses and so on, knowing that you have had this conversation and what are the next steps to be taken and so on, we can better deliver care in a more respectful and patient-centered fashion. So what are these steps involved in terms of assessing the patient's and family preferences? Here are four buckets, if you will. One is to ask questions. One of the things I try to teach the learners, you know, in medicine, we ask a lot of yes-no questions, having shortness of breath and so on and so forth. I think we have to untrain ourselves and learn to pause more and ask more open-ended questions. You know, what do you think about that? What is your religious and spiritual belief about afterlife and so on and so forth? Learn to reshape or re-ask our question in a more open-ended way and allowing time for a patient to reply. That can help open or direct more specifically in terms of where we should go with our conversation. Try to understand the historical context of a patient's life and how that may impact their decision-making. And as in Christina's case, address any communication or language barrier that might be in place. And I think the best practice is to use a language translator rather than using family members for multiple reasons. And when necessary, you know, get religious community leaders involved when it's desired by patient and family. I have called rabbis, I have called chaplains, I have called pastors. When there are concerns that families have, for example, you know, stopping tooth feeding, what are the religious implications within that community that perhaps a leader from their faith community can better address? Next slide, please. Next. Long day. Next slide, please. Yes. So the more specific steps are, you know, assessing the cultural beliefs regarding truth-telling or withholding of information. You know, the Asian culture is about shielding your loved ones and the number one son being the go-to person for all the kind of the medical information, right? So getting a feel for that. And it's also important to get a sense of what does the patient want? In terms of whether the patient want the information or does the patient want to defer that to family. Again, paying attention to the cultural, spiritual values of your visit. And you can also get a sense of that just being at the home, right? As you're talking with the patient and so on, if the son is constantly, I don't know, cutting is the right word, but perhaps answering on behalf of the patient, maybe you would get a sense of the dynamics at home. That the son is probably making all the decision for the patient. Be aware of the preference for family-centered decision-making in many cultures. Again, just be aware of the fact that in America is, you know, I did it my way, as Frank Sinatra said, you know, it's my way or the highway, but that belief is not shared across the globe. And finally, getting a feel, especially the patients as she wants to know, assessing the family's preference in terms of balancing, respecting the family's wishes, as well as your call to be truthful to your patient. Next slide, please. So I want to take a moment and ask you to turn to your workbook. Janine, if you can let the learners know what page this is on, page 49, or Sarah, thank you. And I want you to go ahead and read and review this case. This is a real case. I met her probably more than a decade ago in terms of, you know, what I encountered and what was some of the concerns and pressure points for myself. So why don't you take a moment and go ahead and read that. And then we can come back and we can discuss the case. Any initial thoughts, reflections, as you work through the case here of Mrs. Chang? Janina, Melissa, is it possible to pull up the case on the screen here? Sure, I can do that. Give me just one moment. Thank you very much. Yeah, I mean this isn't esoteric stuff because I saw a patient. Two weeks ago, and my nurse practitioners out seeing him today, where the wife is asked that we do not reveal his cancer diagnosis to him. So, situations like this, like Christina, like Mrs. Chang, it does come up in our practice because we deal with patients who are sick. And they need our help and many of them have limited access, and they look to us for some guidance and direction. All right. Any, any comments. What would you say to the sun. What would you say to the well let's start, let me back up what would you scroll down on the slide or Janine please. And, and when Mrs Chang asked me, our things. Is everything okay. Thank you. Start with open ended question. Great to determine. I think says what she wants to talk to the family explain my duty to the patient. Okay. Asking the patient what she thinks is going on or how does she feel to see if she has any suspicion at all. Absolutely. She may understand a lot more than what the son thinks. She may be reading between the lines very well. And the son is trying to shield shield mom from this right. Would you tell her if she says, Do I have cancer? I think that's a really good question and then I would want to start seeing if there was other family that can kind of help verify what's the true decision, in the sense of how to best handle the patient and what the family wants and is the sun, you know, correct in that. Yeah, that's that's even then that's not really the right answer. So, that's. Yeah. It's hard for us right we again, as I said before, we want to have a great relationship, we know we need to work with the sun. We cannot burn bridges with him because he's the caregiver of the patient we need to work through him. But at the same time, patient is asking us, do I have cancer. And, you know, our duty is, we shouldn't lie to the patient. No, you don't. Um, you know, you just need to eat less, you know, ice cream, you know, I don't think that's necessarily the best way to build trust with a patient because at some point down the road, even if we said nothing she's going to know that something's up. What do you do in terms of her faith in you. If you just kind of said nothing to her. Any other comments. I agree as well I my duty is always to the patient and if she asked me directly something I'm not going to lie to her. Again, there's not much of it looks like there wasn't much of a workup done except the CT scan so if she asked me if she had cancer I would say, well there's some concerning, you know, findings on your scans, and then go from there, see which where that leads you. Yep. Absolutely. Yeah, great, great comments. Again, learn to ask open ended questions, what are your concerns. You know, what are you worried about. And also perhaps having the sun in the room. So that, again, you know I tell during my visits. Nowadays, you know, patients have the ability to read all our records anyways, right, they have access to my notes, and I tell my patients look this is what I'm typing they're no secrets here. Okay, because I think trust is important in taking care of you, and having the sun in the room and caring and listening to what you're saying to mom, asking open ended questions, asking things like, um, you know, I want to be respectful of your question but I also want to be respectful of your son, and your culture. And I say, you know, in some cultures. The family and the patient decides to let the sun handle everything. And that they, they don't have, they don't want to know what their issues are, and let the sun handle it and I want to be respectful of that. And you can ask her, and put the ball in her court said how would you like me to navigate this going into the future. Would you like me to work with you directly, or do you want me to work with your son, and having the sun in there and perhaps hearing it from mom himself may be able to take some of the heat and responsibility off of you and put it with her and and and So in summary, you know cross cultural competence, as we've heard with Christina with this real case with the real case that's going on with my nurse practitioner is critical for what we do, because culture impacts the way we think we how we make decisions and how we behave. And, and we ought to do things in a, in a sensitive way to help facilitate shared decision making conversations, and over time address these differences and having difficult conversation, hopefully will become easier and more natural as we acquire more skills in making these tough calls. Thank you, Dr Chang Megan when you're ready, we'll start medical decision making capacity. Great. All right. So thank you, Dr Chang that really helps to put in light some of the questions that come up for all of us as we're out there and talking with family and and the best path forward so that leads us to the medical decision making capacity and as the patient understand and what is their role. So our objectives are to define the difference between capacity and competence and to discuss the clinical approach to assess medical decision making capacity and explore scenarios that illustrate those kind of complex situations, just like we were previously looking at. Next slide. Alright, so decision making capacity, it's a clinical term, the ability to understand and appreciate the nature and consequences of a decision regarding treatment or foregoing treatment, and the ability to reach and communicate and inform decision. Can you reason through why or why not that decision is being made. Next slide. Competence, which is a legal term, a person can be determined determined by a judge to be competent or incompetent. So that's the end result informed valid consent. A patient must be given adequate information, including nature and purpose risks and benefits and alternatives. Be free from coercion and have medical decision making capacity, so they have to have capacity, be able to give consent, and they have to know what the procedure is, the purpose of it, risk benefits, and if there are any alternatives, i.e. sometimes doing nothing. Next slide. Next slide. Approach to assessing capacity. So clinicians intrinsically assess decision making capacity at every clinical encounter. You know, we come in the home, and we have, you know, basic conversations with the patient, and often we think that they've got capacity to make these decisions, but when you look at a pillbox like we did previously, it does mean that you need to look a little further into the situation. Because assumption that a patient has capacity, we assume that they have capacity to approve it otherwise, but sometimes they don't, so you have to be careful. We tend to overestimate a patient's decision making capacity, again, the pillbox. Next slide. So indications for a formal assessment. What makes us say we need to look into it further? We need to do a more explicit structured assessment for capacity in the event that they have a neurodegenerative or psychiatric illness or substance abuse history, they have acute medical illness or end of life care, a diverse cultural background, limited education, and if they have a language or communication barrier. If they're having a hard time understanding what's going on, we need to look into it more closely. When consent is given too quickly for a high-risk procedure or complex treatment, without taking the time to explain the pros and cons or understand the risks, that's another reason to say, wait a minute, they said yes too quickly, we need to look more into their capacity to make this decision. And if the decision is in conflict with prior decisions, it seems like, you know, in the past, they felt pretty strongly about saying no, and suddenly they're saying yes to treatment or vice versa. Those are indications that, again, we need to look at this more formally and make sure that we're in alignment. Next slide. So the steps to assess capacity, there's four specific decision-making abilities. One is you have to have understanding. Two is communicating a choice. Three is appreciation for your decision. Four is reasoning, how did you come to that decision? Next slide. So understanding. Can you tell me in your own words, what have I told you about your condition? In other words, we really want to make sure we state the fundamental meaning of relevant information. We want to make sure that we've included the treatment risk and benefits. And then it's important to ask the patient, again, what have I told you about your condition, but what do you think will happen if you choose not to have treatment? That way there's an understanding of if you do this or if you don't have treatment, how is it going to change? What is the difference between the two options? Next slide. And then the patient must be