Essential Elements of Home-Based Primary Care-Virtual Workshop-Main Session / Clinical Break Out Day 2 Video 1

Main Session / Clinical Break Out Day 2 Video 1

Video Transcription

without boundaries, we're not able to be our most open and vulnerable cells. So, especially those familiar with Renee Brown's research.  Amanda, while that's setting up, I have to really share. I had a patient referral from the emergency department and I was doing home visits on.  She would call every day or every other day and often drunk or crying.  And it finally got to a point where, and I felt really guilty, but I had to set the boundary that that was enough.  And I think it's really important to recognize for all of us that we have to set those boundaries for our own self-care  because it was the best feeling when I didn't have to worry about when was she going to call next and when was going to be the next issue.  It had just reached that point where it wasn't productive anymore. And so boundaries are key as a provider.  Absolutely. One of the most shocking findings of my work was the idea that the most compassionate people I have interviewed over the last 13 years  are also the absolutely most boundaried. So I'll give you a great definition of the definition of boundary that I use in the book.  Boundary is simply what's okay and what's not okay. What I think we do is we don't set boundaries.  We let people do things that are not okay or get away with behaviors that are not okay. Then we're just resentful and hateful.  I'd rather be loving and generous and very straightforward with what's okay and what's not okay. And I did not that. I learned from the research. I was the exact opposite.  I assumed for the first 35 years of my life that people were sucking on purpose just to piss me off. That's what I assumed that. Yeah, right.  Whether it was someone who worked for me or it was someone who family member who was constantly like, oh, it's critical and judgy.  And I was like, why are they choosing these things? Why are they making their choices? They should know better.  And then when this thing came up for my therapist, what if people are doing the best they can? I thought my husband had the most beautiful answer to that question.  He said, I'll never know whether people are doing the best they can or not. But when I assume people are, it makes my life better.  So now I think I am not as sweet as I used to be, but I'm far more loving. It's not just some like technique so that you can do that.  That's really like a way of being to nurture that soil of wholeheartedness. Yeah. Generosity to assume the best about people is almost an inherently selfish act.  Because the life you change first is your own. Yeah. And so it's so my question is big B.I.G.  What boundaries need to be in place for me to stay in my integrity and make the most generous assumptions about you?  But generosity can't exist without boundaries, and we are not comfortable setting boundaries. Because we care more about what people will think.  And we don't want to disappoint anyone. We want everyone to like us. And boundaries are not easy.  But I think they're the key to self-love, and I think they're the key to treating others with loving kindness. Sustaining. Sustaining. Nothing is sustainable without boundaries.  I think compassion and empathy are different things. And again, I'm relying on my data for this.  I think compassion is a deeply held belief that we're inextricably connected to each other by something rooted in love and goodness. I call that God. Not everybody calls that God.  My dad would call it fishing. Fishing? Fishing. Is it fishing? No. There's no G in fishing. But I think compassion is a deeply held belief.  I think empathy is the skill set to bring compassion alive. So empathy is something we can teach. I mean, it's something we've taught our kids since they were very little.  It's about how to communicate that deep love for people in a way so that people don't know they're not alone.  I think there's a lot of new and interesting information out there about empathy not being a good thing.  There's an argument that says if Travis is in struggle and I practice empathy with you, I'm taking on your darkness and it leads to burnout. But empathy is not feeling for somebody.  It's feeling with them. It's touching a place in me that knows where you've been so I can look at you and say, Me too, brother. You're not alone in this.  And I find empathy to be infinite. I think it gives back tenfold what you put out. It's sustaining.  If you've done the work and you have your boundaries, I mean, you could tread that water forever and never get tired. Okay, so empathy. I'm quoting Travis here. Empathy.  If you've done your work and set your boundaries, you can tread that water forever. Amen. It's not finite. And it keeps giving back to us.  And so this idea that, but here we go back to where we started this conversation. Empathy minus boundaries is not empathy. Compassion minus boundaries is not genuine.  Vulnerability without boundaries is not vulnerability. So you see that there's a huge riff here, which is boundaries are freaking important. And it's not, they're not fake walls.  They're not separation. Boundaries are not division. They're respect. Here's what's okay for me and here's what's not.  Okay. So hopefully, hopefully we got a good group and that came across really well on everybody's screen. It came across great on mine.  We're going to throw the questions back up here. But initial reaction to Brene Brown's video here. Brene Brown's video.  Boundaries are always the hardest part because it adds and flows with the situation.  Because some people, their boundaries need to be expanded versus some, you have to have real top boundaries. Yeah, absolutely. So anybody, especially the providers, are you working?  Are you in the ones where there's one or two providers? Are you the only provider who's on call 24 hours a day, seven days a week?  I feel like you can't take a vacation, feel like you can't step away, to Megan's point, around that need all the time.  And then maybe not giving your full authentic self because you're getting bogged down. You know, Amanda, I just have a comment to make.  And piggybacks on my comment at the end of the session yesterday. I actually showed that video to my practice here because we were going through some rough times here.  Even though we are a good group, very loving, kind people, and dedicated to the mission, but we were struggling. We were swimming upstream.  So I had actually scheduled a couple of staff meetings. One was showing the video and reminding us that, hey, we need boundaries to be loving.  Megan talked about this patient calling. We have several patients that call us several times a day, five, six times a day. That was exhausting. We have demanding patients.  COVID has caused a lot of anxiety and so on. And there's a lot of pain and suffering. And then you add on top of that, say, opiate, I should say opiates. Okay.  You know where I'm going with that comment.  So I think it was good for the group to come together and see that we do need boundaries to be more caring and loving people.  And that saying no sometimes could be a good thing because we need to protect ourselves and our own integrity. And just something to consider.  I actually started a Word document that's circulating around the office in terms of what I call boundary setting talking points.  For example, you know, I'm so sorry, that's the best we can do in terms of getting Dr. Chang to see you. He's coming to see you as soon as possible.  And if they get upset and angry and all that, you know, that is the best we can do. And we just have to let it go there.  So just an example for the patient that calls, you know, six or seven times a day.  And just coming up with phrases such as Mrs. Smith, you know, something to the effect that, you know, we would appreciate it if you could bunch your questions together.  And ask all your questions with one phone call because that makes our office more efficient. We have other patients we have to attend to.  And these multiple phone calls actually causes disruption to the flow of the day. So that document is actually circulating around.  And the staff is adding their own kind of boundary setting smart phrases, if you will, to help them, to remind them of their boundaries and to equip them so they have a go-to document where they can say, you know, this is what I'm going to say to my patients when I'm facing this kind of a scenario.  So, you know, so I'll just leave it at that.  I found the video very helpful and was a good reminder to all of us that, you know, we are giving mission-oriented and so on, but we still need to know when to say, you know, we can't do, this is the best we can do.  Yeah, I think that's great. You're all leaders in your practice, whether it's just you or you have staff.  And so how can, how can we help you and how can we help your staff in setting those boundaries? And those are really great tangible examples of how to do that, Paul. So thank you.  I am also really excited to pass it off to my colleagues who are going to talk about operations technology and staff safety.  So it really requires so many players to get this rocket off the ground here when we're heading to the moon.  And there are a lot of moving pieces and they've prepared a great session for you. So I look forward to watching it with you and asking questions.  So feel free to use the chat or unmute yourself.  Thank you, Amanda. Megan, just let me know when you're ready, and we'll start advancing slides. Okay. Good morning, everybody. Welcome back.  I'm going to start off here with the team member functions and community services, along with operations technology staff safety.  So we are going to compare the role and functions of team members and different practice sizes and configurations, because it's not one-size-fits-all sometimes.  We're going to explore resources and strategies to help identify and connect with the community services.  I'll talk about geographic scheduling and DME referral coordination strategies, and examine options for diagnostic and operations technology  to improve patient care efficiency and staff safety.  And this is the goal is to implement recommended policies and procedures aimed at ensuring staff safety.  Next slide.  So starting off with team member functions.  Next. All right. So you see the pyramid here. You know, you've got the obvious clinical part of it, which many of us are very familiar  and have been for years, you know, the MP, PA, the physician, nurses, the pharmacist, you know, the kind of key core block of any practice.  But then there's also the practice managers and all the additional resources that we need to help make this engine move.  And then to really be efficient, you know, having the social services part of it. And it all comes together.  And for some of you in this group, you've got all different people in your practice that can kind of help and take these different roles.  And for others, you might be wearing all of these hats yourself trying to figure out how to make it all fit.  Next slide.  So when you have a big group of people in your office, or you've got the ability to have people who wear those different hats, it's important to make sure  that you have meetings and that you all come together. And it goes back to what Dr. Chang was kind of saying earlier,  that having the meetings together helps to identify what boundaries might be needed. But at the same time, it also makes it so you can find out what resources are available  and see what your team members might need from you as a provider or as the office manager.  But make sure that you set an agenda. Just like all of this, when we have a meeting, we want to make sure we know what we're going into.  So that way, if we have anything we want to add in that meeting or any points that we've thought about that we'd like to bring up, it's, we've had a chance to think it  over and have a nice, good, constructive thought. So make sure you set an agenda and that you've appointed a leader who's going to run that meeting effectively.  So everybody will appreciate your meetings and show up.  Next slide.  So a sample of what you might put on your agenda, the metrics that you're trying to review. They're important to your practice. Review hospitalizations.  You know, what happened the previous week, last week, seeing the week before that, and the current week.  What was the diagnosis? What was the root cause? Why did they go in the hospital?  Review the care management. You know, what could be done to improve somebody's care that you're currently having some struggles with or has been calling quite a bit.  What kind of updates? What's new in the practice? Is anybody joining you?  Changes that are being made to the procedures.  And identify waste. You know, where are the opportunities to improve overall in the practice? You know, things that are not cost effective.  And then at the same time, it's reviewing those home health care codes to make sure did you get all the opportunities and the documentation you needed to achieve that.  Some practices might even send out where opportunities could have been improved because down coding occurred, if that's something that you're auditing and keeping track of.  And a really essential part is recognition.  I know Amanda mentioned yesterday, ask how people want to be recognized. And I thought there was a lot of value in that, ask how they want to be recognized.  But make sure that you do that, you know, recognize those that have gone above and beyond.  Next slide.  Other effective communication strategies are team huddles, where maybe it's not necessarily a set meeting with an agenda, but it's a quick touch base,  maybe for five to 15 minutes in the morning. It could be by Zoom, it doesn't even have to be in person, obviously.  And anyone on the team can contribute, you know, maybe a rotating schedule so that way everybody gets involved in case you can't be there  or the person who usually leads it can't be there.  But that provides leadership opportunities for everybody.  And try to make sure you have a standardized flow to it so that, again, if somebody wants to be able to contribute something, they know when their opportunities are.  And it should be an opportunity for information sharing, problem solving, organizing,  and that way everybody knows what the priorities are of the practice and can help improve the overall performance.  Next slide. Some practices use a huddle board.  Maybe they're not able to quite meet together in the morning or because their geographic schedules are so varied.  So they will write on the board, you know, what's going on and who's where or what's happening.  It's an opportunity to still continue that communication. So this is the whiteboard, a huddle board. There's also, you could have a document that is shared amongst everybody  so that way it's in real time.  Same concept, too.  Next slide.  And there's another bit more detail where they do the recognition, as you can see up in the upper right-hand corner, what they're doing for process improvement.  Again, waste is down the left. So, and then they have an open position. So whatever you would want to put on your board, but those are just some examples  of what has been helpful for these practices.  Next slide. And from there, we'll go into community services, other resources that you may not have considered.  So what makes the inclusion of community services so important in home-based primary care? And how do you currently identify and connect with community services?  You know, everybody's got different thoughts on this, but there are a lot of avenues that maybe you haven't considered.  And how do you evaluate services to ensure that they are legitimate? Because the last thing you want to do is get another service involved and then find  out later that they weren't up to the standards and your patient's disappointed.  Next slide.  Okay. So a great resource. How many people are familiar with the Antbirtha?  Has anybody used it or looked at it? If you haven't used it, I highly encourage you to go on and try this out.  In fact, it's, you put in your zip code, and you're going to find every possible resource. In fact, if you look over here on the right-hand side, that's the sample,  that's the screen that's going to come up. And if you look on the top banner, it's got all the different types of services that you could possibly want.  Everything from housing to how to help find food in your area, and even dental.  And I briefly mentioned dental services yesterday, because that's not traditionally a service that maybe many of us have heard or thought really that it was possible.  But amazingly, you might find that there's mobile dental clinics that come to your area or that you can put in a request, and they might show up.  For example, in our area, the Baptist Church has a bus that they send around and will schedule.  It does take five to six months, but then they make it a real point to try to serve everybody in that community, or that they could possibly reach out to.  But it's a really good resource, even if you don't think you need additional ones,  that you might go on there and take a look for your area, because you'll be surprised at what's actually out there.  Has anybody, before I forget, has anybody used it at all? I mean, I saw some of you weren't familiar with it, but has anybody used it and found it to be in their area a surprise?  Or a success?  No? That's good if it's all new, because then that way, it gives you another opportunity to look up some of those resources.  So, and again, if you, another thought would be is to make sure to reach out to social workers in the area, often, whether it's by home health companies  that have social workers, the emergency departments all have social workers that are very familiar with different resources.  But they often can tell you what's going on in the area, and who's available. If, say, Megan? Yes.  In my past life, I was the chief medical officer for an accountable care organization, and we had a team of care coordinators that were constantly trying  to connect patients to community resources. And what we found over time is just what you said, that certainly there can be resources  that are available when you look them up online, but there's a big difference in terms of how meaningful and helpful they really are.  So, what our care coordinators ended up doing was just sort of starting like a preferred list  of the most helpful agencies in the community that then they would continually add to over time, sort of like a running library.  And as new staff members came on, and people were trained, we would try to discover those preferred relationships of the agencies  that were the biggest bang for our buck for our patients.  Absolutely. And that goes back to making sure that they're a reputable service that you're trying to call up, that they've got that real value for your practice.  Excellent point. And then that's where, going back to some of the social workers, you know, that I've talked to,  they find out about new things, and at the same time, they can tell you who might not be servicing the area anymore, but that changes, you know,  every six months to a year, so you want to make sure you follow up and establish those relationships, and that way, they know that you're in the area, too,  and you're available for anything that might be needed.  Very good point.  And all right, go ahead and next slide.  And Brianna's going to talk about geographic scheduling.  Great. I would encourage, just to kind of tag on to Megan before we dive into scheduling, that resource inventory is so valuable.  I don't know how many of you use welcome packets in your practice, but we would always include, you know, non-emergency transportation,  a list of other community services, Meal on Wheels programs, all of those kinds of things in our welcome packets that we would give to new patients  in a previous practice I worked in, as well.  That's really helpful for them to have all that. You can also, you know, thinking back to kind of boundary setting, put in your office hours  and guidelines for after hours, and, you know, how they reach you.  All of those things are really helpful, but definitely, to Laura's wonderful point, you know, have a resource inventory that not just, you know, the clinical staff,  but everybody has access to, because that way, your front office can, you know, give information without a message having to be routed,  if it's a simple ask, and they can provide a resource. If anyone else, I mean, love sharing in the chat, too, if you guys have found other community  resource, or, you know, search engines that have been helpful for you all.  All right, so let's talk about geographic scheduling, and while I'm kind of going over the why, or the importance behind this, which I think we all have painfully come to know,  if you're at this conference, and you're doing home-based care, we'd love to hear in the chat what strategies you guys are currently doing,  or how do you accomplish geographic scheduling today. We're going to go over some technology resources that we're aware of.  Just a little disclaimer, you know, I'm not personally recommending any particular solution  that we reference, but I do think it's important for you all to know what's out there, you know, what are some of the solutions that I know home-based practices are using.  Especially when we think about efficiency, the number one goal in your practice should always be to minimize travel time, you know, and it's going to depend  on your geography, you know, are your providers driving, are they really in a city, you know, if they have time in between patient, but they can't provide the care to the patients  that they need and meet their productivity goals if they don't have reasonable travel time,  and if there's not an actual thoughtful process where people are not only scheduling patients in a certain zone and proximity, but also thinking about the driving route,  which is really kind of equally as important, and that really has, you know, come down to, you know, provider satisfaction and just the overall care that you're able to provide.  When you get really good at this, it will also help you identify, hey, okay, we may serve, you know, these various counties, but 50% of our patients are in this area,  you know, there might be certain facilities we have over X patients that we need a set day per week to be there.  It can really kind of help guide those decisions as well, and, you know, help you from there.  Next slide, please.  No one's telling me what they're currently doing. I'm hoping you guys have a process for geographic scheduling. It's okay if you don't.  We'll get into it, but I know Patrick's practice has a great solution. I might pick on you later, Patrick. I'm giving you a heads up now.  All right, so when you think about geographic scheduling, what we talked yesterday about first when you're starting a practice or you're even considering your current practice,  you have to think about what area am I going to serve geography-wise? What's the farthest distance I'm going to go?  But then you need to break it down even further. Generally, practices, you know, are covering a decently wide area.  Your providers need to have territory zones that need to be even in closer proximity.  And then you need to, you know, look at that, look at the mileage, look at their patient panels. Sometimes some reallocation needs to happen to really make it efficient  because you should also be considering where that provider lives  and where they're starting and ending their day. I also, you know, I think sometimes it's hard for us to make time to document processes,  and we'll have an example of this later in the slide, but you should have a scheduling guide that for whoever in your office is doing the scheduling that says, okay,  certainly with flexibility, on Monday, we're going to aim to be this provider in these zip codes or this county or these areas.  On Tuesdays, we're going to be at these assisted living facilities.  On Wednesdays, so on and so forth. And furthermore, talk with your providers and get their preferences. I mean, they're the ones that know their routes.  Not that you want to have different processes across the team, but, you know, if you know provider A starts from home on Mondays and Fridays, so she should be in this area.  Or, you know, maybe it's a newer provider that has a little lower productivity goal than the other, or someone that should only be, you know, seeing so many new patients a day.  It's okay to gather those things and have them on a central documented place so that your scheduling team really can use that feedback to schedule appropriately.  So, patients don't fall through the cracks, too. Generally, what occurs is after you see the patient,  the provider uses their clinical judgment and might say something like, okay, you know, schedule a three-month follow-up or a two-week follow-up, whatever the case may be.  Then they can, your team can use that scheduling guide to actually proactively plan days that are already going to be in the next area.  You need to think about who's doing this and have they actually been trained? Has anyone actually sat down with them and spent the time? Because it's not as intuitive as you think.  I was talking to another practice, and we were kind of joking that it's almost like Tetris. Sometimes when patients cancel and you're moving things around, I mean,  there's a lot of work that goes into scheduling. So, it's really important to consider that. And I'm just going to take a quick look at the chat here.  But also, you know, understand who on your team is going to do that. Make sure they have the tools that they need.  And I know we have a lot of practices that serve assisted living and group homes. You should really know your patient list or know, you know, and ask the DONs.  You know, if you don't know, don't try and reinvent the wheel. Have them fax you a list. They know who your patients are because they know who to call for their patients.  So, you can really make sure that if you're sending that provider to a particular facility  that you're seeing all the patients that are due for follow-ups on that day. So, yeah, Manicopa County is very large. So, we split the valley into territories and use MapPoint.  That's great. And then also, connecting dots based on Google Maps.  Yeah, Google and Bing Maps, even just for route planning. Let's say you do all of these things. You use the scheduling guide, everything we just talked about.  But is somebody actually putting those dots on a map and looking at the most efficient driving route?  And comment tracker. I love that I'm hearing some that I haven't heard of before. That's great. Thank you for sharing in the chat. Next time, or next slide.  So, I'm not going to talk through all of these. These are just some information of some specific solutions that we're aware of. Care Link is one.  I will say this is probably one of the more expensive solutions. But it was actually developed by a home-based primary care practice.  They do have a practice management system and a scheduling system. So, you can, you know, certainly just have the scheduling option,  and then it's priced based on the number of providers. But that screenshot on the previous slide was actually a view of Care Link. Next slide.  So, Road Warrior, this I like for route optimization. So, especially if you're a provider that's, you know, hopefully you're not doing all  of your scheduling and routing on your own. But if you are, you can actually download the app on your phone. For up to eight addresses, you can use it for free.  You can change your start and end point, and then you can hit optimize route. And it'll actually tell you the most efficient driving route. It also tracks your mileage.  So, if you're trying to do mileage reports and things like that. Like, for example, I don't know how well you guys can see this. Oh, no, never mind. I can put a screen capture in.  But I have it on my phone. I've used it in the past. But really more of a route optimization than it is a full scheduling solution.  Some of the FedEx and companies like that I know have used it. And they do have a computer version that would be more in-depth that you could purchase.  Another one, and these are all going to be similar to Maptiv is another one. Again, you can create custom Google Maps. You can color code by provider.  You know, you can upload a spreadsheet to do that. You know, a little bit lower cost.  And also comes with some features where you can help not only schedule and plan routes, but also use route optimization.  Multiplotter is very similar to the last one, too. Again, just giving you some food for thought of solutions to look into.  I will say the value in having any sort of, whatever you end up using, any sort of mapping system is the time.  Again, we talked about how much time it really takes to do something like this. And your scheduling staff is going to be a lot more effective and a lot more efficient  if they have something like this. It also just makes defining those provider territory zones, understanding how many patients they each have.  All of those things are a little bit easier. And if we go to, I think we have one more solution here I actually wanted to invite. Next slide.  Megan, I know you and your practice have used even just a Google Maps business account where you signed a HIPAA BAA, and she was, you know,  kind enough to kind of share this screenshot. Do you want to share a little bit about, you know, how this worked for you?  Sure. As you can see, we didn't just have a geography problem. What we had a significant geography problem is that there's a lot of water there.  And so, as we would go down into that southern peninsula, which is a town called Englewood,  there's only a couple of different bridges that would allow us to get back over on the other side, which is where then we would have quite a few clients as well.  So, what we had started to do is we color-coded our patients by when they had been seen. So, you could do that as an option, but it just also helped to see visually the clustering.  So, we could call and try to make sure that we scheduled them on specific days and really reduce that time because doing this visually helped us to see who was in close proximity.  So, we didn't end up zigzagging back and forth and spending our day driving more than what we needed to do. So, again, it was very simple. It was our business account.  You can go in, you can plot the data, save it as a map, and then we divided it out by, you know,  last visit, you know, when it was, the time of it, and then you could kind of also plan forward that way too with it as well and see it all visually in one piece.  Yeah. So, I mean, kind of thinking about there are a lot of solutions out here, and if you're thinking about your current process, you know, maybe you have.  I've seen some pretty effective homegrown processes as well, but it just really is a different capability, efficiency, and all of that when you're able  to actually see your patients and color code them and use it on the map. And I just want you to know there is a lot out there.  The other solution, and I can, I don't have a slide on it because I actually, Carolina Caring was kind enough to share what they're doing, BatchGeo, B-A-T-C-H-G-E-O.  I know I spent some time with a practice that was using that, and they, you can actually just drag and drop, you know, your spreadsheet of patients in there.  You can color code it really easily.  You can use it for different service lines. I think it was a very low monthly cost for like up to 10 users.  You know, Patrick, I don't know, do you have much experience with it? Did you have anything to add? No, I don't.  It's on my to-do list to work with Scott on, but I have not got there yet. So, yeah, I do understand that it's pretty easy to use and pretty helpful.  And I envision us using it, especially in the first year because, you know, Carolina Caring has 12-county service area, and so probably that first year,  we're going to have one nurse practitioner. We are going to target about a three-county area, but, you know, as partnerships develop  and the word, you know, of the program grows, there may be times where, you know, there's patients in other parts of the service area that's kind of far away,  and that could grow. So, I could see something like this being helpful in determining, you know,  how to be efficient with our time if we are covering, you know, 12 counties with one person, kind of going through that growing pain phase, you know, before adding that second one.  So, I think this would be very helpful to us in the first year and, you know, obviously in the future, but as we map out with one provider, how to maximize that time, you know.  Yeah, absolutely. I mean, even if it is one provider, you know, you could then color-code service areas or things like that.  But it really does make a big difference, and you really do need to have a kind of proactive plan so that when whoever is scheduling those future appointments,  they can do so within reason and in certain geographic areas. And especially, I know, Talisa, I think you were sharing, you know,  you cover such a large area, that's really where you want to kind of say, okay, well, what zip codes or what specific area of this map am I going to be in in one particular day?  Hey, Brianna, I work with Patrick at Carolina Caring, and the two other things that all sort  of go in line with that, having to have your office in the car that they really like and use, are we have ClickSoft, which is the secure messaging piece.  And so, then our teams will be secure messaging photographs of wounds back and forth, and, you know, lab results, et cetera, just via their cell phones rather  than having to have some other technology. And then also, we have mileage tracking so that we can enter our patients' addresses  into the big mileage tracker thing, and then the team can get reimbursed for their mileage.  Absolutely, yeah. I mean, if you don't have something with mileage, then, you know, unfortunately, they're kind of trying to manually at the end of the month or whenever go back.  So, that's great. Thank you for sharing.  Was someone else going to jump in? I'm sorry. Was there someone else that wanted to share?  Okay. Tiger Text is another secure messaging app. Yeah, I mean, those are really great because you talk about efficiency.  And I know Megan, in the clinical session, I believe talked about acute and urgent care yesterday, you know, how do you really determine if someone does need  to be added onto the schedule, what kind of information are you getting in that respect, which can be, you know, you have this beautifully planned geographic scheduled day,  then what do you do when someone calls and really needs care? So, you know, thinking about that, if you have a multiple provider team,  some practices use like the designated on-call provider that might have one or two less patients a day.  But again, depending on your geography, you know, team huddles in the morning, that's where that's really helpful.  You know, okay, these are the areas the providers are in, you know, even if it's just a quick five or 10 minutes, here's how many patients they have on their schedule.  That way that you know, when you get that call, okay, well, provider B is kind of close to that area. Let me call them or send them a secure text and see if they'd be able  to add this patient on within reason. And then you can really kind of make those decisions. Also, you know, if you do have home health, home health,  maybe the home health nurse can do a same day assessment and get you some information, you know,  or some practices will leave, you know, certain slots open or offering a telehealth visit, even if it's a nurse that can go out and facilitate that telehealth visit  if the provider's not in the area and able to get there. So, just some food for thought on kind of thinking about your scheduling strategy.  But you also have to kind of make a plan for how are you going to accommodate those acute and urgent visits.  Next slide, please. And then we talked about Bing and Google Maps. Again, this, you know, if this was more kind of a homegrown process,  let's say you had that scheduling guide, but then you really need to think about that driving route. And either of these could be used for that without a cost.  Next slide. So, I really want to kind of drive home the point that these are two separate activities, right? You're planning your route.  You've defined your provider zones, like we talked about. You know kind of a plan on where you're going to be on what days. What are you going to do about route planning?  And are your schedulers actually considering where providers are starting and ending their day?  Generally, it's going to be usually a little easier if you start with your farthest patient away and then make your way back to wherever you're ending your day.  But you may have, you know, making sure you're using EHR flags or notes in the EHR of when patients may be not available or what's not a good time for them so that if you can,  within reason, accommodate that, you know that. And then your scheduling staff isn't trying to have to do all these last minute changes  at the last minute because, you know, it wasn't noted that the patient had dialysis that day or their daughter needed to be there and they can only be seen  on Wednesdays and Thursdays or something like that. Those things do come up and we do have to, you know, keep our patient preferences  and their lives and their caregivers' lives in mind when we're thinking about scheduling and route planning.  One pitfall that I've seen is I would really encourage you not, when you're calling for appointment confirmations, not to give your patients an exact date  for follow-ups or an exact window of time. There's a lot of different ways that you can approach this, you know,  but generally you could give a two-hour timeframe window or I know practices that just say a.m. or p.m. If you do have an add-on, that's going to allow for that flexibility,  but these schedules change constantly. It's not going to be set ahead of time. So if, you know, when the provider is finishing their visit, they might say something like,  okay, I'm going to come back and see you in a month or three months my office will call you. That's also, we talked in the nonclinical track yesterday about your intake process.  Those are things that the front office or somebody should be going over with the patient at the start of care. Hey, you know, for future visits, you call us any time you need us,  but you'll get a call a week ahead of time, two days ahead of time, a day ahead of time with your visit date and timeframe.  And we always have to give a window of timeframe to account for travel time and other patient emergencies that may arise in our day.  And if you really explain that reasoning to people, generally they're a lot more understanding and receptive to that. And again, use your EHR flags and things like that.  You know, for example, let's say your first patient starts at 830. So it's 830 to 1030.  Your next patient, maybe you have 30 minutes knowing your travel time before their start time. So their timeframe would then be nine to, you know, 11 or something like that.  You can kind of play around with what makes sense based on your geography. But if you know, okay, my provider is generally going to have 15  to 20 minute drive time in between patients, then you can stagger those timeframes. And have that be a lot more effective for your practice.  But you do need to kind of consider travel time.  Especially for practices that are traveling with an assistant, you may or may not have that benefit or that may or may not be part of your staffing model.  But especially from an EHR perspective, they need to take breaks, they need to have a lunch break, you know, and not get back to the office at the end of the day.  I can, that is challenging. But you do have to think about that.  Even if you're alone, though, you know, we talked about documentation burden a little bit yesterday, too.  And how do you make time, if you're waiting until the end of the day to try and answer all of your patient callbacks, all of your messages, reviewing all of your lab results.  Number one, if you're relying on a clinical staff member to do that, and they're not getting  that information until the end of their day, that's making their afternoon really hard on them to try and call all of these patients back that need a call before they clock out.  So really trying to find little time in between visits, you know, if you have to pull over at a Starbucks or whatever is most effective for you,  or if you're at an assisted living facility, you know, can you take some breaks after a few patients in the nursing area before, while you sign some orders and answer some messages.  I think that's where that secure text that Laura talked about, and Talisa also put one in the chat, can help, because if you're able to kind of have some real time communication  with your team, we know that providers are traveling and they're providing face-to-face care all day, but there's also patients that are not going  to be on your schedule that are going to have needs, and how do you address that throughout the day without, number one, saving more work for you and callbacks  until only the end of your day, and also being considerate of your clinical team or other people that may be having to help those patients.  Before we move on, any thoughts or questions or things that have worked well for you in anything we've talked about?  Okay. So, when you're thinking about your team, you know, whose job is it gonna be to review schedules too? And as you're, you know, getting ready to confirm these appointments,  thinking about your productivity standards. Okay, if I know provider is supposed to have five or eight visits per day, but I had two cancellations,  who's looking at the schedule to fill those gaps? Who else has a need that's in that area that can be seen?  Making sure that you're providing approximate timeframes. Again, not being too specific. And then decide how far in advance you're gonna call. I wouldn't do more than a week.  I would say a week would be the longest I would, you know, the most advanced notice I would give someone because keeping in mind that this patient population,  they have, you know, memory issues perhaps, or, you know, caregivers are just so busy even when they get that call, they're gonna forget.  So, you know, maybe it's two days in advance or maybe you call two a week in advance with the appointment date and a day before with the time.  And that's kind of that another reminder. So you make sure that you're not having a no-show situation.  Megan brought up the idea about patient portals. You know, the challenge, I was in a health system practice previously and the patient portals would give them exact timeframes.  So we actually had to add in appointment notes that said, do not look at this for your schedule. Do not, you know, use this timeframe. Our office will call you.  So we actually had issues with the patient portal. Megan, I don't know if you had a different experience. Well, I guess what I was thinking about,  one of the issues brought up yesterday was that patients have results from other facilities and hospital systems. And, you know, those big hospital systems  now have patient portals with their results. So, you know, one thought would be is to make sure to ask the patient, can you bring up the hospital portal that you were just at  so we could review those results and you have them ready since I can't access them by my resource. The patient sometimes is actually able to do it much faster than I can.  That might be a time saver. So you're not trying to sit down and figure out where are you going to get results from? Now the backend of that is many patients  don't have a smartphone or that, they have an accessibility problem. But if they have the information for a portal, that might be something with a consent, like Chris mentioned,  that you could facilitate via your laptop. You're not saving their information, but yet they are consenting, they're getting access  so that you could have those results that you need and you're not hindered by that lack of information.  Yeah, absolutely. And if you do have EHRs, I mean, some, most, a lot of the bigger EHRs may have access or depending on your area to what's called an HIE  or a health information exchange where you could actually get a consent signed where you'd be able to see records from a different health system.  So I would definitely encourage you to look into if an HIE is available in your area and with your EHR.  But when you're confirming appointments too, I mean, to Megan's point, if it's a post-discharge patient, is your staff trying to get that information  for the provider in advance of the visit? All of those things would be, should go into your scheduling process and your appointment confirmation process.  So your office team, if you have one, is doing everything that they can to help the provider be the most prepared for the visit. But that's, I love the idea of,  hey, if the patient has a portal, can you even just pull it up and look at it in real time at the visit?  So one of the huge pieces of interoperability and data sharing between different health systems and EHRs has to do with a field in the electronic health record called the PCP field.  And that's essentially a way that all the large vendors  predicate autofaxing and sharing electronic health records  back to the PCP. It's their solution for some of the interoperability issues. But the problem is a lot of the time at registration,  people will jump over that field or they won't update it, or they won't include the correct spelling of the name. So then the EHR glitches and the information is never sent.  So I think that that's a huge piece of patient education is informing our patients how important it is when they go to a specialist office or they go to the emergency room,  that they identify the PCP as the PCP, and they're very specific with the importance of having medical records sent correctly. So I actually was just thinking  it probably would make sense as we're just starting out to have little business cards printed up or brochures or something like that that we urge our patients to put in their wallet  so that as they are traversing the very complex  transitions of care and various systems where they're receiving care, that they're correctly identifying the PCP including the right contact information. Yeah, that's a great point.  And I think that really does come down to patient education. I mean, we talk about transitional care visits. Part of that is how quickly can you get to the patient?  So number one, they need to know that if it's not an area where you're gonna be getting access to that automatically, are they not only telling the hospital  that you're their primary provider? Because if so, then you will get their discharge summary faxed to you automatically or sent to you electronically, however the case may be.  But that is reliant on the patient or whatever system it is, knowing that you're listed as the primary care provider, or is that patient at least calling you  to let you know that so that your staff can try and reach out and get that information. The welcome packets that I mentioned earlier, generally that might have a practice brochure.  I know some that have magnets for the fridge so that in an emergency situation, or if other caregivers or other people came into the home, they would see your practice information  right on the fridge. I like the idea of business cards too. So if the patient is getting out to like a specialist or something like that, they just have that that they can give.  All of those things are gonna get you timely information  that you need to help care for your patient. And really goes into,  it's not just calling the patient to confirm our appointment and tell them the time and the window or the time and the date, but what else do you need before that visit?  Or what else is going on that you might need to be aware of? And then doing really good patient education at the start of care when you're doing those patients.  Or if you find out for a visit  and you didn't know, can you have that conversation with the patient? Like, hey, next time it'd be really great if you could make sure you notify us right away  when you're in the hospital. And also please give the hospital our information so that I can get that.  Any other thoughts on that?  The other thing, we talked a lot about recognition too, but also making time for feedback. So hopefully you should meet at least monthly as a team.  