able to communicate a choice. They have to be able to clearly and consistently state a decision or a preferred treatment. Based upon what we've talked about, what is your choice? Do you choose to have this treatment or not? What have you decided to do? What is the choice? Next slide. Next slide. And then appreciation. To be able to acknowledge the medical condition and consequences of treatment options on one's own life. Again, can you tell me in your own words, what do you think the treatment is likely to do for you? How do you think this treatment will help or hurt you? What do you believe will happen if you are not treated? Why do you think this treatment was recommended? So, for example, if you have recommended, we're going to go back one. If you've recommended that they go to the hospital or you're concerned that they got a septic from a UTI and they say, no, I don't want to go. Can you tell me why going to the hospital or not going to the hospital, what is that, what do you hope to achieve out of that? Do you understand what's going to happen? Next slide. Reasoning. To be able to reason about the choices consistent with their personal values, beliefs, and demonstrate a logical thought process in determining the choice. It does not require a rational approach. Patients have the right to make unreasonable choices. Again, can you tell me in your own words, how did you come to your decision? What do you think makes your choice better than the other options? And when we talk about unreasonable choices, you know, that can be the person who's an alcoholic and chooses not to go get medical treatment because they want to stay home and continue to drink. It's not what I consider reasonable at all nor appropriate, but if they have capacity, even though I completely disagree with it, unfortunately, they can make that choice. Next slide. So the spectrum of capacity, you know, it's temporal and situational. Capacity exists on a spectrum. Capacity thresholds change according to the specific issue and risk-benefit analysis. Low risk versus high risk on the procedures if it's a high risk versus low risk. It's important to consider and be aware of the capacity of not just the patient, but the caregiver as well, particularly the caregivers trying to motivate or incentivize the patient a certain way. Next slide. So what about cognition and capacity? Cognition is the main determinant of capacity. Capacity is distinct from cognition. So this is where often the MMSE, the Minimum Mental Status Exam, comes into play. So if you have a score of less than 16, typically it's really hard to argue that they have capacity. And so again, it goes back to your documentation, making sure you have this in your chart to help back up if they have to make a serious decision. What was their MMSE? Because if it's higher than 24, then that's reasonable. They likely are able to have that ability to make that kind of choice. Next slide. What is the impact of dementia on capacity assessment? Well, when it comes to understanding, it's highly impaired and mild to moderate dementia. So even in the early cases, they have difficulty sometimes understanding. Their communicating a choice is usually preserved even at advanced dementia. Superficially, they can answer the questions, what or not does it really make sense, sometimes is another problem. And appreciation, they don't typically have insight. Often they are in denial, and they do not acknowledge their own illness. So if they don't even acknowledge their own illness, it's really hard to appreciate the decision. And their reasoning is frequently impaired even in mild dementia. Some reasoning is usually preserved among those with advanced disease, which is why it's so again important to make sure you've done documentation in your chart to verify that they have capacity. Next slide. And what about psychiatric illnesses and capacity? Psychiatric illness does not correlate with a lack of decisional capacity. So you have somebody with schizophrenia, they are more likely to lack decision-making capacity than those with depression. But that may be intermittent. If they're well treated, they may be actually able to have decisional capacity. Among patients with psychiatric illness, lack of insight into their disease is a strong predictor of lack of decision-making capacity. So if they deny that they have schizophrenia or don't seem to agree with the diagnosis, that's a huge red flag. Next slide. So what to do when a patient lacks capacity? Consider, you know, is this expected duration of impairment, severity of impairment, and seriousness in urgency of decision? Is there something we can do to reverse the cause of impairment, such as a delirium? Is it temporary? And for patients with mild to moderate cognitive impairment, listen, discuss, and try to educate. Now, if it's urgent or irreversible, you have to identify a substitute decision-maker. It's time to get somebody else involved and make sure that we identify who that person is going to be when their condition worsens. Next slide. So guardianship and surrogate laws vary by state. And in the case of a court-appointed guardian, the process and length depends on if there is a willing guardian or family member. And then, of course, access to bank accounts, or if a third party is required to take the word on, and if that third party accepts without requiring a court hearing. Again, this may be if you have voluntary and involuntary, of course, as well. And if the patient is not willing, this is where adult protective services need to get them involved. Exactly. That makes for a smooth process. It helps with documentation purposes for the court and to help make it so that everybody is taken care of. Next slide. So tools to assess capacity. So first, we have the Aid to Capacity Evaluation, ACE. That is a readily available tool. You can download it if you've never used it, but you can get that form. Same with the Hopkins Competency Assessment Tool, ACAP. It's available to you, something that you can pull out and use. And it really is based off those four questions. And then you have also the Assessment of Capacity for Everyday Decisions, and you have the MacArthur Competency Assessment Tool for Treatment. Next slide. So the assumption is that patients have decision-making capacity when you first go into the home. And sometimes that decision-making capacity can be hard to recognize. It's decision-specific, although assessment of everyday function is more complex. Make sure to explicitly assess capacity using a structured approach. You need to use one of the measurement tools and have that in your chart. And remember that the impact of specific clinical situations, sensory impairment, health literacy, language, communication barriers, cultural norms, and cognitive impairment can also have an impact on that as well. And don't be afraid to get Adult Protective Services involved sooner versus later. Next slide. Thank you so much, Megan. We have a minute for questions if anybody has any at this time. I just have a quick comment. Doing capacity takes a long time, and we spend a lot of time with our patient. And actually, Medicare says, hey, there's a payment increase for doing something like this. It is 99483. It is about 3.8 RVUs, and national payment is about $282 Medicare. That's higher than your Level 5 new patient visit for those of us who are living under fee-for-service. So keep that in mind. There are specific bullet points you have to hit, but Brianna can answer those questions in much more detail. Good point. Thank you, Dr. Chang, because, again, get paid for what you do. That's really key. Absolutely. And Dr. Deleginitis, whenever you're ready, we'll get started with the quality mini lecture. Okay. Thanks, everyone. So I'm going to talk about quality. So when we talk about quality, there are quality metrics, and there's quality improvement. And I'm going to talk a little bit about both. So the objectives for this is just to describe the value of quality measurement and why home-based medical care requires unique metrics. I'm going to cite the benefits of learning collaboratives or learning networks. I'm going to reference some key quality metrics being used in alternative payment models. So, actually, before we go into the next slide, that's okay. Actually, let's go back one slide. All right, good. So I want to ask the members of the audience, when we talk about quality metrics, what do we think about and what have you had experience with being measured on, like with a scorecard? Quality metrics, like what quality metrics were you scored on? Yep, I see MIPS, I see ER hospitalization rate. Low or no readmission, yep. Immunizations, yep. Great. And, you know, one of the things that I just wanted to pause and say, you know, when we, yep, and patient satisfaction, yep, you know, did they get what is important to them? Excellent point, Dr. Bender. There's, so I come from a background of full-spectrum family medicine, and I used to be in the clinic as part of a hospital system, and we used to have quality metrics of colonoscopy rates and, you know, breast imaging, you know, breast imaging, A1Cs under, percentage of patients who had A1Cs under 8.0, actually initially was under 7.0. And one of the things that was challenging for me was I had patients in my previous practice where they had to decide about, they had to decide about paying for their water or paying for their medications. And here I am talking to them about, oh, you know, these are your gaps in care, like, you know, you should get a colonoscopy, and it just felt really disconnected, disconnected from their goals of care. And so the real, the really awesome thing about a home-based primary care was what Dr. Bender had mentioned about, are you doing the things that are important to your patients? So if we can go into the next slide. So, you know, these are some key metrics that, you know, that you can choose to, that you can choose to measure. And why are these quality metrics important? I believe that these quality metrics help promote your practice as a valuable practice. It helps you with your elevator speech. It helps you with, you know, when you have to negotiate with, you know, payers and, you know, getting contracts. Having, being able to measure these, some of, you know, these metrics and more is really important. So let's go over some of these specifically. So number of deaths at home. So how many, you know, how many patients, what, you know, your percentage of your patients who die at home versus, you know, going into the, you know, versus dying in the hospital compared to other non-home-based primary care practices. Incoming referrals per month, number of visits per day and per month per provider for the practice as a whole. Number of deaths on hospice or more specifically referrals to hospice. But as Dr. Cheng had also mentioned, hospitalization rate, right? You know, per, you could say hospitalization rate per, you know, per a hundred per beneficiary months, hospitalization rate per, you know, thousand patient days. These are all different, different metrics you can use. ICU stays 30 days before death. That is important, not just for your practice, for your patients as well, for, you know, when you talk to different, different payers as well. Hospitalizations 90 days before death. Re-admission rates, that's also going to be important and something if you're, if you work with hospital systems, they're going to want to know about that, especially for people who are working on their STARS rating for hospitalizations, sorry, re-admissions. Time to first visit, time to TCM visit. Those are important. The other thing though I want to mention is cost of care. And if we can go into the next slide. So cost of care is important. And one of the things, so Independence at Home is a CMS, Centers for Medicare Medicaid Services. It's a demonstration project and practices are measured by six, on six quality metrics and cost of care. So it's not just focusing on quality. It's also about focusing on cost. And so that if you just focus on costs, you're not cutting quality and the metrics. So some of these metrics are the same ones as, as before, like follow-up contact within 48 hours of either admission or discharge or ER visit. Med rec in the home, 48 hours after hospital discharge or ER visit. Annual documentation of patient preferences, most forms, advanced care planning, things like that. All cause hospital re-admissions within 30 days. Hospital admissions for ambulatory care sensitive conditions and ER visits for ambulatory care sensitive conditions. Those