I'm a fan of at least daily or weekly huddles.  I think even just a great five minutes in the morning is super, super helpful. But monthly more elongated staff meetings, maybe you alternate that with an IDT meeting  and then more of kind of an operational staff meeting in nature. But are you asking for feedback? Or if your team is really struggling with scheduling,  have you pulled your providers last week or last two weeks of routes and looked at it and tried to figure out what was going on? I think a lot of times we have really cohesive teams  and sometimes people don't want to burden others by sharing, hey, I had a really difficult day or this patient, I'm not really sure why they were scheduled on the same day.  But are you really making time for feedback and evaluating how effective your current scheduling process really is so that you can understand your need and improve on it?  And again, that's where having something like that documented that this is how many visits per day, these are some provider preferences. Again, the providers know their routes,  they might be able to give you really good patient information so you can make those kinds of flags and notes and things that will help with scheduling in the EHR.  Generally, if you have someone else to do the scheduling and the routing, it's still helpful to have the provider that's actually gonna be doing the route  review it a day or two in advance so that if they have recommendations or changes because they know their area so well, then those can be made before the day of.  And then if there is a no-show, we think of this more in the office setting, but if you have a patient where despite the calling, despite the confirmation,  how many warnings are you gonna give? Who's gonna have that conversation of that boundary setting of, hey, we really value you as a patient, we wanna take great care of you,  but we can't do that if you're not able to answer the door or we're getting there and you're not home for your appointments. Can you help me understand what's going on?  How might we make this better in the future? Because we do need to have you ready and expecting the provider for your visits.  That kind of goes into that, thinking about no-shows or that flexibility. Also, thinking about your appointment confirmation, I don't really like to send providers to our house  if the appointment's not confirmed. Did you actually talk to somebody or did you at least ask the provider, say, hey, I've made multiple calls  to not only Mrs. Smith's primary contact, but her daughter or her emergency contact. I still haven't been able to get ahold of them. Do you know anything, what's going on?  Maybe they're in the hospital or a nursing home. Are you really even gonna send a provider out if that appointment isn't confirmed? That's another thing you need to consider.  Next slide.  So this was just an example and I believe it's in your workbook too, of again, just very general. I think the worksheet is actually more detailed than that  where it had some preferences and things like that that we were talking about on the bottom. But again, proactively planning where you're gonna be on what days  and then making sure when you're doing this, you're using technology or even just Bing or Google Maps or something to really identify those.  Because the other thing you have to keep in mind is you could have patients that are technically in different zip codes that are backdoor to each other.  It's just how geography and things work out. So that's where using some sort of mapping system is really gonna come in handy.  But I really do encourage you to have a very well thought out and documented scheduling process that you go over with your team.  This is a little hard to see, but again, to just kind of taking that one step further, what's the process for new patient scheduling but versus established patient scheduling?  How are those visits getting coordinated for your assisted living facilities too? Are you making sure that someone's faxing a copy of your progress note to those facilities  so they have your care plan? Also, I think I mentioned yesterday, but when we're calling assisted living facilities, we call whoever the patient likes to be called  for their appointments and things like that. But generally the facility knows who we're seeing and we ask for MARS, their medication list and their recent weight ahead of time.  That needs to be sent to us before we're there that day so that the providers have some information before they're seeing patients. So again, a lot goes into that,  thinking about follow-up after the visits, coordinating with the facility staff. It's also really helpful if you're calling them and they're like, hey, you know,  Mrs. Smith is also having some edema. We'd really like to get her added on the schedule. If you know that in advance, it's gonna make your provider's day easier.  So this is just an example of how you might document something like that.  Any other thoughts or questions on scheduling?  All right, DME, one of our other headaches and I don't have really any magic solutions to any of this, but how do you handle DME knowing how time-consuming it is in your practice?  And again, I encourage you all to put some things in the chat or any things that you've thought of, but knowing that our patients are gonna need hospital beds  and wheelchairs and oxygen and all of that, hospital beds and wheelchairs and oxygen and all of the requirements and the documentation that goes along with that.  I can tell you one of the things that most likely slows down the process is the DME supplier not having the correct documentation or all of the orders that they need signed  right at the start. So do you understand the requirements? We have handouts that go over the Medicare requirements for each of these things. This is where you need a template.  Your providers need to know what to document in the face-to-face notes when they're certifying these patients for these types of things.  What qualifications would a patient even be qualified for so that you can kind of answer those kinds of questions? And obviously a clinical team that's really good at that  and being efficient. Yeah, RMAs can be on hold for 20 to 30 minutes. It's really rough. Absolutely. We're gonna talk about it in a later slide,  but that's where I would encourage you. Generally, the big DME companies in each of their area have, well, if it's, let's talk specifically about wheelchairs,  a customer service rep or even a mobility specialist that's assigned to your territory. I have found really great success in working with a specific contact. If they know your area,  I would encourage you to think about who that is and see if there's a more direct person. That's not always available or that person may say,  hey, I don't have access to that information. They do need to call this number or this office. But generally these DME companies, they have to put in for Medicare bids.  They're gonna have territory reps for the area that your practice could be, get a more direct contact person that can be a huge advocate for the patients also  and helping them follow up on things, but also for your practice staff.  Next slide.  So if you're struggling, let's say we talked about patient experience of care. You have a DME vendor that is just consistently not delivering. This is just how you would look up  which suppliers in the area actually have the Medicare bid to provide DME equipment for Medicare beneficiaries. And then understanding that typically  what goes along with that is they need, actually in your progress note, you need to be saying, usually they want the chief complaint for the visit  or somewhere in the HPI to say that you're evaluating them for the equipment and that you're certifying them and this is their need  and that you agree with them needing that equipment. And then usually that comes with another form that needs to be assigned from the DME company called the CMN.  So making sure that you know that and that your documentation is matching up.  Next slide.  Yeah, Chris was sharing that four to six patients extra every two weeks, they have documentation lined up where we need to come through and have a pre-documented template.  And again, that's where that template is gonna come really easy. And when you think about who on your team can do this, it's really difficult to know all of the ins and outs  of this. So if you have certain people, maybe it's your MAs or someone that can be kind of your DME specialist and then all DME messages get routed to them for them to help.  But again, I can't emphasize enough forming that relationship. I'll give you an example, actually a company that we had a really good customer care rep,  that was also their mobility specialist that we could call anytime we sent an order, she would make sure it was gone through, she would give the office updates  and she actually really went on a limb helping a patient actually submitting an appeal for something that wasn't being covered.  I mean, the patient and the caregiver had to fill it out but I mean, they can really get involved if you make those relationships.  But I can't stress the templates enough for efficiency. You guys are providers, you need to take good care of patients. There's no way you're gonna remember  all that needs to be documented for each of these equipment without having a template.  And then also, we know that patients not having these supplies, especially if it's something to prevent a fall or something could lead to readmission.  So making sure they're safe at home but then also educating them, especially if it's a motorized chair or something that's gonna take a long time,  the expected wait time and how lengthy this kind of process can be. And this is where I would even further say your clinical staff should be using  some sort of systematic care management alerts to make sure, to follow up, to make sure the device was actually received because I can't tell you how many times  orders have been placed for a DME. The office did everything that they were supposed to do. A month later, the patient calls, hey, I never got that.  Call the company, oh, well, we never got your fax or we never got your order. So really thinking about wraparound processes, how are you actually making sure  that not only are you doing the documentation and you're sending all the orders but that your patients actually got the supplies that they need,  where it was denied and the patient never got a call.  Anyone else have any DME tips and tricks they wanna share?  It's, you know, it's not fun, but, you know, we do, having equipment makes the difference in their lives and unfortunately it's just like prior auths for medications  we can't get away with it. Supposedly they're making it easier on us and the insurance companies have more tough turnaround times as we all focus more on interoperability,  but, you know, it's just something that we have to do.  If anyone wants to share too, you know, how big of a stressor, Amanda's talk about grounding and boundaries and stressors that DME is in your life, please share in the chat as well.  All right. The other thing that you can kind of last solution is some of the DME companies will have online platforms. Yes, that's one more system.  That's not your EHR that you have to log into, but some of the pros would be you can actually track orders in real time online and, you know, it'll tell you these things.  So rather than sitting on hold for 20 to 30 minutes, like Julianne was mentioning, you know, maybe you can have access to an online system or portal for the DME company.  This isn't always,  but I'm telling you they are available, so it's something to look into.  And they can also sometimes sign orders electronically as we all try and be more, no, it's okay, you can go on to the next slide, more paperless and, you know,  have less physical orders to sign. I will say, if you don't have an e-fax, you're not using your electronic health e-fax, you're not using a DocuSign or something  for signatures electronically, that will make a huge difference in efficiency as well.  All right, and with that, I'm going to turn it over to Dr. Chang. Thanks, Brianna. Just a couple of comments. We do have a portal here in our office regarding signing for DME.  So it does help time, and I saw the comment about Tylenol every time. Yeah, it's a headache every time we're doing DME or the other dreaded project, and that's prior authorization.  I think that may be Tylenol and Imitrex and maybe some other medication as well.  And I had a comment about,  oh, it was about scheduling.  You know, it's so important to have a happy front office, you know, to have a great team, because like I keep saying, this is teamwork.  A happy front office really makes my job a lot easier. I depend on them. And one of the kind of screening questions I've asked them to start asking is when they get the intake,  is to ask the person who's either sending the referral or the family member calling in and saying, are there any pressing issues that needs to be addressed urgently?  And the other is, has your loved one been in a hospital recently? From those two comments, you can kind of get a sense like, yeah, you know, this is the third time  dad's been in a hospital for the last two months. That certainly puts a more urgent visit request  than, yeah, and you know, dad's okay. He just needs an annual checkup to get his medications refilled. So, you know, as providers, we're always balancing between  trying to meet the urgent needs, especially those ones that are just coming out of the ED or out of the hospital or the nursing home or whatnot,  trying to prevent and readmission at the same time, not overloading the providers, you know, adding to burden, burnout, pajama time, you know, documenting at home at night,  which, you know, I talk to my staff, I want them off computer as much as possible, minimizing that, you know, the pajama time at home because that is still work  and can lead to more frustration and burnout.  With that, we can segue into equipping the modern house call. You know, with the rise of technology that really led to the decline of house visits, right?  You know, back then, if you needed some technologies, had some tests and whatnot, you needed to go to the hospital or go to the doctor's office.  But now, fast forward to our current culture and technology and so on, we have a lot of technology that's coming that we can bring to the home,  whether we're talking about patient monitoring, like wearables and stuff that we talked about, or point of care testing, which the video we'll talk about here in a little bit,  whether it's a blood test or an EKG test, like the one that I showed yesterday, or also diagnostic testing like a POCUS or a formal ultrasound or portable x-ray.  The technology is allowing us to do more to take care of our patients better and keep them out of the hospital.  So I wanna, next slide, please. So the video, just an introduction regarding the impact technology is having in our field and review some of the technology that's available  for us to consider and something for you to think about, whether you wanna embrace or consider some of the technology that I'll mention in the video. Go ahead and play.  My name is Dr. Paul Chang. I'm the Chief Medical Officer here at the Home Center Care Institute.  Let us talk a little bit about how to equip your house call program.  Technology is a critical part of a house call visit, but there are so many options that it can be a bit overwhelming.  In the first part of the 20th century, house calls were common. The black back toting physician is a familiar image from that time. However, technology advanced,  x-rays and ultrasounds and blood testing and therapeutic treatments required visits to a physician, a clinic or hospital. And so the house call practice became in essence obsolete.  But time passed and with the advancement of portable technology, diagnosis and treatment at home are now possible and often are preferred by patients and families.  House call physicians are in a unique position when it comes to the care of our patients. We have to be able to reliably assess and treat the patient at home,  often without input from specialists. Along with other basic medical equipment you pack in your bag, these critical diagnostic tools will increase your effectiveness  in caring for the patients at home. Once you have covered the basics in diagnostic technology, a wealth of advanced diagnostic options exist.  Point of care testing enables house call providers to make assessments and treatments in the home, which were not possible only a few years ago.  While there are many positives associated with these advanced tools, there are a lot of challenges as well. Let's explore some of these advanced options  and the implications of their use. Point of care tests are designed to be done while the provider is still with the patient.  Point of care testing can improve patient care since results are available during the visit and diagnostic and therapeutic intervention can be instituted.  Examples of point of care testing include radiographic imaging, ultrasound, cardiac monitors, oxygen saturation monitors, glucometers, and portable blood analysis systems.  The upsides associated with point of care testing include their portability and rapid results turnaround. The challenges to point of care testing are cost and maintenance.  Some are complicated and require fairly extensive training to be used accurately. Some require specific adherence to storage and maintenance schedules.  Failure to do so can result in inaccurate test results or wasted supplies. Just like any device that uses batteries, these devices have to be recharged.  You may need to carry around extra batteries or other charging cables. Many mobile apps have made the practice of evidence-based medicine in the home more convenient.  They provide quick answers when you are in the field and allow for better clinical decision-making. A potential challenge with these apps is access.  For example, if you're in an area without internet access, you may not be able to find the answer you need.  Some apps are free, but others require a one-time purchase or yearly subscription. An additional important consideration is the source of the app.  While the internet abounds with free medical advice, as I'm sure you know, practitioners need to be sure to access reputable sources for information.  One rapidly growing area of patient care is remote monitoring technology.  Partnered with telehealth, this technology allows us to monitor or communicate with patients in between visits. If a patient's vital signs become concerning,  triage staff can contact a patient to assess the clinical situation. While this may require additional clinical intervention or a house call visit,  it may also prevent an unexpected emergency room visit or a hospital admission.  Again, while there are many advantages to this advanced technology, cost and complexity often make it inaccessible to some practices. Perhaps these are wish list items  or could be focus of philanthropic assistance.  As you can see, mobile healthcare delivery system now have an amazing choices, such as point of care diagnostics, apps for clinical management,  and connecting multiple devices through the internet, called the internet of things, to all improve patient monitoring and care.  Cost is of course a factor.  Some of the devices can be expensive and many monitoring services comes with a monthly fee.  Consider the return on investment on any device you're going to purchase. Many devices and services require internet access. Using dual connective devices  with both wireless and cellular connectivity can help maintain a steady, reliable connection. The benefits of these technology in patient care  and security concerns will be an ongoing discussion as technology continue to evolve in our field.  In addition to diagnostic and treatment tools, every house call provider needs basic operation and communication technology.  Personal safety alone makes remote communication and some type of navigation device necessities.  Just like diagnostic technology, options in operations and communication technology are many and varied. Much depends on the size and the scope of your practice,  the investment you are able to make in such technology and the willingness of your staff to engage with these devices. No matter what device you choose,  you must ask about device and system security.  Consult with an IT professional if needed  to ensure you get the information you require to make an informed decision. Smartphones are now nearly ubiquitous and can be an important part of house call medicine.  Take a moment to appreciate the capabilities as well as the challenges when you're using a smartphone in the field.  In addition to the benefits and challenges shown here, one of the biggest benefit to using a laptop or tablet  is the ability to electronically access medical information and perform documentation during the visit. This can be accomplished in two ways.  One way is via cloud-based electronic health records, which can be accessed by connecting through your secure cellular broadband connection. The advantage of this approach  is that there is no medical information stored on the device should the device become lost or stolen. Cloud-based system allows you to access other parts  of the electronic health system to view a patient's information.  Although it's important for home-based primary care providers to access and document information electronically during the visit,  we recognize this might not be an option for all practices.  Another way of accessing and documenting during the visit is asynchronous charting. This method require that the charts for the day be downloaded onto a computer  or be completed in paper form, then synced with a permanent record once you're back in the office. This can be a much more time-consuming process. And one critical security issue  is the presence of patient data on a portable device that can be lost or stolen. Because of this, data stored this way should be encrypted.  We strongly advise providers to not connect to the patient's home Wi-Fi or a public Wi-Fi to chart or send pharmacy orders. Other options exist for creating internet hotspots  that allow for secure data transmission. These must be carefully investigated. Connectivity issues and cost concerns can make this valuable technology problematic  for many practices. Again, work with a reliable IT staffer or consultant to make the best choice for your practice.  Many vehicles today have USB ports for charging electronic devices, like a cell phone. But charging laptops and some point-of-care devices  require they be plugged into a standard 110-volt outlet.  Power inverters convert power from your car's DC battery current to AC current, allowing you to plug in your device just like you would at home. A mobile practice requires  that you be ready for emergencies, such as having a jumper cable or properly inflated spare tire. Another alternative is enrollment in a roadside assistance plan.  Technology well-chosen and implemented can be a house call provider's best friend. Advances in technology have made it possible for our field to thrive again.  Examples of devices are provided in your workbook as a starting point. This does not constitute or imply any endorsement or specific recommendation  by the Home Center Care Institute. As you make choices in technology for your practice, think about how you and your patients will benefit from this. Let that be your guide.  Anybody want to share about what they're using currently in terms of hardware, software,  whether we're talking about, you know, charting documentation or apps to help with efficiency and clinical care?  You can put it in chat box or just on mute and just share with the rest of the team.  Next, Jen, are your providers using laptops in the field? If so, do they have a broadband connection or is it a kind of asynchronous, as I said in the video?  It's always scary to see yourself on the big screen. As many times as I've seen myself, it's just like, oh, dear. Or are you guys documenting asynchronously?  O2SAT, RPM Solutions, great, yes, we, there are practices out there that are partnering with RPM companies to help monitor the patient, again, not only to improve patient care but  also as a potential source of revenue as well for the practice. Laptop hotspot from phone or Wi-Fi in a facility would love to purchase offline charting options in a Prima. Got it.  What about security issues with the Wi-Fi? You concerned about that? I assume it's a public Wi-Fi.  Do you run a VPN software connection, I should say?  We have a Verizon Jetpack for Wi-Fi, awesome, a VPN, yes, terrific, great, great. What about software or apps, I should say, in terms of either efficiency or clinical care?  And later on, we'll talk about safety as well. Anything that's like, I use this app every single day or a couple times a week to help me with patient care and so forth.  Again, I'm not endorsing any products or anything, just here to share some conversation.  Thank you for your comments. Hippocrates. Absolutely. Yeah, I use Hippocrates a lot. Anybody else? Up-to-date? Dynamed. Those are other resources that I've heard at Providers U.  P-PID? What is that? I'm not...  P-PID is a great app for if you want to review conditions. It'll take you from start to finish, the background diagnosis, treatment plan, you name it.  So sometimes it's a good resource just to go back over and learn everything you could possibly want to know about a condition and or even just medications down to psychiatry  diagnosis. It was designed by an ER doc. Awesome. Thank you for sharing. Anybody else? Yeah, I'll be happy to share. I won't take up too much of the time here.  I use a lot of apps, up-to-date, Hippocrates, and anti-coagulation toolkit to talk to families about CHAS-VAS, HAS-BLED scores, anti-coagulating grandma at 95 years old.  That question gets thrown at us often. It's great to have these apps and really share it with them in real time, decision-making tools and what we're talking about.  Dr. De La Genetis talked yesterday in a clinical session about using MD-Calc in terms of prognostication, bold index, and so on. Great.  Lots of calculators there to help you, again, have that real-time on-site support as you're talking about prognostication and so forth.  But I'll be happy to share with the team later regarding some of the apps that I use. All right. Next slide.  Five-minute consult, diagnosaurus, yes, I still have that on my phone, yes, for differential diagnosis. All right. I want you guys to turn to your workbook. I think is that page 80?  Help me, my ACCI staff. And as you watch the video here about staff safety, can we go to the next slide?  I just want you to think about some of the good things perhaps that Nora does and some of the things that maybe she can improve upon as she goes about doing her house call for  today. Again, we want to focus on the safety of our staff as they're out in the field. What should we be considering in terms of, again, we can talk about apps and so on, and  also fostering a culture in the office of supporting one another, caring for one another, and monitoring one another.  Because we live, as we all know, this is a crazy world we live in, right? What can we do to improve our safety for our patients, for our staff?  A few years ago, we had a police officer from our local department here, local city here, come to one of our staff meetings, talk to our providers, talk to our office about what  to do in crisis situations. So let's roll the video.  Meet Nora, a nurse practitioner who's on her way to a home care visit with Sylvia, who lives in a rent-controlled, fourth-floor walk-up apartment.  Nora's getting ready to leave for the appointment. She takes some cold medicine before she goes. She has a bag with her tablet PC and charger. Here's her box of supplies.  After packing up her car, Nora checks her navigation app to remind herself where she's headed. Then, she checks the weather app.  She text messages Reg, the coordinator at the office, to let him know she's getting on the road for the day. There's no response, but Nora heads out.  Ah, here's Reg with a text message response.  Hello, Tony. This is Nora from House Calls. I just wanted you to know I'm about five minutes away.  Can I ask you, Tony, to make sure that the cats are secured in the bathroom before I arrive? Thanks to Reg's message, Nora avoids the accident area and arrives at Sylvia's on time.  She parks in the first available spot, since Sylvia Street is usually tough for parking. Nora's phone shows it's 8.20 a.m., so she thinks she can be out of the spot before 9.  Nora gets out of the car quickly so she won't be late. She gets all of her bags onto her rolling cart. She places her phone and keys in an accessible pocket.  Her shoe covers go in her other pocket. It's a quick walk to Sylvia's building. Sylvia's stairwell light is out again.  Even though Nora's been to visit Sylvia before, she shows her badge before entering the apartment. She also pulls her shoe covers out of her pocket and slips them on.  Hmm, Sylvia's daughter wasn't able to get both cats into the bathroom. At the end of the visit, Nora goes through her mental checklist to be sure she's repacked  everything she brought. It all goes back on the cart so that she doesn't have to struggle down the stairs.  Sylvia's daughter, Tony, grabs a flashlight and escorts Nora down the stairwell. After Nora leaves Sylvia's, she notices her cell phone is below a 50% charge.  She pulls her car charger out of her glove box so she can charge on the way to her next appointment. She remembers to text Reg before she starts the car.  Got a cute little video here meant for us to use that as a kind of a discussion point regarding what Nora did well, and maybe not so well comments.  Any comments? Charge our phone early, yep, before it runs to zero, and we use our phones a lot for many different things for texting, calling for apps and so on.  So yep, that's that's that's good. She got her foodies, she got her foodies ready, you know, in her pocket, ready to just  pull them out and be ready not digging for them or forgetting them. So she went to the visit prepared. What else? Parking too close to the tow zone time was risky.  Yeah, if there was an urgent issue, it would have gone over. Yeah, I thought that, you know, while she was there, she had 40 minutes, you better  time that visit really good and to be out and get away from that parking area. I agree. That's a little too dicey for me. Anything else? Good. Let's see. Agree with Chris.  I use Google Maps when I know they're going to voice slow down. Yep. You know, this gets a great teamwork communicating with Reggie about the traffic.  This gets back to what Brianna was saying about scheduling with your, you know, who's who makes the schedule? Is it the front office provider?  Often the providers know the traffic knows when the trains are coming down, right? So sometimes it is good to have the providers have another look at the schedule.  I know this is sidestepping an issue a little bit here. Anything else? Anything that she could have done better?  Paul, this is Amanda. I thought I'd jump in here, I don't know if I've ever done this before,  but a couple years ago we had a situation where a patient pulled a gun on an employee in the home  and just a couple of notes, either OSHA or your state have requirements on safety committees, and so over certain sizes you're required to have a safety committee.  But when she called ahead and asked just about the cats, one of the things that came out of  our safety committee meeting was to ask about guns, to ask about smoking, who else would be  in the apartment, and so if you have any animals to make sure those are put away, so she did that,  but it was a pretty bad situation and nothing ended up happening, but the employee was pretty traumatized, ended up leaving and getting out of home-based medicine because of it.  And that's too bad, because we need passionate providers to stay and thrive in this space, right? So that's a great comment, Amanda, about asking about firearms.  And the other thing is, your comment got me to think and ask the learners, you know, do you have an emergency plan for your staff who are out there? Do they have a safety app  on their phone? Do they know how to dial on their phone on an emergency basis? Is there a way for,  maybe not a very confrontational, like a gun thing, but if the provider is sensing some heat  at home and feeling uneasy, I should say, is there a code word that calls to a dedicated line  in your office? We know one practice, when that line rings, it says, you know, Dr. White,  I need you to page Dr. White, that's their code word that I'm in trouble, that I need Dr. White at  Jesse Brown's house or whatever. So the office would know that you are in trouble. Again, just  consider some of the safety protocols. Yes, the three-second, yes, on the iPhone. So the, although 911, yeah, but these are great comments. Again, review with your staff.  Some people don't like to have apps on their phone. They don't like to be tracked and so on  and so forth. So be respectful and discuss that with your staff, whether Dr. White is something  you want to consider or something else. Again, have a plan, support your staff so that they feel  enabled and not like abandoned or ill-equipped. Right? Okay.  Can I say something? So when our office staff make the appointment, they always say, you know,  any guns, any animals, just put them away. So they go through the spill at the time when they  make the appointment. So that has worked for us very well. Great, great comments. Again,  you can build this in as you're scheduling your patients, whether we're talking about, you know,  pets, guns and whatnot. And now we're also talking about like, you know, do you have any COVID symptoms and so on? So some of those intake questions for your front office. So again,  your providers, when they go out in the field, that they will be as supported as possible and  hopefully no bad surprises. So just some safety checks and chats here. Be Sherlock Holmes. Keep your eyes open. Observe, observe, observe. If you don't understand something, ask,  what is that? You know, and so on. And listen to your gut. If you have concerns, that's even  when the police officer was here from the city, he said, you know, just if you don't feel  comfortable, just get up and leave. We'll talk about, you know, whatever issues later, but get  out of the situation as quick as possible. And finally, we talked about having a practice,  consider an emergency call plan. Is there a code word? What's your action plan? And kind of related  to that is if your patients are not behaving properly, abusive to your staff, either in person  or on the phone and whatnot, do you have a process of dismissal for your practice? You know, we love  our patients. We love to take care of them. We know they're sick and they need our care. But again,  as the video stated, we need boundaries, right? We're not doormats. We're not to be stepped on  and abused. Do you have a process in your office? Is it three strikes you're out? Is it a warning  letter and whatnot so that the providers don't feel like they have to keep on seeing this patient when the patients have been terribly abusive? Next slide.  Just some takeaways. Just be aware of the clinical and operation roles of functions of your staff.  And the degree at which these roles may overlap, depending on many different factors, including  the practice size, the program budget, and the practice setting. Our patients are complex with a lot of medical and non-medical issues and building a team of support people,  as well as a specialized professional is really important in providing comprehensive care.  And properly using technology can help you with clinical and operational efficiency  and also provide safety for your staff as they are out making these calls. Next slide, please.  Don't forget your learning plan. Go back to it. Fill it out. Think about things that you've  learned this morning, things that you may want more information on, or things you want to bring  back to your office and implement on Monday. Before we go to break, I wonder if we could  take the slides down and just do a smiling group picture with everybody. I think if we've got  everybody on, if you could turn your video on just so that we can take a peek and be able to record for posterity who we have. I'm going to give you just a minute. Those of you who,  please turn on your video if you can. Thank you. We appreciate it. And I'm giving you this  forewarning so that you can smile and not be looking away, right? All right. We got everybody  and so hang on there. All right. I got y'all. Thanks. All right. Janine, we are right on time. Thank you. And we will come back in 10 minutes. Is that right, Janine?  That is correct. We'll see you guys in 10 minutes. And Josh, your hair looks great. Josh, your hair is perfect.  All right. Thanks, everybody.  Hello, everyone. We're going to reconvene in another minute or two, so if you could join us again then, Melissa will be sharing slides for our next session, Economics of Home-Based Primary Care, led by Amanda and Brianna. See you in a minute.  Melissa, you're on mute. All right. Sorry. Thank you, Brianna. Yeah. So I'm sharing with you the screenshot that I took, just so you can all see how fantastic  you look and that I am not capable of taking a good selfie, so I'm looking off to the side. And I do have a request, because we are all kind of taking attendance, so to speak, just  for credit purposes. I know there's several of us here that answer to mom, but we kind of need to know who this person is here that's mom.  So if you're mom, either put it in the chat or share, you know, change your screen name so that we can give you credit for being here. Thanks. All right.  So I'm going to take this down, one second, actually, I'll get all set up and we'll move on.  I think that's the best thing I've ever heard on a Zoom. If you're a mom, it'd be great to know who you are. Well, there's a lot of us, right? I mean, all right. So let us share.  Okay. All right. Amanda and Brianna, take it away. Well, thanks for coming back for this part. This should be fun. We'll do economics and then coding.  So quite a lot of ops and money components. Certainly ask questions in the chat or just jump right in. That's how we prefer to take questions for our section. So I'll take a slide.  Here are a couple of things we're going to talk about. Socially economic drivers, the business case for why to do this.  Many of you, as we learned yesterday, have already created a business case. As you get going on it, you want to continue to prove yourself and prove what you're working  on and that it's working. And so we have some tips in there for that. Strategies for starting, which some of you are in, are growing or joining a practice.  Sometimes when we do these two, as people grow, they also think about consolidation. And so joining it and combining with other practices. So that's always fun to talk about.  Review some core components of success and financial success. And then we're going to go into some budgeting.  And I'd love for everyone to kind of jump in on how they budget and how they think about expenses and revenue for their group. And then compare and contrast different marketing.  So I think we'll get through quite a bit of marketing today. And before we transition to the non-clinical breakout, we'll talk about what we're going to do in that space.  So I think we'll get, so everybody can hear a lot of the marketing components. So let's start out with healthcare's perfect storm.  So the founder of HCCI, Dr. Tom Cornwell, actually wrote the document here, the article, the perfect storm. And it's really worth a read.  I'm sure it went out in all of your learner packets and information. This is something you can keep going back to.  And I will tell you, I keep going back to the document because the data is still very relevant. The importance of why we do this work is still very relevant.  And what we're trying to do is continually say, why are we relevant? Which means why do we need more funding? Why do we need better support?  So by 2030, more than 20% of the population will be older than 65. Some of the things that you think you know, the silver tsunami is coming. Social security.  When social security was started, I think I said this yesterday, but there were five workers for every one retired person and people didn't live as long.  And now in 2030, there will be two workers for every one retired person. So these stats that you think everybody knows, they probably don't know. It's always good to ground in this.  The population is aging and it is outpacing any growth population under it. The baby boomers will live longer than any other generation prior to that.  I think it's the largest component of state budgets in 2015, consuming almost, I think it's over 30% now total spending. And then here's some components of quality of care, right?  Medicare hospital discharges within the 30 days, 34% were readmitted within or 20% were readmitted within 30 days and 34% were readmitted within 90 days.  So I always think about it this way, when nothing is going wrong, change and transition is super easy.  And then when something's wrong, especially in healthcare, when it's health related to your body, to your loved one, all of a sudden we feel these breaks in the system and complex  systems are solving problems for complex people. And that's really tough to get right. So as I think about geriatrics and I think about home-based medicine, I think about it  kind of like a quarterback model. If you think about pediatrics, there's a quarterback model.  This is the complexity and the unknowns with aging, the unknowns around dementia, not only  the multiple complexity of systems, but also pharmacy, living, psychosocial, family relationships, family dynamics.  So anyway, I think, go back to this article, I use it all the time as I'm trying to prove my point on value. Take another slide.  Ian Morrison wrote a book called The Second Curve and in it, his theory is the first curve is a traditional business model of how things work.  It's your kind of corporate traditional growth. And then the second curve is the future, the new technology, consumers and markets that  the companies must figure out to command and survive. So we, as we think of kind of this two curved world, I think, you know, I think and HGCI  thinks, right, that the fee for service is that first curve. And now we're entering that second curve for payment, for how we think about connecting  complex system for technology and home-based primary care addresses many of the concerns and issues that we actually have in our health care system today.  And there's, you know, the financial components that play into this of how innovative we could be from a financial standpoint.  I think we're still at the tip of the iceberg for where we're going to take this thing. And I think in the next five years, maybe 10 years, we're going to see even bigger,  more sweeping changes of things we haven't thought about or things that we can start to organize together from a financial component and a value contracting component.  Take another slide. Every good health care economics contracting discussion includes some sort of dictionary of what everything is.  So fee for service in this bucket, I'm truly counting as regular fee for service. It's going through your 1500 process.  You're doing a service, you're billing it with CPT codes, you might even be billing it with, you know, procedure codes, but true, true, true CPT codes going through here.  Your augmented fee for service, I like to think of that as things that are still widget or volume based, but they don't require necessarily a provider.  I would say chronic condition management, transitional care management, care plan oversight.  These things require interaction with health care, but they're not, and they're still widget based so that you have to do something, you physically have to initiate an activity to  get paid for those things, but they don't have to be necessarily by a billing provider. And these open up opportunities, but they're still extensions of fee for service.  Then there's something called per member per month or per enrollee per month. It depends on your state and your contract groups and how people like to talk about this,  but some general concept of we're going to pay like a care coordination, total fee contract per month.  And you don't, you then have to do a general service, but we're not checking up on you on exactly what you're doing. So you might get paid $200 a month to manage the patient.  And some of those components of managing the patient are, you do a med rec or you have an attached primary care provider, but these are things that kind of pay for just being  in your program for the additional services you're providing. And they're supposed to offset the expense of providing care for complex patients.  You might get paid fee for service and care coordination, which is absolutely possible. We get the fee for service for sure.  We do the billable visit and we get paid on top of that, you know, $100 a month. We get paid $500 a month, you know, for the whole package of what we do.  We carve out just transitional care supports after someone leaves the hospital and someone the ACO, the payer is willing to pay us, you know, again, like $150 to take care of that  patient for these additional supports. And typically as I think of care coordination, it's more paying for programming. You might have shared savings.  So we look at everything and what we've done together and we've said, did you beat benchmark? Did you beat what you, what the national average is?  Did you beat what you did last year? Did you, did we just make money on the product? And now we're going to share in that savings together.  So typically there's some methodology that whoever you're working with is saying, now we're going to, we're going to share in this and you get a piece of this component.  There's a quality bonus, so a paid for performance. You might be at risk for certain measures that are important to people. You might be at risk for 30 day readmissions.  You might be at risk for star measures, right? Did we, did we do all the things we need for breast cancer screening?  And did we keep the star measures that the health plans have high enough that we get a bonus for that? And so you're, you're actually being paid for some component of that.  I'm going to go to the last one quick. I'll do bundles, bundles of care. This, this kind of is your next iteration in which you look at one specific type of care.  Total knee replacement always gets the brunt of the examples of being bundled because it's a really specific episodic care, but you can do it with lots of other heart events.  And if you go to CMMI, you can go online and see how they look at bundled payments.  And there are lots of diagnoses that could fall under a bundle payment, but it essentially takes typically a DRG.  And it says you're going to, you're responsible for the total cost of care for the initiation of that event, the total knee all the way through their recovery and for a period after  their recovery. So you might be at risk for the 90 days after that they weren't readmitted. So, and, and you're responsible for the care.  And this is where you see, you know, care centers popping up or hotels popping up that it's a one night intensive stay in, you know, in a, in a kind of a hotel-like experience  after you get your knee replaced, because it's way cheaper if they can do, they figured out if we can do just intensive care for 24 hours and then let you go.  You also see with bundled payments, there's some disincentive for a structure in, in which they're not doing as many, like it can be hard to find an orthopod who's going to do  a total knee replacement based on some qualifications. So if you have a certain BMI, for example, you may need to lose weight to do a total  knee with some groups because they're at risk for that total cost. And they know that over a certain weight, that you have a likelihood of returning to  the hospital and they're not going to take risk on you. So I don't know if you guys have seen that in your area, but certainly that those disincentives  start, start coming into play. Then you get to things like a gain share and, or full and significant risk where you are  truly responsible for the revenue associated with that patient and then all the associated expense. And so both of these structurally work the same way.  Revenue comes into the system and it's attributed by patient and by member month, Medicare is risk adjusting their patients.  You may be risk adjusting your patients, but you'll get attributed, whether it's an assignment or attributed model. This is your patient population.  