are, you can imagine, those are very meaningful metrics. And it's meaningful also for not just for us as providers and clinicians and business owners and members of health systems. They're important for patients because they don't want to be bouncing back and forth to the emergency department. If you can keep them at home, because that's why they signed up for home-based primary care in the first place. And you can show that you are able to take care of them at home. This is important to them. And in addition to that, CMS showed that in this independence at home demonstration project, within the first five years, that was $81 million in cost savings. I know for our practice, we had a 30% cost reduction as part of our home-based primary care practice. Next slide. There's, I don't know how familiar you are with these new payment models, but there's the primary care first. There's the significantly ill population. There's direct contracting. These are all different demonstration projects. And I'm very similar to the IAH independence at home demonstration project for patients who are moderately to severely ill, meaning HCC score of 1.5 and higher. Advanced care planning, total per capita cost, patient satisfaction, 24 seven access to a practitioner and days at home. Those are quality metrics. And again, these are meaningful metrics. So it's important. So I guess I want to underscore the fact that when you want to show your value to, you name it, your health system, your payers, when you're making contracts, you want to choose metrics that you can, that are meaningful for your patients and are meaningful for your practice. So if we can advance one more slide. So we talked about quality metrics and there's, but the other thing, the other part of it is quality improvement. So there are care. Let me just bring it back a moment. So there's care that matters. That's what we've been talking about all day. That's what we do day in and day out, delivering care that matters and, and, and making goals that matter. And that's why, you know, we're, we're fighting for advocacy for home-based primary care practices individually. Now, in addition to individual practices, there are, there are groups like HCCI, the American Academy of Home Care Medicine that, you know, together help with advocacy for home-based primary care and, and, and help with, you know, address, help us focus on quality metrics that matter, like we talked about earlier. So when, when we're dealing with quality metrics, we're not, you know, we're obviously not going to be hitting, you know, a hundred percent, you know, or hitting our goals a hundred percent of the time. So there's always room for improvement. And so I want to bring up, there's a national home-based primary care learning network, where different practices join together and learn about quality improvement tenets to help practices individually meet their, meet their goals. And, and so, for example, there's the Institute for Healthcare Improvement, the IHI, and they, they have, you know, this entire model for improvement. And you might've heard this phrase, you know, PDSA cycles. Actually, Dr. Chang at the first, in his first presentation mentioned about plan, do, check, adjust, you know, that cycle. And that's exactly, you know, PDSA is exactly the same thing. You plan something, you do something, you study it, and then you act on it. And you, you do these rapid cycle improvements in order to, you know, try to hit your goal, hit your goal for whatever metric you choose. So the learning network is great because you learn from each other what works, what, you know, what doesn't work, how, you know, what strategies might need to be used or what strategies might need to be adjusted. And this is all to help each individual practice get better so that we as a field can get better. And so I, and, and I know this from experience because our practice has, was part of the second and third cohorts. Actually we're, we're part of this current cohort as well. And there's a next cohort that will have the request for applications in June of this year. So if you're interested, you know, please, I'm just putting in a plug for this, improvehousecalls.org, take a look at that and see if that, if that interests you. But if we can go forward one, one more slide. One of the, so just in just talking about that learning network, one of the important metrics that we've been focusing on has been either cognitive assessment or functional assessment. Each practice as part of the learning network has to report on either one of these assessments, because as, as a practice, sorry, as a national organization, if we individually can report on these, on these metrics, these metrics will stay in, in MIPS with, without, you know, if we don't report on them, then they'll be taken away and we'll kind of be pushed towards less meaningful metrics. So that's, there's, there's an, there's an additional kind of like advocacy, like we're, we're by helping each other work on these two assessments, where yes, we're helping address, you know, goals that matter and care that matters, but we're also helping make sure that nationally CMS allows us to report on metrics that matter. Let's go forward one more, one more slide. So the, so just, I mean, it's, it's just a brief summary. So, you know, the value of quality metrics in home-based primary care can't be overestimated. It's especially important when you are discussing and advocating for your value to, you know, to organizations, to payers, to health systems, etc. I would say create a scorecard with quality metrics and practice management metrics that tell the story of your practice. If you're just starting out, it might be something as, you know, immunization rates, or it might be something as, you know, advanced care planning discussion rates. And if you're not, you know, at where you want to be, implement quality improvement methods so that you can, you can hit your goal. And if you need further assistance, consider, you know, a learning network to be part of a, part of a group to help you meet, meet those metrics. So that's, that's a short and sweet presentation that I just wanted to ask if anyone has any questions about that. Okay. Oh, we might have one in chat. Let's see. No questions. All right. Okay. Thank you so much. Wow. Everybody's timing was incredible. You covered so much excellent content. We're about to take a break for 10 minutes. We are going to have the non-clinical group join us back for reimbursement and sustainability followed by self-care. So thank you everyone. Please go refresh yourselves and we will see you in 10 minutes. Are we back yet or no? Very shortly, I think. Momentarily. Like running back to my desk. Thank you. I think we'll get started here in about 30 seconds. So if everybody who can come back from their break, if you're hearing my voice, we're about to start. Well, I'm really excited for this next session because it's a new one for us. And I thank Amanda Tufano and Brianna Plentzner for putting this together. I went to them a few months ago, and I said, you know what, we really need to start addressing on day one, the reimbursement and sustainability question. And that's pretty much the guidance I gave. And so they came up with this next presentation, and I'm so thrilled. So I'll go ahead and turn it over to Amanda and Brianna. All right, thanks, y'all. Thanks for having us. I have decided I think I'm going to call reimbursement and sustainability and then after this self-care as the palate cleanser between day one and day two. Because the most interest I stand by that the most interesting probably topic is Brianna's coding, which is tomorrow, which I know is super exciting. We go into a lot of economics tomorrow as well. Feel free to ask questions. My style is certainly jump in with questions, jump into the chat. I can manage looking at it all. Brianna will manage it too. But what we really wanted to start off with is reimbursement. We spent a lot of time in the non-clinical track, I think, talking about expenses. How do you run a practice? How do you think about hiring? How do you think about technology? Tomorrow, we're going to cover more marketing and branding. All those things are dollar-dollar bills out the window. So how do we think about securing revenue and sustainability today? And again, a palate cleanser between kind of what we know today and then I think even more meat on the bone tomorrow. This from a vegetarian. Slide. I actually don't know who's advancing them. So thank you for doing that. I just, you know, slide, but no, no, stay here. So okay, a couple things. We're going to review and identify different types of revenue streams in home-based medical practices. This is, we're going to talk a lot about this. So like pop in with how you guys get revenue to discuss strategies for sustainability. You know, develop these model of services with virtual and in-person. And Brianna is definitely an expert on what Medicare is doing with some of the virtual stuff today. So if you have questions on, is this still in play? How virtual can we be? Do you think any of these will be long-term? She's our Medicare expert. And then core components of how you determine the optimal distribution of resources to support this work. So certainly expenses always come into this. I was telling our smaller non-clinical track that my financial mindset is expenses always follow revenue. So, and it's not everything's that way, but as you're building something, expenses follow revenue. Even if you're a projection of revenue, what point are you going to get there and when are you going to hit that tipping point? Would you add anything, Brianna? No, I mean, I think you kind of have to think about your business model, but really getting down, you know, once you figure out your people and what that expense is going to look like, okay, how are you going to support it? You know, what services are going to be offered and more importantly, build for to build and maintain that business? Yep. So let's talk about revenue streams. This is the next slide here. So where is money coming in from? Fee for service. That's going to be a big portion of your business, even if, even if you're managed care or well, any sort of managed care, you know, ACO, MSSP, part of direct contracting, primary care first, any other programs through CMMI, any of those things, you're still tracking the fee for service component. So having a, a well-oiled revenue cycle management system and machine in your, in your group is, is going to be really key. Now they're care management services and thank goodness Medicare is starting to pay for not, not just face-to-face care, but you know, care coordination. There's procedures services that you might do in the home. There's any sort of capitated or value-based contract in the advanced course, we go into the different types of contracting, but even gain share, quality bonuses, bundles, full risk contracts, those things we'd kind of put in that bucket, things that you're getting paid for. As you start to look at overall quality or total cost of something, total cost of spend and maybe one specific type of spend, like in a bundle or in a specific like total cost of care for the patient over longitudinal care and telehealth, remote patient monitoring. Again, I bet you guys have a bunch of questions on what can I do with telehealth? What can I do that is typical under telehealth and what is under a waiver right now because of COVID and then any other sorts of income. I'd also add to this, you know, grants, philanthropy, state income, angel investors, medical directorships. If you do any facility-based work, other things that we're missing on this list that you guys are getting revenue from just pure revenue, where else is money coming in? We get revenue also from doing physicals at the assisted living facilities that we go into. We do those physicals there for them instead of them sending them out to their primary care. They just pay us a flat rate and it's next to nothing, you know, there's no time even off the board to do these. Yeah, that's great. Hey, what is my partner? What do they need? What are they paying for that they could pay me for at a lower cost? We just partnered with a group. So we're an independent joint venture and a group just bought 10% of us and they're a senior housing group and they said, we spend $400,000 a year on some sort of nursing staffing support for any sites that we're at. And you know, we just need someone's left, we need temporary, we need training support, we need backfill. And I was immediately