I have Mrs. Smith on it for 12 months, the entire 12 months, she had a RAF score of two. And you know, with my multiplier, she's getting $2,000 per member per month from a Medicare  standpoint to come in and then all the expense. So does she consume any DME, does she consume any pharmacy? Does she go to the hospital in my area?  Does she go to the hospital in Florida? Does she go to the hospital? Not at all. And all the expenses associated with it, and essentially works like any, like a P and L  revenue comes in, expense comes in or expense goes out. And then your net profit or loss is the number you're finally looking at.  And when we talk about, is it gain share or full risk? Now we're saying, well, what is your arrangement with whoever you're negotiating this with on that net profit or loss?  Is it gain share where if it's positive, you get 20%. If you, you know, for the her total cost of care, you're responsible for it and you don't,  you don't have any negative downside, but the positive would be, Hey, I get 20% on top of this. Well, if you're willing to take some risks, maybe they'll give you a 50, 50, or maybe  they'll give you, you know, 80, 20. So if you, and sometimes these things can include ceilings and floors, I'm willing to take risks up to a million dollars on a population.  Well, great.  You know, there, if you put a floor in place, they'll put a ceiling in place. So you can't make more than a million dollars if it's positive.  A full risk would say I'm a hundred percent at risk minus an admin fee and a care coordination fee for the patient population. And I get the dollars at the end of the day.  And if there's any dollars that I owe, if I owe $5 million back, I write a check for $5 million because I'm at risk, the total cost of care.  And there are payment structures that you can set up with lots of different groups. And we'll keep talking about those, but any, any questions for me on this?  This is like one slide that says a lot of stuff.  And while we're in there, Brianna put in the CMMI website and link. If you haven't played with that, I certainly encourage you to do it, sort by your state  and see what interesting projects are out there.  Okay.  I will take a slide.  So kind of what's the future based on value? We've talked about a couple of these things in the nonclinical track, but, you know, independence  at home, they're not taking new applicants, but it's been extended. It's certainly a program that was very successful, it was very financially successful for redirecting  dollars from high cost areas like hospitalizations and pharmacy and to lower cost spaces like outpatient and provider utilization, that will continue for some time.  So I think it has a couple more years. And then my guess is anything coming out of CMMI is going to be re-evaluated, kind of constantly, honestly.  MACRA and MIPS, this was kind of a combination of PQRS, Meaningful Use.  How do we get all of our provider systems to start thinking about risk or at least, even if  you're not kind of going in an advanced payment model direction from a MIPS standpoint, that you're at least starting to think about how I connect quality, my technology, my care  model in our work. And so MACRA is legislation and MIPS is one of the options that does include some downside if you don't participate at a minimum level.  Accountable care organization started, oh gosh, I know all the dates for when all the Medicare started, but at least 10 years ago, maybe 15 years ago.  But the idea that organizations can join together, be accountable for the total cost of care. I would say in Minnesota, almost everybody's gotten out of ACOs because some of  the models under the ACO models, under the Medicare Chair Savings Plan and NextGen were continue to improve on yourself.  And some got out of doing that because it's eventually hard to keep improving on yourself. The APMs, it was originally a track just off of MIPS or with MACRA, it kind  of created advanced payment models and MIPS, but I think they're just using the term. It's now become a much broader term here.  Some of the things you might have heard of is primary care first, the SIP population and direct contracting. And Brianna is going to have to fact check me, but I think primary  care first is like in 26 states, you can still maybe sign up if it's in your state. Yeah, so for primary care first, and I'll put the link in the chat to the specific  webpage on the Innovation Center, but there is a first cohort that's participation period just began.  If it's in your region, which it says all the region on the website, you have until May 21st to apply for cohort two, which means your participation period would start actually  in 2022, and it would be a five-year period where you're paid a capitated amount like a PMPM based on the average HCC risk score of your population plus a flat visit fee and  the opportunity for a quarterly performance-based adjustment payment. So if primary care first, just the general track, they're not taking new applications  for SIP right now, but if the general track is available in your area, that is an opportunity for you to potentially kind of explore value-based contracting.  And SIP was supposed to be, to Brianna's point, was it like a subset of primary care first that you could sign up for?  So that's been paused, that was paused, you know, prior to this last week, but the direct contracting got paused this last week.  So direct contracting continues with the 53 organizations who've already signed up for it, but you can keep, you can partner with direct contracting or DCE contract that already  exists, but you can't sign up for a new one right now.  There's also just Medicare Advantage plans and some shared savings arrangements, and some of these, especially the Medicare Advantage plans, those are coming out of Part C.  Part C is part of the legislation that's not going anywhere, it's not out of CMMI.  A subset of that is the dual eligible population, so they're called the special needs plans. There are three special needs plans.  There's the dual special needs plans, there's institutional, so dual is your eligible Medicare, Medicaid, institutional special needs plans means that you either live in a  nursing home or you live in a SNF or NIF, or you could, based on your criteria, based on your complexity, could live in a SNF or NIF, but you don't, so you can, and it's how  you define the application when you fill it out, what that looks like. So it could be you're in assisted living, you're IL, or you're either in like a  community, or you're in your own house in the community. This is how you define that. And then there's a chronic condition plan.  And all of these SNFs, D-SNF, I-SNF, C-SNF, are subsets of Medicare Advantage that say, hey, we need your own care model, and we need our own plan, because these patients are  really falling through the cracks. So anything under Medicare Advantage is going to be total cost of care.  And then you're going to have these SNFs that are going to be total cost of care, but they're going to be focused on areas, people with chronic conditions, people in nursing  homes, or could be in nursing homes, and then dual eligible patients.  Medicare Advantage plan, just to note that anybody who offers any health insurance, if you go to your county and you see what health insurance is where I live, or where my  patient lives, anybody who offers a Medicare Advantage plan, Humana, Aetna, Cigna, Blue Cross, Blue Shield, if it's a Medicare Advantage plan, the payer is at risk.  So there's money to be made, and they're making money. So if you make changes and you improve the care, if it's Medicare Advantage, they are at risk for that patient.  And they are, you know, they're putting in networks, they're putting in utilization management, they're putting in care management to manage those patients.  And you are a solution to them not putting in all that infrastructure and partnering in interesting ways.  And then managed care organizations, you know, MCOs have been around for a very long time, but anybody who's taking any sort of managed care risk, you could take.  And I mean, you could put commercial insurance in here, too. But for most of us, most people are dealing mostly with Medicare.  But anybody who's taking risk on a population would be an MCO.  Questions for me.  Okay. Chris said, will there ever be a push to have a home-based primary care EHR system to match local health systems, i.e. Epic in Minnesota?  That's an interesting question. I've always thought, okay, when we were getting our EHR, one of our owners uses Epic, and we looked at it, and it's so intensive.  Like, there was just never going to be a way we were going to do it. I think Epic does something like this. So you guys have to fact check me.  But I've always thought Epic should have, they should build a small competing EHR that ties completely to their system that they could sell, right?  Like something that would be like a Prima, a GeriMed, even an Athena, something that would be relatively low cost.  Epic is everywhere here, and nothing talks to anything. So the only thing we have is Epic is care everywhere. And so it's kind of like a picture into everybody's system.  And so we can get access to that. But from any sort of interconnectivity, we don't have that.  And unless your state has built, what are they called? Their I?  The HIE, the Health Information Exchange. Yeah, unless your state has built or maybe a large enough system has built an HIE, then  they're not like, we still are a long way to go on tech.  But to your point about like, if Epic is all your health systems and you're struggling, you can potentially get read-only access.  You know, that was kind of what Amanda was talking about, or care-only, so that you could at least, so that would be something you could look into, you know, contacting the major  hospitals that are in your area. Sometimes they will grant to, you know, practices and partners, you know, read-only access.  And that would at least make your lives a little easier with getting discharge records.  Yep, yep. That's where we've come. And that's about as far as we kind of can go. And that could take forever, depending on the system.  You need to find a champion within your system. I think Chris is agreeing with us.  OK, I'll take a slide. So, you know, in medicine, in geriatrics, almost everything you do to improve quality lowers cost. And that's a really cool spot to be.  You become a solution for everybody. And if you're not pitching yourself as a solution for literally everybody, that's your opportunity, because it truly is an enhanced quality.  You know, you're in people's homes. You have 10 things you do from a quality standpoint that you aren't quantifying or maybe  are, but could continue to quantify all of the value with that, you know, de-prescribing.  You know, Paul was talking about DME usage, right? You are putting together quality and quality of life measures for an individual that's improving their total cost of care.  And I mean, you can't, you can't do it without quality and quality of life.  You can't argue any better access than going to someone's home.  And you have this less inappropriate utilization around. And I have some slides to show you coming up here where it's like lower admissions and  readmissions rate, lower ED, lower OBS care, shortened inpatient length of stay as you're there, when you're truly managing and quarterbacking that care.  And people love it, right? And if you can quantify how people love it, if you can do even kind of a net promoter  way of being able to just capture, even if it's not a detailed survey, but just being able to capture how much patients and caregivers love it.  And, you know, we've talked about the decompression of the office-based primary care providers. This is really, I mean, this is your quadruple aim.  This is the solution for vocationally interesting work. And again, if you, as we talk about these things, you know, we're going to give you all these places to go, right.  And here's things to look at. And you're going to have to decide where I want to kind of focus, what quality measures I  want to kind of prove out, what I want to track longitudinally and who I want to tell that story to in the in the advanced course. We do more on contracting.  Where do you take that story? Who's the right people to go to? You know, how do you really hit home any negotiations? That's where I love to spend most of my time is negotiations.  So, you know, is anybody tracking data and documenting and showing their success over time for how your practice is making a big impact for your community, your system,  value that you're providing and what are you tracking and what's what's your story?  Yeah, Chris saying hospital admission decrease for ALS.  Yep, absolutely. Yeah. And I've never heard of SCALP, but I guess that's skilled care ALS. Is that right? Close.  Dementia wards. Oh yeah, memory care. Yep. Okay. We just call it memory care. Perfect. Yeah.  Well, I'll give you, we'll keep going. I'll give you some ideas on what to track, where to look. So next slide.  So this is actually,  you draw in the, press the next button here.  I think there's a picture. Yep. Okay. This is actually a patient of Brianna's old practice. I'm not sure if it was Paul or Tom's, but this is Amanda, she's 35 years old.  We cover her a little bit in the nonclinical track. These are her diagnoses and information that was tracked. Again, the start of care,  the pre home-based primary care intervention. You can see here, hospitalizations, ED visits, and how many days in hospital she was in.  Now after the start of care, and then after a year later in 2018, that she's at all zero. And this is a picture of her actually  participating in her community event and out in the world. And so I make the argument, you don't have to track all data on all patients.  Find a couple of things that are easy to track that you can actually pull in the least manual way, the least manual way, a couple of things you can pull out of your system  and make sure those are things that kind of make sense. Right? Like, I mean, hospital readmissions is probably the easiest one, but you might even be able to easily pull out,  decreasing drug cascading and reducing polypharmacy because you have maybe the start of your medications in the end. I don't know, that one I'm still working on myself,  but pull out whatever you can get from your system  and track those longitudinally across all patient populations. And then take a couple of a sample size populations like this, take one person's practice,  take one area, take a couple of people from everybody's practice and track a couple of really specific things. And those you may have to get out the piece of paper  and just kind of start jotting them down and track it for if your data point is a month or six months to start putting it down. And that just starts to tell a story,  have a couple of patient stories to tell over time.  Slide.  Then what you want to do is start mirroring this information up with the information that already exists. So our argument here is that there was quality  end of life care and that 25% of care is just in the final year of living from the Medicare dollars. And so are these data points that you can kind of track  and then you could compare your numbers to them, right? How many days at home, how many days on hospice? The number everybody tracks is how many hospital days.  This is a counter number to that. Just take 365 and subtract it. And then you have how many days at home or how many days in any location, right? Track that information.  How many people died at home? How long was someone on your service? How many people died in hospital versus at home versus a hospice house versus a SNF?  Keeping all that information, you then turn it around and it has real dollar impacts. So if you go to the next slide, these are the dollar impacts that you can be making.  This is a study done, I think it was 2012 or so published in 2014. And this is from the VA system because the VA has offered home-based primary care  for many years and they have a good infrastructure in place because they have a captive assigned patient population, which again, if you know who your patients are,  their care is really great. And you can put here the total cost of care before home-based primary care and during home-based primary care. And if you just take one number  and this is what sometimes systems will do, payers might do to you, they would say, oh, look, your home care and your outpatient utilization are higher, especially your home care.  Home care and primary care is gonna go up. Well, then they look at just that number and they think, oh, this isn't worth it. This is not worth doing this work.  You have to look at the whole picture. And this is why, if you see here, you see nursing home and hospitals severely decrease. We're talking over 50% decrease in spend  because you're shifting spend to a more appropriate, higher quality of care, better and more accessible care  in the healthcare system. And so this is when you get to come back and you get a say, and you take this data. I would take, you get your comparison data here  and pull this out and say, our average length of stay for an individual is 18 months on our service. For 18 months, we take this multiplier of $9,000 of annual savings.  We're gonna multiply that by 1.5 and that's our total savings. And then here are all the associated quality measures that come with it.  You know, you've told a story of,  let's see, what is that? $13.5,000 of savings while someone was on your care alone.  That's really a valuable story. And that's one patient's story. So I always say, you don't have to reinvent the wheel, steal from other people, get your data in order.  Would you add anything, Brianna, to this? I know some of these were your patients. Yeah, no, this was just the VA, but again, just there's a lot out here to share with stakeholders.  You know, if you're trying to gain support for your program and you're kind of struggling because they're just looking at dollars and not thinking about the return on investment,  that's where these little tidbits of stories and other respectable data sources come in handy.  Yeah, because what I hear, and it doesn't look like, I took notes on the list. It doesn't look like that many people here are associated with big health systems,  but when big health systems get in financial trouble,  COVID, you know, COVID, other things, but when there's a financial trouble, they have only eyes for the expense lines. And the thing that they go through and they start slicing out  is small programs or expense-only programs. And in this way, you know, you start to attach revenue to it because sometimes in big systems, what you have is you don't have anybody  who's appropriately assigning the revenue  to some of this total cost of care because they can't, you know, they get it as a lump sum at the highest level. And then it's very difficult to spread out.  I mean, there are whole departments at some of these systems just trying to figure out how they allocate dollars for value-based contracting to where they actually work.  You know, I have a buddy who works at Aushanar, I was talking to him a few years ago and he's like, budget month to budget month, I can have million dollar swings  for my revenue department because they don't know where to allocate my dollars. They don't know if that's my dollars or not.  So May, it's my dollars, a million dollars. And then June, somehow that gets off the budget. Now they're just looking at expense and they're starting to chop stuff out.  This starts to tell that story. So you're growing a program, you're expanding a program, you're transitioning a program. You tell the story every time.  Quality of care and lower cost.  Patrick agreed, yeah. Large health systems, certainly, certainly, certainly. And part of that is because often,  so, okay, I have two thoughts on this.  One thought is if they're not in a lot of value today and they're still really in this fee-for-service space, they fall in this, like, do you remember this horrible,  like, I don't know if it was a euphemism or whatever, this horrible saying about 10, 12 years ago where they were like, we're gonna be on a dock  and one foot's on a boat and one foot's on a dock and the boat's leaving. And I'm like, that's so ridiculous. Like the boat has left and that boat is government payers, okay?  And I think commercial payers will follow, but by and large, it's been for a long time, but it's gonna be government payers. If you don't have a big enough government payer source  and you haven't had to transition and your value-driven care is 20% of your business or in some cases where we work, 5% of your business, what do you care?  Everything looks like an expense line you can cut. And again, the bigger systems that are way into value, they struggle with how to allocate it appropriately  because we're still babies in this value world. In 20 years, well, if we're still having the same conversation, at least I'll have a job, I guess, but hopefully we're not.  That's my hope.  Chris said, we had been in talks with local health systems to help them reduce their 30-day readmissions. At one point, they wanted a reduction possible  to remove the penalty from the payer. Yes, and that's great. And be aware that they're all big health systems. And this comes into play when you're thinking about ACOs.  They're always talking out of both sides of their mouth. Part of it is they don't want the penalty, but I have had health system individuals say to me time and time again, they say,  we make more on the admissions than the penalty. So like, I really, we don't love it because it looks like our quality is going down, but it's still a lot of money to us. Slide.  So here are some core components of home-based primary care success. Cashflow and profitability. Cashflow is a lifeline of any, oh, could I have the next slide?  Cashflow is a lifeline of any business. It's the money that's coming in. You know, even my business where 80% of our revenue, not 80% of our patients are in value contracts,  but 80% of our revenue comes from value-driven contracts. 20% is fee-for-service. We still, I still look at the fee-for-service report every single month it comes out.  Where's production? Where's productivity? I don't pay people on that.  I pay people based on panel size. They're still at risk for their pay, but I'm not, but I'm looking at it because that's, that is money that I know is coming in.  My risk contracts, they pay me kind of when they want to pay me. And that's a whole nother story, I bet. So, and then the profitability is, you know,  how you manage your expense and revenue. So here are just a number of components that come into your home-based primary care success. Some of these are processes. Some of these are,  some of these are payment and revenue structures. Some are even kind of expense structures of what you put in place. And I would say, this is a great place to start  and start decompressing this list and where you are and bucketing these things and how good you are. The easiest thing you can do is take a list like this  and give yourself a scorecard. I'm red, yellow, green. I get it. I've maximized it. I'm doing great. Whoa, I got some big issues here.  I got succession planning issues and retention issues. I don't really understand what we're doing. I haven't figured a way to maximize some of these things. Whoa.  And then if someone could throw in the learner manual page  because I know there's a lot more information in your learner manual specifically around this and how to think about cashflow and profitability impact in these areas.  So it'll give you a good starting point. So I don't go too much into depth with that, but look in your learner manual for a lot more resources.  Next slide.  So what economic models work in home-based primary care? And if someone could throw the learner manual to this because this is one that you're gonna want to come back to.  It's a one-page snapshot of what models work in home-based primary care. And it's giving you six examples of organizations and how they split up their patient population  and their payer mix.  And so I think this is one where you may say,  I'm not, you know, I'm 100% fee-for-service today. How do I make it work? Understanding how much Medicaid you can take, how much risk you can take on your patient population,  these economic model, that is gonna be really cool. And here are examples of groups that do that. So I really, I hope you guys, you maybe have kind of looked ahead.  Does anybody have any questions on this? Let's see if there's any.  Thanks, Sarah, for popping in some of those. There's a green box that says, you know, where to find funding. And we talked a lot about that in the non-clinical track,  but there's a lot of local funding. And Brianna was sharing the SBA in your area will have pieces, especially if you're in an underserved population,  there's opportunity for funding. And so we have to think through different, different funding sources. And this is revenue diversification  and understanding where your revenue is coming in. And then what are your limitations? I can't accept more than 20% of Medicaid because of the payer source. And I, you know,  and you have to have that number in your head. Everybody has to have that number in their head so you don't find yourself in hot water. So if you haven't figured out your number  of what, where is my revenue diversification today? Where do I wanna see it? And what can I absolutely not do? And where could all these roads go?  You know, this is a good place to start to see what other groups are doing. Questions for me.  I'm gonna jump into budgeting, everybody's favorite topic.  You know, and for the record, I went to film school actually. So I have a film degree and I have a BA and a BS in government or, you know,  poli sci. And then I went and got a degree in healthcare administration. So I had very little training in film school on how to do anything financial. I will say that.  And we all know they don't teach that stuff in high school. So I was brand new to budgeting and all of the, everything that comes with the joys of budgeting  and P&Ls and charge of accounts or charge of accounts until graduate school. And I have just found an absolute love and passion. And I hope you all join me in that love and passion  for financials.  Oh, no chat comments, surprise. Okay, next slide. So there's no one size fits all for budgeting. There are certainly common pitfalls. We all know that the margins are super thin,  poor productivity, someone's out, misaligned staffing, someone, you know, I hired someone to do X, I really need Y, I hired someone to do Y  and turns out I actually need four people for that. It's too big, I need to scale back, right? And then there's all the rising costs,  like somehow costs continue to go up and up and up. And, you know, and I'd add in there, it continues to be technology and how we connect technology in a way that supports us.  But certainly legal, marketing, if you have any overhead. So some of the questions we ask, are you asking providers to work on top of their scope? Yesterday, Chris was nice enough  to put in the Burt and Associates links for PAs and NPs. And so you can see what is everyone's scope? What is it by state? Have you considered using the APPs?  It sounds like pretty much everybody has here, but how are you using them? Also, I would encourage you, if you're in a state where your APPs don't have independent practice,  see what is, I'm telling you, just call up the local NP trade association in your state, and they are working on some sort of legislation  to get independent practice and sign on with them. We don't do policy legislative work, but I certainly signed a number of letters for policy support and coming out and saying,  these are the things that we need. So that's really important. One thing that's always boggled my mind is that APPs can't, or nurse practitioners,  maybe all APPs, but nurse practitioners can't sign the diabetic shoes. Just unbelievable. I was one day, I was, well, these gotta be like Marty McFly shoes.  When I look at these things and I was like, this is ridiculous. You can't have a provider who sees patients constantly and totally gets geriatric care assigned  for these diabetic shoes, blew my mind. But it's a much longer list of things I don't know or don't understand than things I do understand.  And have you considered using your physicians in different ways? We talked about this for revenue yesterday, but medical directorships, other contracts, would you loan them out?  Maybe they're not fully up and running in your practice. Would you loan them out to do other things? So, lots of different options. Other options we're not thinking about,  people, your biggest expense are your providers and is people, within that is providers.  Okay.  Okay, next slide.  So here, I think this is one of those slides you just keep coming back to. Again, if there are a couple of slides to take away from operational,  I mean, obviously I'm biased, take all of the slides away, but if you're gonna really take some away, start looking at things from financial standpoint  that are impacting the bottom line and make a list of your positives and negatives. This isn't similar to SWOT, which I've said adds a lot of value, but do it for your financials.  Where are we getting, like, are we maximizing our visits? Are we maximizing our geography? Have we figured out our staffing model? Have we figured out our coding system?  This is a great way, again, just to put a chart. If you're considering a job or buying a house, you write up kind of pros and cons list,  you write up where we wanna live, what we want. This becomes just a true assessment of what you're doing, what we're good at, what we're not good at,  and it'll start to give you some opportunities for you. So I just, I really love this slide because I think it gives you an idea of where to start focusing.  All right, slide. If you think about kind of budget busters, I love that. Beware of the budget busters, but we're super pro alliteration.  So if anybody has any afternoon alliteration they would like to share, I think that's gonna really spice this thing up. So staffing, never underestimate the RNs, LPNs, and MAs,  and we talked a lot about that. Two, continue to push licensure there and how can you make things more efficient? Brianna would counter me if she were on mute,  I bet she's gonna say this. She would counter me and say, look at how many touches you have and look at who's doing those touches. So you could put an MA, an LPN, and an RN  have all different scopes. Do you need all of them for one patient? No, probably not. So then what are the number of touches and where do you wanna optimize them?  Now, physical office spaces are really, oh, sorry, I have a couple more comments on medical assistance. So prepping paperwork, triage when appropriate,  handling DME, how you start thinking about those staffing pieces are really, really fun and I think really push you. And I've always said hire for flexibility,  you're gonna change your mind. And so how do you hire someone who can kind of handle a little bit of change?  Physical office space,  it's such an interesting bullet point and everybody's probably in a different boat now that we're kind of in a virtual world, but how do you, you will have needs in the future.  You will have meeting needs, you will have training needs, you will have supply needs, you will have administrative needs, you may have office needs,  you may decide you want office needs because you don't wanna pay mileage for people and so you wanna have kind of a central hub.  You may have lots of different components, but really think about your physical office space. And like I said, these last 18 months,  we have a lot to think about of what that looks like and we probably need less than we've ever needed before. So we also need some amount of human interaction.  So it's a real balance to bring this whole thing together.  And then the EHR, everybody has EHRs. A couple of years ago, we didn't have an EHR. And so I think when I first started teaching,  we just got an EHR and I used to be so embarrassed because I just got one and I was like the last person on the planet. But it's worth the expense  as long as it is optimal and efficient and you invest time in keeping it optimal and efficient. What we all do with technology is we start something  and we always do it that way forever and ever. And so visit, go back and make sure and do a test and say, every three years, I'm gonna check in with my EHR vendor  that everything I want is everything I'm getting. And every six months, I'm gonna check in with my provider that everything I want them to be doing, they're doing  and they haven't built bad habits into that. And so we're not getting that optimal efficiency piece because you're gonna spend a lot of money on tech  and you want that to be top notch.  And I would add too, I mean, there's so much that goes on and so much that's overwhelming during EHR implementation that sometimes we develop bad habits unintentionally  because we didn't have time to look into the true method that that EHR offers. And so that's where really looking to understand, I mean, it really takes honestly years to understand  and optimize the capabilities of your EHR. So having someone working with the customer service rep and looking at workflows or asking questions of,  if something seems like it's tedious, there's probably a better way to do it.  Yep, absolutely. Well, I hear about it a little bit less, but it used to be a couple of years ago, I remember you hear about how many clicks everything takes.  I don't hear that as a measurement as much, a time has kind of replaced the clicks of it's just taking too much time, but something to think about. Megan put in here malpractice.  I don't know if I have a tip or a trick to manage malpractice expense. I don't know.  We made the mistake that we set our caps too high  and did not realize that we could have gone much lower, which would have been a reasonable choice actually. We got talked into a much higher policy  and the policy was based upon each patient. And it was coming in at about 35 to $40 a patient is what we were paying. It was outrageous. But so that's something you,  it's easy to fall victim to thinking that that's what you're supposed to pay because that's what they tell you, but really make sure to look around and talk to others in the market.  That's great advice.  Thank you.  Oh, okay. So, company vehicle mishaps. You know, so what a company owns as their property  and then what an employee owns, that is a real challenge that really takes writing again,  kind of that pros and cons list of what you want to own and how much you want to manage of those pieces. So I have to tell you, we have never owned a company vehicle.  Maybe others who have owned their own company vehicle have some key tips of that, but that has been something that feels like too big for me.  Go ahead.  Well, Chris, we'll keep on the company vehicle if anybody has any tips and kind of need to circle back with you on that. So, and then curious what others pay an MA for our hourly and if it has been challenging in COVID times to find people.  Anybody want to weigh in.  I know I may as are always, you know, hard to in demand and hard to find I mean I know even the large health system I was that we were always talking about the ma shortage, you know, and and what we can do and quality ma is, let alone, you know, finding  the right person.  And I know we talked a couple Chris about some of the mishaps and stories that we had nightmares with company cars like I didn't think I'd be filing accident claims and researching, you know, those kinds of things in a medical practice but there's a practice in Chicago  that's actually looking into an electric car because of the tax write off available was the only thing that I was thinking of. So you know getting creative with that.  And there's usually surveys Julianne through the I could try and find the link for it but the the medical assistants have like their own association type society and I know I've seen some salary surveys and of course obviously doing some market research for your area  as well.  I know a lot of colleges that have ma programs, or, you know, hope sniffs home health and hospice I know a lot of people that are getting out of, you know, especially if there's an acquisition going on in a certain health system or things there's probably  a maze that want to jump ship and are looking for work.  I would say from a salary standpoint is, you know, you know, go online and figure it out and I think that the, the idea of calling a local school on what the averages, you know, and the highs and lows that people get paid.  I think a lot of schools are going to track through surveys, what people are getting paid because they're going to post that, and they're going to use that internally for recruitment.  So, because I would tell you are Patrick put in here 13 to $16 an hour and ours is higher than that. But it's it's market dependent, for sure.  Okay, I'm going to, I'm going to. Oh wait, I think I have one more slide coming up here.  So, you know, as we think about productivity, it again it completely matters you know I guess you know of all the titled slides that we have, you know, you know completely, but review that budget and the FTA ratios against productivity cluster, the geography  if you're just starting out clarify your geography, try not to make too many exceptions about your geography, and then figure out who's going to continue to help everybody work at that top of licensure component.  So that's where you can really have staff that costs less relieve that burden and review with each provider and educate them on worker, or on your RV use, you know, what are people billing.  What did they review, the more we add and we say we want you to collect this or we want you to do this, it gets overwhelming but can we simplify and focus for a couple of key things, a lot of the work they're doing is face to face.  It might be virtual, and it's long. So there are a lot of codes that can help maximize those pieces which Brianna will go into so I don't have to do too much discussing of that.  And then I always say under this one is the provider compensation plan incentivizes what you want to incentivize how you pay people is how they're going to act.  So, think about where you want to spend your time, and you can push fee for service really hard you could push quality really hard you can push combos of those things.  Paul talked a little bit about that yesterday but whatever you however you set up your compensation compensation model is going to be how they act, and it's going to be hard to move off of in the future.  So, put a lot of thought into the setups of what that's going to look like and if if in the interim you're not ready to take the big leap into a compensation model that has incentives in it.  You know, start with start with a salary model that gives some bonuses for what you're looking for that will probably be the things that you grow into.  Yeah, and I know Amanda and I were talking about you know creative ways to think about payment structures and incentives you know health systems are historic for being RVU based but that's you know not generally always the best way, but to Amanda's  point about incentive incentives if you're asking them to do extra documentation and really be good stewards and bill for advanced care planning and prolonged services and chronic care management and document their time and do all of those things.  They're generally going to feel like they get something you know reward in return they're generally going to be more willing to do those kinds of activities and and have, you know, kind of a say and things like that so you know thinking about what  you can do to get buy in from your team. And, you know, especially if they're contractors but if you are going to pay a per diem my only other caveat is really make sure you understand the allowed amount, because what's billed to the insurance, or, you  know, what's the fee schedules and understand you know the, the allowed amount of the fee schedule and show them what you're actually getting paid so they understand, you know, their percentage why it is what it is between the overhead  and whatever percent that is that you may be paying them.  Okay, Brianna, your next slide. Yeah, we can go to the next slide. We wanted to make sure in the larger group, I know some of this is a little repetitive yesterday,  but, and I'd love for everyone to share in the chat, like how many patients are you seeing on average per day? So the things we have to think about  from a practice management standpoint are, what does my territory look like, right? Like, again, if you're in a really country area, you have a lot of travel,  or even in the city where there's a lot of traffic, I even know someone in San Francisco that was playing around with like an Uber model  because the traffic was so terrible and things like that. But all of those things go into account. The type of visit, you know, sometimes new patients  or transitional care management count as two.  You know, are you considering, you know, especially if you're a provider that's seeing a lot of new patients, are you considering if they have an assistant or a scribe?  Generally, if they do have a scribe or an assistant that financially they should see two more patients per day, you know, thinking about that. And maybe it's not a visit per day,  maybe it's more a goal per week. I know a lot of independent practices that really appreciate that flexibility of maybe they have one lighter day  so they can catch up on documentation and other things. And then a couple, you know, the other longer days or their facility days,  definitely if you're seeing patients in one central place, you should be having higher productivity on those days. So this is what we've seen just by collecting,  you know, and talking with practices nationally. There's no gold standard, but I can tell you, you know, it's a high performing, a good productivity, closer to eight to 10,  more if you're going to one place, if you have a lot in assisted living or even just two group homes. Group homes generally tend to be clustered together.  So especially if you're, you know, providing foster care and things like that in one place.  We can go to the next slide.  Yeah, and thank you for sharing in the chat. I think, you know, your peers just really appreciate that.  So thinking about kind of revenue, and Amanda talked a little bit about this, so I'm not gonna go too into deep, but I know there were some people  that shared other ways that they get revenue. Like I loved the idea of doing the physicals for your assisted living facilities. I've heard that a lot. Doing annual wellness visits.  Amanda talked about opportunities with Medicare Advantage plans. They want good annual wellness visits so they can get their HCC scores captured for their patients  and they can be paid more for their members that they care for. I know a lot of MA plans that will contract that out rather than having like Optum  is big on employing their own nurse practitioner as part of UnitedHealthcare to do those home annual wellness visits. But have you thought about that angle? Or mobility exams?  Your headaches, I'm glad that you take that on. Doing those mobility exams for patients and things like that. But what other services can you kind of partner with agencies to offer?  Especially community services that are maybe looking for more medical partners and things like that. And then really understand what you're getting paid.  Unfortunately, from time to time I'll hear horror stories of this particular payer is just decreasing our revenue every year. They're denying things they used to not deny.  You need to make a decision, is that really worth, how many patients do you have with that plan? And is it really worth it? And can my practice be sustainable  if I'm doing those kinds of things? And to Amanda's point, unfortunately Medicaid, if they're not eligible and you are taking a lot of traditional Medicaid patients,  can you get at least some Medicaid or some managed care contracts in there? Because we all know what Medicaid reimbursement comes out to be.  And I would add to that, certainly also check all your contracts on a pretty regular basis that they're being paid what they say they're gonna pay. That happens to us too,  is someone starts paying under that amount for whatever tech reason occurs. And all of a sudden we figure out we're not being paid what they said we were gonna be paid.  And sometimes it's because, and you have to review your charge master every year to make sure that it lines up with at least what Medicare is gonna pay.  Because many of your contracts, as you know, will say, we'll pay you what you charge us or what Medicare or what Medicare Plus, whatever points you're doing on top of that.  And if Medicare outpaces what you actually charge and you haven't changed your charge master, they'll pay under that amount. So you just wanna keep up to date  on your whole 1500 system.  And the comment about the city division on aging, we talked yesterday about staffing models and community kind of creative ways you can use staff.  So that would be, do they have social workers or people that you can use, or do they have pilot programs? There's a lot of, maybe not your division on aging,  but even like a counseling agency, there's things like behavioral health integration, care management, that's reimbursable. Can you partner with someone  like a behavioral health partner or somewhere where you have a social worker where you're kind of doing pilots like that, that there may be some revenue opportunity  for you in the end. So that would be another one. Next slide, please.  So again, in the advanced course, we're gonna go into more detail, but what I will say over and over again, you have to be billing some service,  care management service to get reimbursed for the non face-to-face code. And you have to be thinking about all of the work that you're doing and making sure  that you're appropriately being reimbursed. I'll highlight TCM because we haven't talked too much about that yet. Transitional care management for Medicare purposes,  they have increased the payment by 30% in the past two years. They continue to incentivize and increase the payment for TCM services. A lot of people also don't realize  they've unbundled TCM with virtually every care management service. You used to not be able to bill TCM and chronic care management for the same patient within the same month.  For Medicare purposes, now you can. And Medicare Advantage plan should follow depending on your payer. Here or there, technically CPT is still listed as bundled.  So the commercial payers might not be on board, but it is very clear. I will give you the citations. They have unbundled TCM with Prolonged Services Care Plan Oversight.  Those other care management services are still bundled together, but Medicare is recognizing the value. They believe their TCM framework reduces readmissions  and gets patients better care out of the hospital. And so they continue to incentivize it. So if you're not formally billing TCM, I know a lot of practices that weren't originally  because the 99350, the high level home code paid more, it doesn't now, TCM pays more. So go back and revisit that. Definitely be a consideration.  Next slide, please.  And before we go into budgets too, the other thing, I know a lot of people were asking about like research and grants. I mean, do your research. Foundations love to give to people  that provide direct medical care. And so see what's available in your area, especially if you're in an urban area like I mentioned yesterday.  And I know, I don't know, Laura, if you want to share the other comment I forgot to make earlier about ACOs. That's a great partnership to explore  if you're just for the learning purposes too, because you could potentially receive shared savings  because again, the ACO and not you individually is at risk for those lives. But they also have a much larger infrastructure. And that's kind of, if you're not big  on quality improvement or analytics, a lot of times they can give you the data that you're not able to have access to on your own.  And then there's financial potential reward as well. But Laura, I'd love from your perspective if you have anything to share on why a practice might work with an ACO.  So I think it would be a really great referral source for home-based primary care. I think about from, if I were sitting at my desk  in the ACO today, why would I want to partner with home-based primary care? You know, ACOs have patients that they just literally do not know what to do with,  yet they're attributed to them because the bulk of their primary care services are coming under the ACO's umbrella.  