like, oh gosh, a lot of my nurses used to be old DONs at facilities. A lot of my nurses have been in the senior space forever. Is there an opportunity there to leverage our services? So we're exploring, can we have a little bit of fixed stable revenue that is just because someone else is giving money away for that service that we might have some expertise being in just general geriatrics. Other revenue guys? Oh, wait, go back. I'm not sure. Okay, thanks. Okay, nobody's popping in. Okay, so unmute yourself or in the chat, what percentage of revenue split would you say you have today, fee for service and other and then if you can call out the other, what's your percentage? So I will tell you mine as you think about yours. Today of our revenue, 80% comes from value-based contracting, 20% comes from fee for service. And the value-based contracting for us is contained within five contracts and two different types of contracts. So I got a dual set of contracts and I got ISNIP, institutional special needs plans. And so those are kind of my two areas and my dual special needs plans are through the state of Minnesota, because that's the one who holds a contract with CMS to offer this fully integrated special needs plan. And I am always worried that, you know, what if something happens to that money? You know, what if something happens with the state to Medicaid and they want to start funding that either less or they want to dissolve the program and moving into something else. So I'm always thinking about diversification of revenue in these other areas. Okay, wait, I think I see some people popping in here. All insurance, 5% cash, no fee for service. Oh yeah. So, okay. Wait, Chris, let me clarify. It's all fee for service, but it's all coming from health insurance contracts, right? Or are you doing value-based? It's all health insurance. There's no concierge service, no straight cash. We have maybe three to five a year where somebody will pay a per visit just because of whatever, like if we don't accept, there's two insurances that we don't have a contract with. And in some of these facilities, we'll get a one-time visit, but that patient will pay out of pocket just because of whatever. So, you know, everything, if y'all see me grinning over here from ear to ear, whenever y'all talk about certain things, I'm just like, bottom line right there, increase because there's nothing we're doing. All these codes I'm asking Breanne about, I'm just like, oh my gosh, here we go. I've already told the guys, I see two or three office personnel that we can increase. And if we're doing this good without all this extra stuff, oh my goodness. That's awesome. I mean, that's awesome. And, you know, and for me, I, you know, I don't know how you're owned, you know, we are for profit. We do have owners. They'd like to see a profit, but, you know, there's a margin of a profit they want to see. The rest of it is going back into providing care, especially from a managed care perspective. We're legally obligated to submit a certain percentage of it back into providing care for what we do. So, you know, I do think, you know, again, if, if, if revenue is leading expense or rather expenses following revenue, the more revenue have, the more you can do innovative things that can drive your revenue in different ways or position you in a better spot to, to have new opportunities. When this, this group bought, bought us, what I told our team was, you know, having the first and the second. So we're a joint venture. We have three groups. The largest senior housing organization in Minnesota is part owner. The second largest senior housing is part owner. And the third largest health system is part owner. So when the second largest senior housing group bought into us, I said, you know, they're offering us, it's, it's not just doors are opening or windows are opening. It's doors that weren't there are opening. And that's what diversification of your revenue can do for your product is it can start to open up what you can spend money on to get even more revenue. Okay. I think you were the only one, Chris, who jumped in here. So I'm going to just assume, maybe wrong, that a lot of people were mostly in that fee for service space. Totally cool. I think that's really great. You know, as time goes on, Medicare is pushing value-based contracting significantly. And so as they move, I mean, and we have to do it for sustainability. So as they move to that, think about what areas you can kind of pivot into on this list. To Chris's point, what are areas where you're already doing it, or you're already doing some of it where you could take that pivot point? Yeah. And I just put some of the codes in the chat that for examples that people were asking about, but the resources and then the advanced course goes in more detail. But just to clarify, so the care management services, that's how are you going to get paid for all of the just coordination and that non-face-to-face care that goes? The caveat now, I mentioned both care plan oversight and chronic care management. You can't do both. Right? They're bundled. They're considered duplicative. You got to choose one. So I did want to just kind of call that out to your attention. But there are lots of ways to get paid. And then if you're not billing for home health certifications and recertifications, just for signing it and the oversight and documentation within the medical record that you're communicating back and forth, that's another 50 for the original, $50, and then 30 for the recertification every 60 days. So think about that. And then I think telehealth has been in a way kind of a savior for some of our programs. I'll put in the chat the link to the resource, but if you're doing video visits, it has to be that two-way audio and video, but you can bill your normal home and domiciliary E&M visits right now with a modifier 95 under Medicare. And they're reimbursing at a higher rate, similar to what you would get paid for an office visit actually in person. And then remote patient monitoring, regardless of what happens with the legislation, they don't consider that. There are certain things that Medicare has a definition of telehealth and what kind of regulations. We need some change in that respect for things to continue after 2021. But remote patient monitoring is its own segment. So that reimbursement opportunity will be here today and after the public health emergency. That's using a technology vendor to gather physiological data, using remote BP cuffs or glucose meters or pulse ox, and that's digitally and automatically transmitting data to the practice that you're then reviewing and kind of using to monitor and communicate with the patient in a care plan. In a nutshell, that's what RPM is. But there is significant reimbursement available for that. If you find using technology like that beneficial. I didn't hear about RPM until the last year, really. And now I'm hearing about it more and more in home-based primary care practices and how beneficial it's been. Absolutely. Comments? Questions? The next slide. Chris asked a question to you. I'll let you take the home health order. So it's per patient. So you can only sign if it has to be an actual Medicare certified skilled home health episode of care, right? So when you first sign the 485, it's their initial plan of care. There's a code that you can drop per patient for that one 485. If they continue, if you recertify that patient for skilled home health services after that initial period and they're continuing for another 60 days, then there is a recertification code that can be billed for that patient once every 60 days. It has to be exactly 60 days apart. And that's that GO179 code I mentioned earlier and then GO180 for the initial. But it's the date that you sign the 485. It's not just for signing it. They want to see documentation of oversight and communication and all of that jazz that you're already doing again anyways. But those codes in particular, again, you're doing it. You're signing those 485s and you're managing your home health. So as we talk about how do you diversify your revenue and again, get into other areas, not just fee for service, maybe not even just widget based like we're doing, you know, per care coordination code or per TCM code, you know, what are the options for a couple different types of income? You have your revenue cycle. That's a thing that you have to be able to really maximize. That's what HCCI will do and help with tomorrow on coding the advanced course. We'll talk a lot about revenue cycle management, including advanced coding in that course. But then as you think about your revenue streams, think about stable income, variable income and your RCM. And so RCM, again, that's your billable provider, but then there's also stable income, you know, and medical directorships, other contracts that you might have. We signed, we agreed to do some fixed contracting around some COVID testing and vaccine distribution. And for, you know, the last almost year, that's been a stable income for us that we've been able to kind of put into place and know that we're going to have there. And now it'll go away, but it was at least stable for a period of time. And then you have some variable income that might come and go, hey, if we pick up this contract or if we decide to do this, or if we do X, Y, Z, you know, another, a good example of variable income might be something like a grant. You don't know if you're going to get renewed again. You don't know if you're going to get the philanthropy money again. If it's a one-time piece, it's going to come and go. And what you want to do is figure out what bucket is everybody in and what are the worst case scenarios? And maybe it's just a healthcare administration degree, but that's where I always go, go straight to worst case scenarios. What if a global pandemic happens? What if you lose your funding? You thought it was a stable income. You know, the group that got funded, it's not a stable income. It's not there anymore. What if your RCM decreases by 5%? What if your lead provider gets hit by a bus tomorrow? Someone in my neighborhood actually got hit by a bus. They didn't work there, but they got hit by a bus, you know? So things happen, and people are no longer there. It's not just people find other jobs. And this component, understanding all inputs of your revenue, how you need to diversify to stabilize, and then ultimately where you can cut your expense if needed. All right, you guys are still talking about codes. Fantastic. Okay, slide. So factors impacting revenue obviously are not just, you know, some of your revenue. It's also what's your expense to get that revenue. So revenue cycle, the strong intake process, the coding and the claim submission. That's where HCCI can come in and help and do an assessment, and Breanna can look closely at that, or the coding discussions will help. Denial management, how long are they sitting there? Every time you have a denial, do you figure out your root cause analysis and fix the problem so it doesn't happen again? When we list payer contracts here, I would say this as a general rule. There's not a health insurance company that doesn't need your help. There's not one that has it figured out. There's just not. You have a product, you have a unique product that they need. Even if you are in an area where they have other home-based medical practices, I guarantee you given the number of lives that they're covering, they need your services. And so what does that look like? And all of these things come down to what is the problem you're solving for other people? Partnerships, ACOs out there, senior housing that might exist, the state, everybody has a problem that needs to be solved, and you have some important pieces here. And obviously productivity, this feeds your revenue cycle. So all of these things come into revenue, and then the majority of your money is going out with salary and staff compensation. How do you flex that? And we've talked a lot about this in the non-clinical track, but how do you appropriately hire and flex? And if you need to lay off people in that structure and keep your overhead, your infrastructure in any other contracts, I think one of the biggest contracts is going to be technology. If it's not today, it's going to be in the future. How can you flex those things and figure what you need in-house and out-of, in-house and outsource? Yeah. And I would just go back and highlight your intake process. Honestly, a lot of breakdowns in revenue cycles start because the correct insurance information wasn't