And yet the teams just feel hopeless to prevent those readmissions, prevent that expense of care using the resources that they have. But what would likely then happen  is the ACO would offload those patients into the home-based primary care model. And over time, then the attribution would be then attributed to home-based primary care  rather than to the ACO. So just sort of shifting those patients, I think appropriately, to another agency where they could get the care that they need.  Certain types of ACOs have then that ability to generate partnerships where savings  can then be shared with those preferred partners. We never got to that point with the ACOs that I was working with in terms of that piece.  So I just think of it initially as a referral source. And I know that Carolina Caring is currently working with an ACO to generate referrals  to its palliative care and hospice program. And I think this additional offering we have will just further demonstrate our value to them, especially if we say that we will continue  to send those patients to their specialists if they need specialty care.  That's great. Thank you for sharing. I'll pass it back to you, Amanda. Great slide.  Here's a chart here. The next two slides are charts of accounts that you can think about. And so as you create your chart of accounts or as you want to get,  or you want to expand your chart of accounts, the level of specificity you build in your chart of accounts is the level of specificity you'll have  when reviewing any changes or opportunities. And so I always encourage people to start really specific. In almost all systems, you can roll up into things,  but start really specific. I want to know how, and you can see these account numbers of the revenue side, how many are coming from each program. I want to know how many are coming  from each service line. I really want to know, I'm not going to put all purchase services in one bucket. I'm going to take purchase services and I'm going to say,  how many am I sending on outside interpreter? How much am I spending on legal marketing? I have a couple of marketing locations. Great. I have a print and I have a web.  Let's split those out. So the specificity you get with your chart of accounts will give you eyes on when there's a problem and how you can make changes.  Well, no, let's keep going. Yep. I'll take another slide. So this is a secondary chart of accounts. These are all just ideas of where, of what to start categorizing.  Slide.  Here is a sample productivity sheet. So Brianna uses this in her practice, the blue, the kind of,  you know, middle of the road blue here are the cells that are highlighted are ones where the visit expectation was higher because they had scribes with them.  And so you can see all of your different providers and by weeks you want to, you know, if you have a schedule, you match that schedule to what actually happened.  You want to make sure people are closing their charts. So you have accurate projections of that. You keep a log of how, how quickly people are closing their charts.  And so this is just an example of, again, something that's going to be rolling up for your productivity piece, but certainly a dashboard. My guess is pretty much everybody has this,  you know, treat this like a budget. You set the, you set the budget, you go back and you compare to budget, figure out what's going, what's going on. So take another slide.  This is a sample P&L. So technically this is a pro forma profit and loss statement. You're going to see expectations of growth at the top  by patients, patient census, and then your total patients. And then you're going to see your revenue and all of your expenses come into this. As you think about a pro forma,  so your year to year opportunities and what that looks like, you know, certainly go back to that as you build out your P&L, your chart of accounts will create your P&L.  Think about building it out also by service line. So once you get your chart of accounts, can you then split it out and say, you know,  I want to track my fee for service revenue by geography,  by service line, like how many of it is in my AL, how much is coming out of my home-based practice, how much of it is by geography.  And again, go through the exercise of distributing. Even if you do it, whether it's in your financial system or if you're just doing an Excel,  go through the exercise at least once a year, I think more than once a year, but at least once a year, you know, maybe quarterly, by service line, by geography,  however you want to kind of split by team, however you want to split that up to see in dollars, not just the productivity, but how successful people are being on their own P&L  or in their own geography and what that looks like. For us, we are working diligently to expand a service line P&L. So I want to know by service line  what all of those numbers look like.  Do other people do that?  Do people break it out by service line, geography, teams at the P&L level, or are they just doing it for productivity?  Well, something to think about for sure, right?  Take the next slide, Brianna.  So, yeah, so thinking about kind of standards and what those are gonna look like for you, but really trying to understand your total cost of care  too for your patients and all of the services that you provide is an important number to try and get a handle on, especially if you're gonna consider these payment models,  before you sign the participation agreement, especially if it's just the primary care first general check you need to understand how, what average risks here with that PM, PM  and the flat visit fee based on what you're currently getting paid per patient on an average visit and an average month over time. So really trying to understand that.  And I don't know if any faculty or anyone wants to share kind of their payer percentage and breakdown in the chat for others to kind of take a look at and just be curious about,  generally we have a high Medicare population, but again, especially if you're working with MA plans, everything is negotiable and there's tons of these Medicare Advantage plans  and other insurance payers, Humana and UnitedHealthcare, although Humana can be very difficult to work with, I realize that are pouring money into community-based services  and they would much rather not reinvent the wheel and partner with someone than hire  and try and do all of these things by themselves.  So definitely think about that and think about what kind of extra services you're providing. I know a lot of practices actually, again, pros and cons, but during COVID,  because they were providing so much extra ancillary testing and COVID testing and swabs and things like that, that they were able to kind of really maximize some revenue that way  and other things that you might be doing that also play a role in that. Next slide.  So this graph, and it's available in your workbook if it's a little hard to see here too, but this is based on 2017 claims data that HGCI had access to that looked at everybody  that build home and domiciliary services. And then I just looked at the percent of each, what level of service. So you should have an internal auditing program.  You need to, for a compliance plan, at least once a year, be doing some sort of internal auditing and monitoring. What you wanna be doing when you look at something like this  is looking for outlier trends. Is there anything that jumps out or even within your own practice between your providers? If provider A is constantly billing a lot more level twos  than the other providers who are billing threes and fours, well, someone's probably downcoding and that's an education opportunity and that's money on the table.  So those are the kinds of things that you wanna be thinking about when you're looking at this. I actually think the level twos are a little bit low.  Generally, we know that the 99349 or the 99336 is usually the most common code that most providers are using. But again, that's gonna come down to the encounter level  and the medical necessity. Because medical necessity, which we'll talk more about in the coding talk is always gonna be the overarching criteria for payment.  So if you are billing a lot of, like you have one provider that's just always billing at the highest level of service, well, are their patients always that sick?  Because if I look at your assessment and plan and I don't see a whole lot of management going on or just based on the lack of documentation, I can't see how sick that patient is  and everything that you're doing, that's never gonna stand up in an audit. So you really do need to understand, whether it's a bell curve report or some sort of thing,  what your provider billing trends look like and how that compares to your peers.  And sometimes there's these things, if you ever get a CBR report, a comparative billing report, that would give me concern that you may be a potential target of an audit.  They try and frame that like it's friendly, but they're noticing a trend that you stand out of and then they're giving you data to respond to that.  So other ways that you can look at things,  somebody in your practice should know what's on the OIG work plan. Those are things they're gonna conduct nationwide audits on. I will tell you, unfortunately right now,  Medicare telehealth services is on that list. So I would go back and look at that HCCI worksheet. They're trying to evaluate the effectiveness in telehealth  if Medicare is gonna continue to pay for it. So they really are trying to do it for research purposes, but are you only billing E&M codes for video visits? Are your phone call,  just pure phone call visits being billed correctly? There's another annual audit report that comes out called the CERT, the Comprehensive Error Rate Testing.  I just control search when I get that for any house call codes and see if there's anything on there that we're billing for that should be a concern. That would be another thing.  But those are things that are kind of CMS and OIG is keeping an eye on for Medicare fraud and prevention and things that you can expect audits on.  Also the TPE, the Target, Probe and Educate program, which actually just took back off. Audits were on hold because of the pandemic.  I'm afraid they're gonna come back with a vengeance. So if you're not doing some internal auditing and monitoring to make sure that you're in compliance,  now would be the time to do those kinds of activities.  Next slide.  So other kind of key decisions, I think thinking about your structure, your staffing, your target population,  what's your growth in volumes. We'll talk a little bit about marketing. What's your overall operational expense? Where can you leverage other resources and technology  to avoid travel times and frequent in-person visits?  Amanda, I don't know if you have anything to add.  No, I would say just on the financial piece, again, sometimes we just receive the financials as they are, but there's just as much kind of PDSA work that you need to do around  setting up your financial structure, setting up your budgeting, checking in on those components, making sure your chart of accounts feels good,  making sure your payables and your receivables from a non-1500 process are in working order. There's a lot to, you may have banking relationships, loan relationships,  there's a lot to maintain on that side. And sometimes it's, oh, here's the report that I'm getting. And I look at the financials and I only look at kind of net profit or loss  that you can really play with there. And have a really active role and just dig so deep into what's going on. And it's easier when you're smaller to know everything.  It's you're trying to build systems for growth. So as you grow, you don't know everything. And so how do you have reporting that gets you every piece of information you need  from a financial infrastructure standpoint?  Yeah, and I'm sorry, I just noticed a comment in the chat from Megan too about looking at local trends by specialty. Sometimes there is data by internal medicine,  family medicine and things like that. I do find it helpful. Again, you just have to make sure you're looking at the actual codes.  It's difficult when you look at like even the 2017 claims data, how many of those people are really doing home-based care all the time  or are there kind of one-offs that are doing it and may not have the same kind of coding and documentation patterns, excuse me,  that a true home-based primary care provider is gonna have. But yes, definitely by specialty. If you're standing out as an outlier, you just need to make sure  that what you're doing can be supported by documentation, but you can't do that without looking at threes and fours versus fives. Yeah, absolutely. But just keep in mind,  it's a completely different ballgame for the office. So if you're looking at like their threes and fours in the office, I don't think that's actually a great comparison  because actually for the established patient house calls, which we'll get into in the billing, level four is your highest level of service. That is their level five.  And the MDM and all of that don't really totally match up. So it's really not an even crossover to office visit coding. It's just different in the home and the domiciliary setting.  And your patients are sicker than generally the patients that are coming in the office. So I would expect coding to be higher  for a home-based practice than I would an office clinic. So you also shouldn't be concerned if you're seeing a lot of fours, you just need to make sure  that your providers actually truly understand what that documentation needs to look like and that there's someone doing some internal monitoring  and auditing to make sure that that's supported.  Next slide.  All right, so we are gonna talk a little bit about marketing and then we'll break for lunch and then we'll talk about kind of the options for putting it all together at one point.  We're gonna talk a little bit about it now. There'll be an optional breakout practice management to go more in depth, but we also don't have to do that.  If you feel like these gets your questions answered, maybe we stay all together or we break off and just do Q&A. So just let's see how it goes,  but let's talk a little bit about marketing now. Next slide, please.  So where do you even find your patients? So these are just some common ones up here. And I heard this yesterday from people too, home health and hospice agencies.  Yes, generally those are one of your biggest referral sources.  If you do do a lot of community work though, are you looking for new construction? Are you thinking about what other communities and not just formal assisted living and group homes,  but just independent living? Where are these patients centrally located who need your care?  Laura said she would add ACOs and health plans. Yes, absolutely. Health plans, referring patients is another great referral source. And have you gotten creative  about even being on any boards? Parkinson's associations or local senior services, things like that, a way that they need to know that you have a home-based primary care program  and that you can be a solution to patients that are without care. And again, I know we have a lot of independent practices here, but I would encourage you to make relationships  with the ER discharge planners and people in the emergency room or hospital care coordination teams because they know who their frequent flyers are.  And again, especially if the health system doesn't have a home-based practice, they're looking for that kind of solution. And the skilled nursing facilities thinking  about where those patients are gonna go or would you be willing to go to the SNF or take on a medical directorship for extra revenue? Laura, you look like you were gonna jump in.  Yeah, I was just thinking about the piece about the bundle payment component.  So when orthopedic surgery practices are mandated to participate in total joint bundle payment,  they have a lot of gaps in terms of what they are capable of doing in the pre-op and the post-op space, right? You have sick patients who are coming in  for their total joints and the orthopedic surgeon really just wants to focus on the surgery. So I actually think that that's another potential  referral source is those groups of orthopedic surgeons that are doing bundle payments and they kind of wanna wash their hands of a lot of the challenges that don't just involve  that knee joint or that hip joint. And so I think that that's another potential is to say, hey, listen, we can go out to the house, we can do a pre-op physical,  we can keep track of your patient and make sure that they're really fit to be coming in and having that surgery done on their scheduled elective date.  And then post-operatively, you can call us  when that patient is ill and having some sort of a post-operative complication that can be managed at home because we'll help you keep those patients out of the emergency room  so you're not paying for that care of your bundle. I think it's such a good point and that's why I love and sometimes I'll just peruse the CMMI website  because you can go by state and look like what's happening in my area outside of Medicare Advantage. We talked about Medicare Advantage,  you know about the ACOs, but you can go by state and say, who's taking risk on what? And some of this is just trying to even figure out who do I talk to, right?  The orthopods are a great example. You might have cardiac groups that have complex patients, homebound patients, ALF patients who are just too much and you can be a solution.  And you can be a solution, again, that they haven't even thought of yet just because of your expertise in complexity and especially in geriatrics, you know?  So I wholeheartedly agree, you know, patients now these days can come from anywhere and we're just trying to figure out, like a lot of these components is figuring out  where there are holes, where's the gaps in the assessment and where I wanna be that I need to be because no one else is doing that right now. There is a lot out there.  Yeah, absolutely. And the community PCP angle too, you know, again, the office-based practices that aren't doing home visits  and don't have any interest to, you know, thinking about the patients that they haven't seen in over a year, but are still at risk for refilling meds  or, you know, really sometimes there's some sensitivity around you don't wanna seem like you're stealing patients, which of course you don't,  but it's the way that you approach the conversation. And if you have the existing relationships, like, look, I only wanna take care of the sickest of the sick patients  that aren't getting the care they need. They can't come to the clinic. You know, how could I be a partner to you and what kind of relationships?  And the comment here about speaking opportunities, that's really more thinking about, you know, grand rounds or presenting to a local community event.  If we weren't in the middle of a public health emergency, I think especially the private duty caregiving agencies are really great with networking events  and always, you know, need kind of places to send referrals and things like that. So just being creative about opportunities where you might kind of find patients from.  And Chris had brought up a good point or a question in the chat too about,  do you market yourself as ability to do controlled meds or do you do it on a case-by-case analysis? And I'd definitely be interested in others.  I think, you know, you wouldn't wanna, unless that was your model, you'd probably wanna be careful not to kind of promote yourself as a pain management,  you know, solution where you're getting all of those, you know, especially in the opioid pandemic that we're in as well. But so thinking about how you're gonna approach  and are you gonna screen for that on intake? You know, if you're getting a lot of those patients that are coming to you just for opioids, you know,  are they really the right patients to take care of? But I'd encourage other thoughts on that question.  Next slide.  Amanda, were you gonna say something? You looked like you were thinking about it. I was thinking about typing something, but I stopped it. Thank you for asking.  So just other kinds of agencies, you know, again, adult productive services, Meals on Wheels, anyone that provides care in the community.  I don't know if any of you go to adult daycare services. I know practices that will see patients in adult day programs and offer services that way. That's kind of another one.  But again, relationships, relationships, relationships. Who needs to know about the services that you provide and who also serves a vulnerable population  that you should network with?  Next slide.  These next few slides are just some examples on some branding, and I would just encourage you to think about how you're coming off externally. Yes, am I saying that, you know,  your 94-year-old dementia patient is gonna be on the website? No, but their caregiver might, and their POA will be. And I mentioned yesterday about the term house calls  being a lot more broadly understood than home-based primary care. I hope that we get to a place where home-based primary care is more largely understood someday.  But also, I mean, I will say even some programs that, you know, I've worked with, sometimes I go to their website, and it takes me a while to really confirm  they're doing home-based care. How easy is it to use? How front and central are you saying, this is what we do, and this is how to contact me?  And, you know, here's the types of practices in different organizations, even if they're not patients that we work with, and this is why.  And then, you know, if you have any testimonials or data or outcomes that you can throw in there, great.  Next slide.  So just another example, again, thinking about what you're gonna call out, you know, about, especially if you do a lot of memory care or, you know, wound care is something  that could set you apart. You know, do you have any trained wound care specialists on your teams, especially when we know  how big of an issue that is for the population that we serve? You know, do you do immunizations at home or annual wellness visits, you know, TCM visits, all of those things?  A lot of times people just don't understand what kind of services are actually being provided in the home, so how are you gonna make sure  that that's, you know, not even just on your website, but, you know, do you have collateral? You know, do you have brochures and, you know, panel cards  and things that you can give to your patients with your team and explaining, especially to new patients that are kind of coming into your practice about what you do,  because they can also talk to other relatives and people that need care.  Next slide.  So how do you think about partnership?  Yeah, and offering labs and radiology at home is a plus. And even if you don't offer it, you coordinate it, right? I mean, generally you should have a mobile lab  and a mobile diagnostic partner, so calling that out to patients is still, you know, a benefit.  But how do you think about approaching a partnership conversation? It's kind of like being prepared to a job interview or something like that, right?  Like, are you in a succinct and clear way gonna be able to say, this is the mission goals and outcomes of my program. Here's specifically the patients that I serve.  Here's who would be eligible for my program. And here's why this is a benefit. And then give them flexibility. You can call us, you can send an electronic referral.  You can, like, how are they gonna send referrals to you? And then what do you need from them? Because again, in return, and I hear this mostly with assisted livings where it's like,  well, we don't have pull, you know, we're kind of at their mercy, but you are providing a great service and they need quality care. So if you kind of have those conversations of,  okay, here's our new patient packet, you know, we need this for new admissions. You know, we'll call you a couple of days advance, please try and give us a heads up  or help us get this information from the family. If there's a new admit you want us to see, you know, we expect, you know, the MAR  and the recent way to be faxed to us ahead of time, we'll ask you for that, but those kinds of things. But then, you know, how can you be a partner to them also?  