obtained and verified upon intake of taking that patient. Or as you continue to see that patient, your front office staff isn't continuing to check for active insurance coverage or updated if it's changed, because these patients don't know all the time. You should have options within your AHR called real-time eligibility to do that, or there's sites online that you can pay for to do that, Medicare, they have federal sites or a phone number you can call even to check eligibility and MBI numbers. But really, if you're not verifying it's an insurance and not an HMO plan that you're not in contract with, or you're not in a network provider, and you're not doing those things upfront, it is going to have such an impact on your back-end revenue cycle management. So just want to highlight that. One other thing on the payer contracts, when we talk about philanthropy or grant money, that doesn't just come from states or from the Kaiser Family Foundation or Robert Wood Johnson. Those things come from health plans too, for-profit and non-profits. Non-profits are putting a certain amount of money back into community, and for-profits often have some sort of foundation to put money into community. I mean, it's marketing for them, right? Like they use this market so they can put money into the community, but they offer money for innovative projects that you want to start and you want to prove. And so being able to come to them in that space too, even if you're not coming with a brand new shiny, here's a big program we're going to start, you can start with smaller things and get money from lots of different places. Yeah. And I know Chris was putting in the chat about if anyone went the route of kind of state and federal grant options for underserved areas and revenue, especially in rural areas. Like if your area is considered a healthcare professional shortage area, you have so much opportunity or there's all of these grants and supports and even exceptions under traditional billing regulations that you can do in rural areas that you can't do normally. And also on the technology aspect, like the FCC and a lot of these federal programs is offering a lot of grants for the actual hardware and the technology itself to be able to do telehealth during the pandemic. So there's a lot of grant options, I think, especially on the technology front now. But if you're in a rural area, there really are a lot more options and flexibility because you serve such an underserved geography. So the title of this is Revenue and Sustainability. So let's go to the next slide. As we think about sustainability, now you have to figure out, you know, who are we? And you could also call this expense. But being able to think outside the box, be innovative, figure out, you know, once you get some of your revenue pieces figured out, you have to figure out all the expense structures that come with that. What role is everybody playing? Is it in-person or the telehealth? How do you think about care management? I tend to think about care management as something that many larger systems just put on top of a broken healthcare system. They're like, oh, the providers aren't doing what we want, or, oh, we're not getting patients to go here. So instead of fixing the problem, we're going to add a whole team of fixed expense care coordinators who are going to make phone calls all day. That's not really why, in my opinion, people got RN licensures, you know, or social work. You know, they want to be out. They want to be helping people. What does care management mean to you? If it's an expense structure, how is it also generating revenue? And I don't mean necessarily by billable visits. How is it generating growth opportunity? How is it generating efficiency for your providers, efficiency for your back office or your systems you're putting in place? When we talk about risk stratification and you think about how your practice standards are going to, your patients are going to go through your system, you know, who's doing that work? Who's following up on it? Could be nurses, could be non-clinical people, could be providers. I think as you think about all of the inputs for the sustainability of who you want to be by revenue stream, oftentimes when we create a profit and loss statement, an income statement, we start with revenue and expense, and it ends in a net profit or loss number. I'd like you to rethink about revenue by service line or revenue by payer, and then start attributing expense to those things. You need to have eyes all the time on what's costing you money. Do you have a loss leader? Is some program you have capturing the patients you want, but losing money today, but again, giving you money on the backend? One example for a loss leader, again, as you're thinking through your infrastructure and applying your expense and revenue together is transitional care. For us, it's been a longstanding theory, or at least in Minnesota, that transitional care is a loss leader. It's very expensive. They're one foot outside of the hospital, but then you capture them in a primary care footprint. We capture them in geriatrics. We capture them when they return to the community in home-based medicine. Not really. When we actually see practices in Minnesota, we really don't do a lot of capture in a TCU way. It's not a loss leader. It's just a loss. How do you really understand who makes money for you, who's a loss leader, and who's truly a loss that you need to start minimizing? These are ways to, again, think about those expenses. Who are your community partners? Where are you going? How do you travel? How do you maximize productivity? How do you use technology? Whatever you figure out here, again, you're building that expense after you find that revenue will continue to drive your revenue success. Yeah. And to Amanda, to your point to care management, let's say you hire a nurse or even an LPN and an MA, and you start putting in these care management actual standards in your practice, such as they're going to follow up with patients a certain period of time right away after discharge or after a complicated visit and re-go over orders or if a referral is placed, that trigger in the EHR is placed, and then you avoid a hospital admission because you have really good care, clinical support staff that is able to support your providers in between visits. That's also thinking about sustainability and revenue and expense. So maybe they're not necessarily billing a billable visit, but are they helping with overall cost avoidance and helping with your outcomes and the overall story that your practice is telling? And top of licensure work. And I talk a lot about top of licensure work. And Chris, I wonder if I could pick on you to drop the Barton Associates into the chat because we were talking about in the non-clinical track, but for PAs and MPs, you can go on a website and by state, you can kind of slice and dice, even if you haven't done this for your own state. And you may be like, oh, maybe I knew some of that. It's a really succinct way to look at what can the practices, the APP practices do in your state. If you cross state lines, it's also for that purpose too. If you want to cross state lines, it's for that purpose too. So I think these practice standards, as you think efficiency and quality of care are really key. And we go into more of it tomorrow too around technology and safety and operations. So it's going to be fun. I'll take one more slide. So as you're building your practice, as you're growing your practice, as you're in a form of transition, as you're stabilizing your practice, here are things to consider. What's your model of care? How do you package it? Who does what? We talk a lot about facility-based versus private homes. I think maybe it's safe to speak on HCCI's behalf. I don't know. We'll see. But I think we see this as diversifying your revenue in a little bit more of a consolidated area. So if you feel like all my money is fee for service, it's all coming from individual homes, it's very stressful. Some aggregating of patients, if you're not going to diversify your revenue stream right away, maybe you aggregate your patients in a facility-based and maybe say, hey, I'd like at least 20% of my patient population to be in facility-based because at least one day a week, I could go to a facility and know that the patient's at least going to be there and they're going to be in their room. And that's great. Staffing model, cost structure. As we think about mission, vision, values, standards, you have to set those and clearly communicate those and then go get the money to fund those. And we put preparing for transformation. But as I thought about it, I was like, every moment of what we do in health care is transformation, isn't it? Like there's not a single moment where we don't show up to literally transform health care. It is so exciting. So anyway, these are just some things as we think about revenue and sustaining the revenue that you're trying to drive to. As we, again, get ready for tomorrow, economics and coding, I think it's a very exciting day. Brianna, would you add anything? No, absolutely. I'm excited for Amanda's self-care talk because I think that's such a great way to end the day. But yeah, I mean, the reason we say a facility-based too, and just to kind of clarify, I mean, assisted living and group homes, I know there's a lot of you that do that here. You know, that's true home-based. That's still home-based primary care. You're going to the patient's place of residence and providing care. It's not a nursing home. It's not an intensive care. It's not institutional. Doesn't mean you can't do nursing home if that's a different, you know, more stable revenue for you. Think about that. But the reason we bring that up as more stable income is because you can see more patients in one central place. It reduces your travel time. And there's lots of even independent living communities or senior living communities, depending on your geography, with a lot of patients that need your help, in addition to private residence, which we know also really need this care. So when we think about that, looking at and understanding what senior living communities, group homes, assisted living, things in your neighborhood that you could provide care and be more efficient. Totally agree. Totally agree. Well, I'll take another slide. I'm going to switch to self-care. Transforming health care is exhausting. It requires us to always think about what's coming next. If you're on this call, it's my guess is 100% of you have people that report to you, you're overseeing, you're responsible for their lives, you're responsible for their safety, you're responsible for their income, their work, their job satisfaction. Those things really build up. That doesn't even take into consideration at all. All of caring for the patients ultimately, right? And how much of a toll and a tax it takes on our sense of who we are. And some of it, it's wildly rewarding. And even when it's wildly rewarding, it's okay that it's really challenging at times. And so I do a talk about self-care. So far, very few people have ever left. I always expect that someone's going to just like bolt it and be like, okay, I got the real content. I'm going to jump out of here. But we're going to talk about, and I'm hopefully going to convince you by the end of our time together, that this is just as valuable as any other spot that you're going to invest your energy. Because ultimately you're investing in other people's lives and other people's energies as they give, give, give to the community and to each other. So I'll take a slide. So here are some of our objectives. We're going to talk through empathy and sympathy. We got a great Brene Brown video. I think it's Brene Brown video. We're going to recognize common stressors. I'm going to talk a little bit about stress, pressure, burnout. We're going to talk about some self-care practices. And we're going to talk about how do you become resilient? And what is it? How are some ways that we can be resilient with others? So I'll take another slide. Home-based medicine is not, so two seconds before you started home. Oh, no, you go. No, I'll go. Let me go real quick. Home-based medicine is not easy work. As Paul was talking about, you are walking into someone's home. You're seeing everything about their life. You're seeing what kind of furniture they have. You see how many people live with them, how they manage their medication, what their hair looks like in their morning, where they feel the most vulnerable. And they're inviting you in. And sometimes they're not, or they're guarded. And it takes extra energy to continue to be on in those moments. And you have to be present. And you have to be present from a clinical knowledge set. You have to be present from a safety standpoint for how you're going to operationalize your work, how you're going to be culturally sensitive to whatever situation you're in and whoever is in the room. And it can be incredibly draining. So as we kind of talk about it, this video is, again, the difference between empathy and sympathy. And we're going to, it's about a two or three minute video. We're going to watch it quick and then debrief. Thanks. So what is empathy? And why is it very different than sympathy? Empathy fuels connection. Sympathy drives disconnection. Empathy, it's very interesting. Teresa Wiseman is a nursing scholar who studied professions, very diverse professions where empathy is relevant and came up with four qualities of empathy. Perspective taking, the ability to take the perspective of another person or recognize their perspective as their truth. Staying out of judgment. Not easy when you enjoy it as much as most of us do. Recognizing emotion in other people and then communicating that. Empathy is feeling with people. And to me, I always think of empathy as this kind of sacred space when someone's kind of in a deep hole and they shout out from the bottom and they say, I'm stuck, it's dark, I'm overwhelmed. And then we look and we say, hey, you climb down. I know what it's like down here and you're not alone. Sympathy is, oh, it's bad, uh-huh. It's bad, uh-huh. No, you want a sandwich? Empathy is a choice and it's a vulnerable choice because in order to connect with you, I have to connect with something in myself that knows that feeling. Rarely, if ever, does an empathic response begin with at least. And we do it all the time because you know what? Someone just shared something with us that's incredibly painful and we're trying to silver lining it. I don't think that's a verb, but I'm using it as one. We're trying to put the silver lining around it. So I had a miscarriage. At least you know you can get pregnant. I think my marriage is falling apart. At least you have a marriage. John's getting kicked out of school. At least Sarah is an A student. But one of the things we do sometimes in the face of very difficult conversations is we try to make things better. If I share something with you that's very difficult, I'd rather you say, I don't even know what to say right now. I'm just so glad you told me. Because the truth is, rarely can a response make something better. What makes something better is connection. I will argue that you're not going to find, whether you're clinical or non-clinical, you're not going to find a more compassionate, empathetic group of individuals dedicated to changing one life at a time than in home-based primary care. I just would bet you it's impossible to find. You place all sense of security and financial security out the window and you say, all I want to do is show up and help. And as we think about empathy and sympathy, one thing to think about, I think, is we're all more alike than we are different. I read an article about COVID and it said in the last year we all thought we'd be doing some more transformation because we had some some opportunity and even if it was the worst it was it was an opportunity that was opening up and so and it said it turns out the last year has solely been about surviving the last year for almost everybody and again as we think about how many things we jointly share you don't have to point to pandemic to say we all have these moments and we all have to show up in empathetic ways providing that level of eq is also exhausting and how do we support people and where they're at so I would ask this how does empathy figure into your role as a home-based primary care professional so I'm from Texas I'm not actually from Minnesota so I don't have the thing where I can't just wait it out you know like I don't silence no problem the faculty will one day feel sorry for me I'm sure how does empathy figure into your role as a home-based primary care professional medical or business ah got some people popping in chat chat okay Chris says coming into a major medical change and helping a patient not be overwhelmed I'm here to go go through this with you absolutely how okay let me ask this Chris secondary challenge question you come in someone identifies that they'd like to change something you're with them and then they don't do it how hard on that is you after you've put forth all of that effort a lot of times I find that it's not that they don't want to do it even though that's their initial response but a lot of times they're scared and they don't see the pathway to do that change so the whole one step at a time let me show you these small attainable goals that you can reach you know instead of dangling the carrots so far out here in front of the patient hey you can reach this goal trust me then I'll go with frequent contact follow-up that kind of stuff is what helps and it is that's the that's the most it's not frustrating it's disheartening because that makes me think this whole time I wasn't with them what in their emotional setup beat them down enough to think they couldn't attain that goal absolutely yep I'm not gonna I'm not gonna tell you follow me I'm gonna walk beside you how cool is that Bruce said we need to be aware of being a family caregiver is hugely stressful absolutely where's respite coming in you know we you know you know we stay in sickness and health sometimes you know we were we're children caring for family members and and it's exhausting and and what if we're tired covid's made it worse and people are literally literally falling apart and they need support in addition to the patient absolutely in the video there's a message of meeting people where they're at and stepping into the reality much easier to be empathetic when you have a true understanding of the situation absolutely and she also addresses um Laura I think it's a good point she addresses it's really easy to judge and again I don't think you'll find a more empathetic group than you guys because and and who works with you and it's still exhausting to put out that much empathy in many ways it's easier to draw some barriers and so we talked about and I think Paul mentioned around how do you draw some barriers and draw some lines to make sure you continue to keep a professional relationship and push them to be the best person they're going to be but you're walking into someone's home every every time or you're supporting individuals who are transforming health care that's that's my job right I I care for people who care for people is what I say okay let me do a little bit of grounding on the next slide so stress is the is the body's okay stress is the body's reaction to change that's something that we feel right all of a sudden we get sweaty palms all of a sudden you know our heart races this is these are physical changes um burnout there really isn't an agreed upon definition it's really as best I can tell from doing some research on this it's long-term stress and then it's emotional exhaustion we're to the point where we draw out our arm and we're we're just we can't be in it anymore we we depersonalize we step away and we have now a negative look at the system physician burnout is a public health crisis that demands action so we talked about the tripling we also talked about the quadrupling the difference anybody in the difference between the triple aim and the quadruple aim is what what's the fourth one they added in the fourth one they added in is the goal of improving the work life of health care providers yes yes thank you exactly this is a major problem slide now this provider satisfaction yes veronica yes I'll take one more that's perfect slide okay oops yes perfect okay um I got this from the medscape 2019 physician burnout depression suicide report I pulled out it didn't have geriatrics specifically pulled out I pulled out internal medicine and family medicine you're going to see 50 percent burnout here in fact I'm a believer that many people are joining home-based medical practice because they're burnt out in the current structure that exists today we're going to talk about how people get here but they they they are burnt out I'm going to extrapolate from when it says physicians and just say all health care providers and all people support health care providers we're getting to a critical crisis in in our work where we are not going to have it and we know this from like numbers and statistics we're not going to have enough people to care for our elderly individuals you know we when social security was created we had five workers for every one retired person in 2030 we're going to have two workers for every one retired person the silver tsunami is coming and we're tired and exhausted and we are unable and lacking empathy to be able to truly connect with our patients and fix the system I'll take a slide so what are the top stressors as I read them off you guys think about them patient family conflict how many times have you sat in a room you figure it all out with the daughter the son comes in the next day it's not the same you know mentally ill how many times have you had have you had to say I'm not just caring for the loved one also caring for their family member and their caregiver they also have some things I work with I've been working with health care individuals forever and people anybody who actually has a health care degree loves to assign diagnoses to caregivers oh they also have and I love when they say that I'm like you don't know that you're not actually their person but they're just that's what they're doing right and they're and they're stirring up the conversation in the situation and a lot of that to Chris's point is what's the root cause of this it's fear it's it's my loved one is going through something I didn't know they were going through or they were going to go through and it's really hard EHRs and paperwork complexity there's this great article I'll try to find it and send it out but there's this great article about how we screwed up EHRs because we just did the United States just put policy after policy to get better data in place and nobody ever connected these systems and so now we have a completely broken health care system that's driving everybody literally mad or depressed to get in you know to do this work financial pressure I mean we spend a lot of our time how do we push and push and push on the revenue side so we can just break even especially with home-based medical practice and I think you found a real home in HCCI the thing that I find so exciting after you leave two days of this is you say to yourself oh look how many me's there are out there how cool is that financial pressures are always this reality patient adherence we I was you know batting around with Chris just a second ago up you do it and you do it and they don't do it and how hard is that and then you're a little frustrated with situation but you keep going back scheduling logistic geography driving driving in the snow driving in the rain driving and you know I grew up in Texas driving when there might be a tornado on the road we don't know providers feeling unsupported in the field and especially with so many complex issues um let's see don't see palliative hospice provider on that list oh that was the last one shoot I missed that okay any other top stressors that we feel that I'm missing here to agree with this list stuff I'm missing no self-care that's a really good one absolutely yeah absolutely we give we give we give and we don't take a minute and if we don't take that minute for ourselves if we don't carve out what that self-care looks like it becomes a stressor yeah we take something that could be really positive and we make it something um that that is negative it's it's drawing on us absolutely that's a great point Melissa it's a pretty good list it may not be perfect but it is a pretty good list of you know what is stressing us out if you look at this list bureaucratic hurdles yes red tape you know what I say and this is the best part about home-based medical practice I always say this we are the ones putting up the red tape we can take it down you build a process you can take it down if it doesn't work you know you you build a structure in place you can take it down how do we continue to again do that that um root cause analysis Laura 100 yep global pandemic global pandemic should be number one on this list in fact I've said and it's a bit dramatic but I have said I really hope to either be dead or not a leader when the next global pandemic comes around because I'm a little bit over it we had it we had over 2,000 positive this is our whole practice 2,000 positive patients and we had a 28 mortality rate you know just over one in four patients we saw once they got it we're gonna die I have so many providers that have been so changed to their core of how they lead and who they are that in some ways it's sad and in other ways I'm just so impressed with the resiliency and I and there are so many clinical leaders on this call so thank you so much for all of your work and non-clinical leaders for your work during COVID unbelievable unbelievable okay if these are the top stressors so we've established it's a major problem in healthcare it's a major problem that the IHI has added it as a fourth aim that we need to address this in our in our caregivers we've now said the top stress here are the top stressors and then what is the outcome if we leave these untouched because these are really things that don't have personal feelings necessarily attached to them we apply negative thoughts is an electronic health record just by itself something that we should feel negative about except nobody that I've ever met has been like I love my EHR it wholly makes my day only better I never have any problems people are like oh it's better than paper or oh it's better than this or oh it solves this problem but it causes this headache or oh it's just horrible you know so nothing you know we assign positive and negative feelings to some of these things and we can turn these things around but if we don't I'll take the next slide then this is the outcome of stress and burnout over time and again that burnout is over time depersonalization so from an individual health outcome when you hit that severe stress burnout standpoint what we're talking about is depression exhaustion dissatisfaction depersonalization higher rates of addiction sense of failure job or career change or suicide rates that medscape report I reported earlier 80 percent of people had never thought of suicide meaning 20 percent had either have either thought of it tried it or preferred not to answer when they were asked of physicians so you have a one in five that has a likelihood of either tried or thought about suicide because of their work and those are all the individuals that might be you but it also is all the individuals in your organization so you have an individual health outcome and how do you start recognizing that something's really wrong and that's why I like to put it kind of in these buckets from an individual health outcome you're going to start seeing someone pull away someone who really cared is totally stepping back and maybe they're changing their hours maybe they're changing their tone maybe they're using different language you know how many times have have you said you can't put drug seeker in a in a medical chart you have to say you know you know maybe has an addiction to this or whatever I mean now you have an individual who used to know that who's kind of changing their mentality of what of the people that they're interacting with is stepping back is lashing out at staff is sleeping more you're hearing from spouses they don't have their pep whatever it's our jobs to look for that but there's an individual health outcome and toll that's going to be that could be attached if they get to that burnout from a patient outcome right so if the individual is feeling that now the patient there's lower set patient satisfaction rates lower quality of care and higher risk of malpractice claims because people aren't a hundred percent into it so if we're talking about from a medscape and even if we just apply this to our entire healthcare system we're saying 20 of the providers that I'm going to see are going to start falling into this bucket at least 20 percent um god what you know or at least 50 percent could be in the total bucket but at least 20 or 20 percent could be in a suicide rate bucket uh how am I feeling about the care that I'm getting how am I feeling about the care that I'm giving so it's important to look for these things these things have domino effects they start with the individual who is exhausted in the system and because of these major stressors and we have the power to change those things and finally the system outcomes from a systemic standpoint if we have individuals who are experiencing this the system just never gets better students are unprepared they're untrained innovation is stalled and we just never actually improve to the point that we need to so I think um from an outcome standpoint there's a lot there's a lot to be lost if we don't address these so coping strategies next slide here's some ideas let's jump in the chat if we have other ones but you know if you know joint visits to manage tension and have separate discussions so if you're having trouble with patient adherence or you're having trouble with family members can you get everybody together and remember pressure is not stress stress is this physical reaction that physical reaction over time to systemic things turns to burnout but pressure we all have and so okay maybe joint benches you know joint visits is an option documentation recognizing the time involved allowing for that during work hours um I can't remember who it was someone one of our providers on the call um I can't remember exactly who it was uh mentioned that they were working late into the night you could be doing the most altruistic things and if you work late every night it's going to take that drain on you so how do you carve out time for work hours how do you carve out efficiencies how do you how do you carve out smart phrases what are the things that we can do to fix that financial model how do we lower that overhead piece right what are the ways that we can fix the model and we'll talk we keep talking about them you know different revenue ways different expense models to continue to increase productivity in a way that is helpful and keeps everybody's sanity how do we do a team approach it's not all on you we can spread it out we can be in it together we're coming up with a joint care plan under our care model this is how our practice is going to act and administrative support there are things that are just not up to everybody's licensure or maybe a better way to say it is maybe some some people have things where different licensures make different sense for scheduling routing other words hi oh i love kids so as we think about coping strategies what are we missing guys what's on the list how else do you cope all right i'd say this from a coping strategy standpoint ah chris yes okay great outdoor life cheap adventures kayaking gym great you're not a plant but you should you you could have been a plant in this moment because i'll tell you this if i was going to do my list it would be running um watching movies uh playing with my kids everybody has a plan and i'm not going to if i was going to do my list it would be running um watching movies uh playing with my kids everybody has different things as they think of coping strategies and when i try to counsel people when they're really stressed out because by the time they get to you they don't say here's my problem and it'd be true they say here's my problem and it'd be an exaggeration to the point you're still trying to figure out what's the real problem in the core of it and having a really good empathetic dialogue of understanding where they're at and then saying something to the effect of hey what do you need what is the thing that we can help with uh it's personal it's it's certainly a personal thing that you get to decide and some of it's systemic like these things here and you can fix these and you say what do you need and what are we going to do about it and i think you can uh oh yes laura we're blessed to have an innovative wellness program guided by our company great um chris also said i want to do all the things my patient can kind of like doing it for them or what they can that's awesome uh patrick strong reward and recognition programs absolutely you know and so i was thinking about this recently i know we have a few more minutes here too there's a form if you go online and i might be able to find it for you guys so if anybody has done any of those programs like the myers-briggs or the insights we've just done for our leadership team the colors insights and i have a bunch of different people there are a bunch of different colors and and i realized you know i'm introverts i have extroverts i have people who are data focused i have people who um you know are people relationship focused and so i i i actually got from the web a piece of paper that you can fill out it's like a form that people your employees fill out and it says how they want to be recognized and then ask things like do you want to be recognized in public do you want to be recognized with gifts if so what are those gifts do you want to be recognized in an email do you know and there are like six questions that individuals can kind of keep keep up and then they can tell you how people like to be recognized because what we tend to do is we tend to apply how we want to be recognized how we want to be seeing how we're would solve the problem and apply it to other people i think if we can again get to that empathetic stage where we're really good listeners and we figure out what other people need and there are tools as employers to get us there our company has given every employee additional wellness day to use in recognition of their hard work during covet that's awesome patrick that's cool uh great point how to want people want to be recognized i'll find that sheet tonight and i'll send it out um or i'll send it to the right people to send it out to make sure and it's not perfect but you guys can you can adjust it and amend it if needed all right any other things we would add on coping strategy guys my am i okay next one if anybody has children how many times have you either heard the statement or made the statement that all i want for my child is for them to be resilient right like i want them to be happy not murder people and be resilient okay great top three um so you know as we think about it you know i so i googled it okay and it is it is the capacity to recover quickly from difficulties or the ability of a substance to uh spring back into shape and i thought oh something i just really want to highlight it doesn't mean you don't have difficulties it doesn't mean you don't have problems it's how you respond to those consistently respond and not all difficulties are created equal something that could be a big pain to you is not a pain to your neighbor and it doesn't matter as much and you don't understand why we're not connecting on these issues and so they become major issues but being able to learn how you can communicate to each other how other people can communicate to you how you show up in that empathetic way will allow people to openly share where those difficulties are for them and which ones are maybe more major for them you know running late to work and yelling at the kids in the car because you're running late is way different than charting every night for two weeks and feeling that level of stress and burden so you know again stress pressure uh burnout these things again are not all weighted equally and they're not all weighted equally for every person um i just hired a manager an np manager into this role she's been with the same health practice for the last 20 years and we also sit on a board together and she was the president-elect and i said to her she pulled out of being the president-elect and it was kind of a surprise and she would have been great and i said i said you know why did you pull on she's like nah i'm not the right person and she was very definitive and calm and it felt great etc and this was a couple months ago so i hire her um a couple weeks ago and i called her up and i said we had a board meeting and i said well what do you think now like you know like i think you could have done the job like you know could you have done the job you're i mean you're not president-elect anymore but you have done it and she goes you know she goes yeah i really think i could have i didn't realize after 20 years how beaten down by the system i was to even have like and how much in a rut i was to even and it started blending it started going into other aspects of my life but i just felt like oh now i can't be as effective in other areas that's what we call burnout and then our response to that making that change bouncing back um being a full and authentic person every time is that resiliency so uh debrief okay i take the next slide so how does your culture typically view this idea of rest and recovery um patrick had a great piece around a wellness day that's really cool other company things that worked really well amanda i know you've shared before uh or someone said after work time gatherings yes but um i think just recognizing and listening to people i've heard from so many practices like everyone like covet has been so hard on their team and and they're feeling that burnout and that just overall exhaustion um so much more than they ever were before and um you know sometimes just just recognizing checking in with them giving them space to just talk about it um i think it's just the just the time that you take to do that um can be really refreshing to hear from other people and know that there's someone that's going to listen um and just be there yeah and then also you know uh if you're gonna listen it also you i really believe you got to follow up with a question of what do you need and really be able to kind of follow through with that each person will need some response to that but you know to the empathetic video bernie brown presented is you know when people show up that vulnerable and they actually tell you what's going on and i've even had some leaders during this coven area like i don't know what i need and i say you know what well i really want you to think about it and get back to me like i really want you to come back and figure out what's the thing and sometimes it ends up with like i need you know i need to take a pto day or i need to take a little time but sometimes it's so funny it's just just even asking the question and putting some thought into it they can make kind of some smaller changes that have some some impact uh mary lynn said our organization has mindfulness classes available in our group walking events that's really cool yep we do that too we do i'm in a steps program so we 180 employees we got 50 of our employees that are doing a steps challenge we got all randomly assigned teams last year i was last in the entire company for the steps challenge so this year i'm just determined not to be last if you see me tomorrow kind of do this that's why but we do two of those a year is we do kind of health challenges and kind of compete against each other and the winner gets a hundred bucks to spend on amazon however they'd like and so we don't give it as a gift card we don't have to tax it we just buy them a coffee maker if they want it you know other things chris we only have two eyes and two ears for reason and only one mouth observe listen more to everyone around us totally yeah i'll tell you i always say ceos um ceos are somehow always right so i fall in that category so that's something you know i could learn from for sure use this assessment of physical but also mental makeup realize if you feel guilty taking time you should be taking realize that if you feel guilty taking me time then you should be taking me time for sure that's a great point megan especially with providers if i step away something drastic will happen someone will miss me someone will die i you know i have to be here i'm the only provider in the practice we need your best most authentic self and we need you to come ready to go so we need even if it's only 90 of the time that we get with you we get a hundred percent of it we don't want we don't want the reverse right we want a little bit less but 100 when you're in it and everyone feels that and if you don't do that you start that that trail of burnout okay key takeaways unless you read through it but empathy really fuels this connection being your vulnerable self if we don't practice empathy we're driving this disconnection we all face the same stressors and our home environment higher the home environment and going into people's homes it's just not as predictable and so that lads an extra level of intensity but an extra level of value and excitement and connection that i think a lot of health care providers are looking to to move away from other systems that don't provide that as much so that's exciting and self-care is incredibly important it requires a lot of uh introspection and trying to figure out what you need to be successful and pushing the system to be successful because we all as leaders have a lot of systemic things that we can change and so i think that's a key takeaway that we can change and so we put some pieces up there so i will i think i'm passing it off or i might not be um okay so here's our hdc learning plan um and continue to fill those out so uh distinguish you know especially for this program distinguish between empathy and sympathy appropriate responses to any patient circumstances recognize common stressors talk about self-care practices i i'd put a plug i know we're about to do a wrap up but i'd put a plug for brianna and i are going to do some marketing and branding tomorrow during the an open session and if you have any questions for us jot them down overnight a lot of people this gets people thinking over the dinner table so just jot them down if anything we can answer going into tomorrow we'd love those ideas coming thank you all right thank you so much amanda and and brianna for the previous session too so we are gonna move into our end of the day wrap up but the learning plan is important i want you to you know maybe before you go to bed tonight do take some time to look at the learning plan and record any insights that you have from today so we're gonna move on to the wrap up and um janine are you doing this janine or is um hello i think we had my name on it i just actually emailed everyone um so uh you will see my name once more in your email inbox i just sent you a copy of the learning plan just in case you missed it this morning please do take notes if you can turn one in tonight that'd be beautiful because that'll help guide the conversation for tomorrow um if not don't stress just please be working on it because that helps faculty customize education and uh meet your specific needs and they very much want to do that as i'm sure you could tell uh by your experience today go ahead i think we'll see just uh i think it's just a slide or two melissa if you could advance us yeah did you um i did advance oh there we go it's just taking a minute probably something wonky going on with the internet it's the end of a long day um so that learning plan will help you revisit some of your perceptions maybe that you had going into the day um so do take some time to to reflect on that um we'd love to see in the chat or you're very welcome to speak up about one thing you are especially glad you learned today if there was one thing that was a real a standout or something that surprised you delighted you to find out um please do let us know um again pause there for just a minute i think that's such an important thing um would everybody be willing to either speak up or or or list in the chat at least one thing that they were especially glad they learned today and coding coding brianna about more money to our practice right on that's right yes um anybody else and i can't see the chat folks so if somebody else who on the faculty can see i was glad to hear what the kind of the national standards are for provider visits because i i'm on my own and i'm in the ballpark so you know not not being the only person that does primary care at the home in my practice you know i'm certainly seeing less patients than my colleagues and i always feel like you know kind of not meeting meeting up to standard so it was nice to know what that is yeah i think anytime you can validate where you are um you know in comparison to your peers on a lot of different things um is really important and patrick shared in the chat staffing models and patient panel and visit targets as well well um i i'll interject one more thing here and if there is and give others time uh if they want but um tomorrow we have another full day um you know we're starting out with um operations technology and um staff safety um we have um a session on economics which goes into some budget considerations uh we have a session on coding and billing uh and i i hope i haven't missed something but i know at the very end we have a session on putting it all together and we'll we'll do some simulated house calls um using uh using cases um as a as a basis for that um janine did you is are there any other comments in the chat or anything else anybody else wants to share about what they learned today there was mention from laura about enjoying the simulation of the home visit great all right thank you laura um and then um we talked about the learning plan so if you enjoyed the brunette brown video um on empathy um there's another one that we recommend that you watch tonight it's only about seven minutes long um it's on setting boundaries uh and this bitly link is in your workbook as well um it's meant to be a little bit shorter than the regular link so it's maybe easier for you to um to key in um if you don't have the workbook that you can just click the link uh so and i think that is sent via email as well oh perfect perfect um faculty did you have anything else that you wanted to say to wrap up today um i really enjoy meeting everybody um and uh do take a look at that other uh video about boundaries um just to piggyback on some of the comments uh amanda made um you know covid has been really hard and some of you know this at acci has been really hard on my practice um in terms of of of um i think uh you know hurting my resource and the resource that i value most are my providers i see them uh you know struggle with you know taking care of patients dealing with the unknowns dealing with the ppes getting disappointment uh uh disappointing news about you know you have to stay home because you're a covid or your one of your family members got covid or your vacation canceled and and whatnot just goes on and on um and it has been really hard on our patients and then and then we hear from the other side right the patients are frustrated and angry and then we get these angry phone calls uh back so having that boundaries and and i did share with uh our providers at one of the staff meeting it talks about we are most loving when we're most boundaried and and some it's like well that doesn't quite make sense but when we when we uh expose ourselves too much you know trying to save the world or drink up the sea it is just uh it just overwhelms us and we are really not effective but we cannot be good providers and loving people to our family and friends uh when we just become unhinged so i encourage you to uh take a look at the video and um and great to see uh everybody today and looking forward to tomorrow thank you thank you dr cheng all right so um we will begin tomorrow um please check your calendar link because it is a a different zoom link that you would have been sent for tomorrow uh we're going to start promptly um with the learners at 8 30 uh and um if you have any questions um you have janine's email if you've received something from her uh so you can reply back um with any questions for tomorrow thank you all so much for investing your time in today and we look forward to um seeing you again tomorrow thanks thank you see you tomorrow everyone
Video Summary
The video discusses the importance of revenue and sustainability in healthcare. It emphasizes the need for diversifying revenue streams and reducing expenses to drive innovation and growth. The speaker also highlights the role of empathy in home-based primary care and the impact of stress and burnout on healthcare providers. Coping strategies such as joint visits, documentation practices, and team approaches are suggested. The video emphasizes the importance of self-care and resilience in healthcare. The key takeaways include the importance of empathy, the need for diversifying revenue and reducing expenses, and the significance of self-care and resilience in healthcare. No credits are mentioned in the summary.
Asset Subtitle
Essential Elements April 15 Video 2 of 2
Main Session and Clinical Break Out Sessions
*please see Video Time Sheet for breakdown of video sessions*
Keywords
revenue
sustainability
healthcare
diversifying revenue streams
reducing expenses
innovation
growth
empathy
home-based primary care
stress
burnout
coping strategies
joint visits
documentation practices
self-care
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