I think I know a lot of practices during COVID that really helped their assisted livings develop their protocols and do a lot to support their communities.  And that's being a good partner that makes them wanna work with you, especially if they open up other facilities in the area.  Other thoughts?  All right. So staying connected, again, I think we've emphasized relationships and I think this is, you know, outside of marketing, just in general,  I mean, relationships with your patients, your caregivers, you know, anyone that you work with, but especially your major kind of partners, your major facilities,  your major home health and hospice agencies, are you meeting with them at least quarterly? You know, are you talking about your patients? Are you asking them what you can do better  or what's going good and what's not going so great? Sharing ideas, you know, making sure that they also have some marketing tools so that they can provide that to people  or know how to, you know, get to your website easily and can share that.  Again, you know, I'm sure Megan would agree with your experience, you know, the relationship with discharge planners and care coordinators and social workers at hospitals and ER,  you know, kind of a different way to think about that. There's a lot of predictive analytic companies out there and a lot of population health data  that you can get about what areas, you know, especially from health plans, to Laura's point, if they were gonna be a referral source, they know which patients are costing them money  and have fragmented care. And there's also a lot of, you know, different ways that you can try and proactively target patient populations if you wanted to, you know, go that route.  All right, Megan was just agreeing with me. Next slide.  So if you're gonna push for growth too, I mean, the other thing, we're talking about some marketing strategies, but you have to be ready for the growth, right?  I mean, do you understand how good you currently are doing, right, before you're taking on new patients? I mean, are your patient panels, we talked yesterday,  are your patient panels full or can your providers take new patients on or do you need to hire? Also, when you're trying to evaluate your partnerships,  you're not gonna be able to do that unless you know where your referrals come from. So if you don't have some sort of referral tracker or way to kind of evaluate  how many referrals are coming from where, that might be something that you consider. You always have to be thinking about growth because these patients are elderly  and you're gonna have a lot of turnover, right? There's generally some of the average lengths of stay that I see are usually like 1.5 years or it's not a super long length of time.  So you may be like full now, but if you're not consistently, if you don't know how many new patients per month you're getting in and you're not consistently growing,  then you're gonna eventually be in trouble because there is a lot of turnover just with the nature of geriatrics and the population that you care for. And then also making sure,  again, you have the right partners. Your patients need a lot of help and a lot of services. How are you gonna be able to provide the best care possible  and connect them with the other resources outside of your practice that they need? And then again, just really understanding your outcomes  and what's gonna make your practice successful or what are other things that you need to do? What's not going great? Like you have a wait list,  you need to do something about that if that gets really long, or you wanna see patients within 48 hours after discharge, but that's not possible right now.  Maybe you need to look at your scheduling process and your availability and figure out how to accommodate for those.  Other thoughts or questions?  Yes, and we are almost done. I am not cutting anybody off of lunch short. I promise you that. Let's see.  Megan said, often the assisted living facilities, retirement condos will have a health fair for their residents. Having a booth at those for the morning  was a low yield from the residents, but a high yield from other health vendors. Yeah.  We just did one where now kind of post-COVID, people are in, at least in buildings. I think Chris is popping up with an activities night. They were doing a wine tasting  and we bought the cheese platter. And then our, I think we bought the cheese platter and maybe the wine or something, but then our physician was the bartender  and we gained a couple of patients.  I mean, it's kind of just like your normal life. Like you value relationships, you value connection, you value making those kinds of, especially, and that's why I'm saying,  be friendly with your DME vendors. You never know, and anyone that you work with and make sure, everyone on your team, I think we talked a little bit about this yesterday,  and I know Dr. Chang was talking about that elevator speech, but does every person on your team actually understand how to talk about your services?  And you never know where that conversation might lead.  So this is kind of key takeaways just for Amanda's section, kind of as a whole, but obviously there's a lot of factors in healthcare.  Saying that I always love is the only thing that's constant in healthcare is change. So I think now is the tipping point for home-based primary care.  I know Dr. Cornwall, our founder, was saying that a few years ago, and he's like, but now really is. I mean, this is a really exciting time for healthcare. There is a lot of focus.  One pro from the public health emergency on how valuable community-based services and home-based models of care are. So don't miss out on the opportunities right now.  And regardless of your business model, making sure that you document and understand your value and impact. We've shared a lot of metrics with you. I'm not saying to do everything,  but pick a couple and rotate every year. You need to be able to demonstrate the value of the model of care that you provide. And understanding it's okay that your staffing model  might look a little different from the person next to you because there's no one size fits all, but are you making educated decisions  and looking at your budget and your productivity not to sacrifice quality, but to be sustainable and be able to eventually maybe add a nurse care manager or more services on.  What kind of things can you be doing? And again, really, I would encourage you to look at the CMMI website because we are moving towards value-based care  and you wanna be at least preparing for that infrastructure now, or thinking about how you can maybe dip your toe in and some opportunities so you're not left behind  when hopefully, Amanda and I could take bets on when this might actually happen,  but hopefully one day we'll be there and it might be those practices that are just living in fee-for-service, service-driven revenue and mindsets are gonna be kind of left behind.  And then market from day one, especially if you're in a new program. I know I said that yesterday, but you can't market soon enough because especially for new programs,  ramp up is generally very slow. I know a lot of providers like to be hesitant because they're not ready, they don't wanna take the patients on yet, but it is generally very slow  unless you've been an established or if you're a big organization that has a great reputation or you got a contract with the health plan  where you're taking on a bunch of lives at once, maybe that's a little different for you, but otherwise think about marketing as soon as you can.  Any other closing thoughts or questions before lunch? Oh, and please, we love reading your learning plans. It's really, really helpful and valuable feedback to us  and also kind of gives us ideas for how we do next time and other things of resources we might have that we could follow up and provide to you. We have an amazing team at HCCI  that you guys may be hearing, if you hear from Betsy or Rachel, they're phenomenal resources and just making sure that your practice is successful  and you know about the new resources that HCCI may be able to provide to you.  And then I was just typing in the chat,  but I'm just going to say it. Some lunch homework. Think about all the sessions that Brianna and I have done. And if you have any other questions or detail that you want,  and we can break out at that 150 non-clinical track if we want to keep going. We do have some more slides on marketing or any other questions you might have.  And if maybe when we get back or even after coding billing, I know staff will tell us when they want it, but just have a, hey, let's all stay together  or, hey, I was part of the non-clinical or I want a little bit more of the non-clinical track. So we just have so many cool options and it's whatever's value add to you guys.  So that's a lunch homework.  Okay, well, thank you all so much. So Janine, you're going to have to help keep me,  keep me telling the truth here, but we are going to break for lunch. Janine will tell you when you need to come back and we will start with an all attendee session  on billing and coding. And then if you could, when, you know, think about it over lunch and then put in the chat whether at 150, if you, 150 Central,  if you want to go into a non-clinical, a little more on marketing and branding and a Q&A or stay with us for the simulated house calls in the clinical space.  All right, Janine, when should they be back?  45 minutes. So that will be roughly 12.50 Central time.  Perfect. All right, thank you all so much. You can stay connected to the Zoom, just turn off your microphone and your video. Thanks.  Hello, everyone. We're going to reconvene in about three minutes for session 10, which will be coding and billing. See you soon.  Bye.  Bye bye.  Okay, Brianna, let me know when you're ready and we'll start advancing slides.  All right. Thank you, Janine. Welcome back, everyone. Hopefully you got up and stretched your legs and were able to take a little zoom break as we continue our day two afternoon.  I promise to make this coding talk as animated and interesting as any coding talk can be. Hopefully you'll have to let me know how I do in that respect.  But we're moving right along and day two here. So thank you for spending so much time with us and we can go ahead and get started.  Just a little disclaimer, everything I'm going to go over is from CMS Medicare guidelines and CPT general guidelines.  Your organizations, especially if you're part of a larger organizations, may have your own compliance policies.  I am not here to tell you to do something against your policies, but certainly encourage you to share this information with them.  I will say, too, you can go ahead and move to the next slide, but if you ever are audited and you have an unfavorable result, you do have options.  You know, that is, you know, unfortunately, usually where you have to get legal and things involved, but auditors, to auditors, especially the RAC auditors, because they're essentially paid commission, can be wrong sometimes.  So my words of advice to you, if you do ever get audited, first off, be very, very careful about what documentation you're submitting back to them.  Don't just blindly have someone pull charts. Make sure you review those charts and the documentation that you're providing is supported.  And if you disagree with something, know you do have appeal options and you could get a second opinion from a big organization or forum that does things like that.  That's enough with that, but again, I'm focusing on traditional Medicare guidelines, as well as CPT standards.  So again, commercial payers, which most of us don't really deal with, may have different policies as well. They like to just make things difficult on us.  So we're going to talk about some coding risks and red flags, and I'm really going to focus on E&M. These are your core services that you're providing.  So it's important that you understand how to build on both documentation and complexity, documentation and complexity, excuse me, and time and how you do so at an appropriate level.  So you're getting paid for the work that you're doing.  We'll get into the specifics on the codes and some common modifiers, and then we'll also talk about some documentation and things like that.  And then again, in the advanced course, we're going to build on the non-E&M services that you can add on.  But we've kind of mixed that in, and a lot of the resources that I've provided will also go in more detail on what those services are. Next slide.  So starting with some golden rules, and I actually kind of disagree with this first one.  I like to change it from not that if it wasn't documented, it doesn't count, but if it wasn't documented, it cannot be validated.  So what I mean by that is I'm simply looking at when I'm doing an audit, I'm only looking at the EHR progress note. You know, I wasn't in the home.  I don't get to see how sick these patients are and the complicated family dynamics and all of those things that go into it.  So if you're not telling me everything that went on, and you know, a lot of us get really, like Dr. Cheng was saying, competent with complexity,  but making sure you're really telling that story of how sick the patient is on paper, quote unquote, even though it's electronic,  and everything that you're doing, all of the discussions you had to do, almost like documenting your clinical reasoning  and why you're changing medications or why you need to get other services involved, all of those things really make a difference when you're validating your level of service.  Also, when we're trying to be efficient and we're trying to think about how to not spend, you know, that pajama time documenting into the evening,  more words do not always mean better documentation.  I am never going to tell you anything that you need to provide good medical care that you think should be in the record should 100% be there.  But you can do things like bulleted documentation and really look at your templates.  And if it's not meaningful to that patient and that particular visit, then it shouldn't be there.  Don't have your templates be so cumbersome where you have so many clicks and so many fields that you have to fill in if it's really not meaningful to that patient visit.  And I'm not sure how many of you are familiar with the word cloning. You know, medicine, we have lots of names and acronyms. Coding we do too.  Cloning is if I look at an entry and it's exactly the same or very similar to a previous entry.  So Epic in particular loves auto population and carry forward and all of those sorts of things.  And there's areas that we can do that, such as if it's an established patient where we're just reviewing the past family and social history and there's not necessarily an update.  But where you have to be careful is each encounter really needs to be separate and distinct and focus on what happened with the patient that day and what their health status was.  And where I've seen this go very wrong is I can tell when people are accidentally cloning HPIs or even their physical exams because their notes will start to contradict each other.  They'll be telling me about a pressure sore that they've already told me was healed and doesn't exist or something like that.  So you really do need to be careful with how you're using those sort of auto population fields and things like that if that's something that you're doing.  It really needs to be different on each date of service. What was the patient's health status that day? What did you do and talk to them about it, you know, on that encounter day?  Next slide. As we're going along too, feel free to put any questions you have in the chat.  You know, happy to answer those as we go along or we can kind of spend some more time at the end if you think of them as we're going.  So we're going to talk about each of these in more detail. But again, your progress note needs to have a chief complaint. And that's not new patient. That's not follow up.  I'll show you. I need a medical reason, a specific medical reason for that visit.  We'll talk about history of prelates and illness, the HPI, the review of systems, and the past medical and family social history.  All three of those make up one three of those elements make up one component of the history. I have to have all three of those things to score your history.  Your physical exam is the other component of E&M. And then your medical decision making, which again, we'll talk about in more detail is the last.  But then ending with medical necessity. I'm going to tell you how to score and how you get to all of these HPI, physical exam, and MDM.  But regardless of if on paper you can get to those things, it comes down to your assessment and plan. What was the medical necessity of the visit? How complex was the patient?  Are you changing things or are there difficult discussions going on?  Or am I getting to your assessment and plan and it's so limited and it's so general that I really can't tell how much is going on or what's being done?  Because that's when, regardless of the other documentation, your medical necessity of why you really needed to see that patient  and that insurance should pay you for it is going to come in question. Next slide.  The other thing with medical necessity, and I think this is a big myth and a lot of people don't necessarily know this.  Before 2019, the patient never had to be homebound like they do for skilled home health services. You can look in the Medicare claims processing manual.  It will tell you they never had to be homebound to receive a home visit.  But before 2019, we did have to make the case that there was additional medical necessity of why the patient was being seen in the home in lieu of the office.  CMS did eliminate that requirement in 2019. So this is another thing that you could consider taking out of your template.  Almost all practices had general statements included in their templates like the taxing and immobilizing effort or it's medically contraindicated for the patient to leave the home.  Therefore, that's why they're being seen in home instead of the office. You don't have to have that.  Now, I don't want you to kind of sacrifice complexity, but just so you know, this did go away in 2019. You don't have to explicitly call that out in your documentation anymore.  Next slide.  So just because I think medical necessity is the most nebulous, and again, you'll hear me say this over and over again, it's always the overarching criterion for the visit.  It has to support payment. Do I mean that the encounter needs to be documented that the home visit was necessary? So it used to have to be, yeah.  So before 2019, for any home visit, you actually had to explicitly document.  I'm seeing the patient in the home because, and there had to be a reason they couldn't get to the office. You don't have to have that in your documentation anymore.  But you mean that the visit, meaning the patient is being seen for a follow-up for hypertension or a wound or whatever, that's the only thing that has to be documented? Correct.  Yes, exactly. So yeah, so medical necessity is just supporting. Is it validated by payment that you needed a face-to-face visit?  So example, like hypertension, management of their chronic diseases. But we talked yesterday about visit frequency and not putting all of your patients on the same schedule.  And so that's where if you're seeing a patient every month, but I'm looking at that assessment and plan, and I'm not seeing anything really change, and it's really just stable hypertension, and you're not even kind of talking about the medicine, that's when just normal medical necessity becomes a concern.  So hopefully that answered your question. And again, and these are questions you can kind of ask yourself to really be able to discern, is your note supporting medical necessity?  Words really matter.  Again, I think this comes down to, sometimes what I see missing is really being able to tell the status of the patient's condition, or how severe it is, or based on your clinical assessment, kind of getting at prognosis almost.  So think about what kind of descriptive words you're using to describe conditions.  And also, kind of like, you know, billing for advanced care planning and things, getting credit for all the work that you're doing.  If you're having extensive conversations with the patient, or you're having to educate and counsel them, that should be documented.  And if you have, you'll see why this is important later, but again, if you ordered or reviewed in a lab or diagnostic testing, we need to know that to score medical decision making, and, you know, changing medications and all of those things.  Again, it's really just telling me that story, and painting the picture of complexity in each and every encounter. Next slide.  So, open encounter reports can be a good thing to monitor. This is just one MAC guidance. They're all different, and MAC stands for Medicare Administrative Contractor.  While we're on the break, I put the link in the chat for the CMS MAC website, if you don't know whose you are.  The majority of us, North Carolina and Alabama, you guys are Palmetto, Massachusetts, and Illinois is National Government Services, and Arizona is Noridian.  They all have newsletters that you can subscribe to where they put billing and compliance guidance, and they have a lot of different resources out there.  So, someone in your practice should kind of be following those and looking at education resources that are available at your MAC level.  But it is possible, if they did an audit for whatever reason, and they were looking at the encounter date and seeing a couple weeks later signature dates, they could actually deny that encounter for payment for lack of medical necessity for an untimely signature.  Now, as specific as at the federal level we get, again, from Medicare's standpoint, it just says it needs to be documented as soon as practical after the encounter, and so that's why there's sometimes some different standards and guidance.  But also, you know, you could make the argument as if you signed a note, you know, a week or two weeks later, do you really remember everything that went on during that visit, and are you able to get that into the documentation?  So, what can you do to support your provider so they have the time to close those notes within 72 hours? That's your best practice standard you want to aim for. Next slide.  So, things we can do to stay out of the CMS spotlight, right? We don't want to be on any of those kind of audit reports that we talked about and, you know, things like that.  Really understanding your billing patterns, you know, not billing for services before you understand the requirements, I would probably say is the biggest thing you can do.  You know, I see a lot of practices that I'll do a chronic care management or even a CPO review, which are such meaningful services, but their documentation just isn't compliant, or they're billing on time and I have no time statements, which I'll give you an example of.  You really need to understand, unfortunately, I know, you know, providers, you should just be taking care of patients, but we all have a responsibility.  It's your licensure on the line to make sure that we're kind of doing things that are staying in compliance and that we're, you know, documenting quality documentation that supports what we're being paid for.  So, just kind of, you know, again, those resources that I mentioned earlier, and I actually also added a link in the chat to the CMS care management page.  I have that as a favorite. Someone on your practice management team, when they post new fact sheets or FAQs on services like advanced care planning and things like that, that's where they kind of house those documents and it's a great education resource for you.  Next slide.  So, these are some other red flags. We talked about medical necessity. Again, if you're seeing every patient every four weeks and I'm looking at your assessment and plan and I really can't see much change from one visit to the next, and you're not painting that picture of complexity.  We talked about the challenge where the facilities might impose that requirement. You can certainly say that there will be a provider in that building every month, and you can, you know, see the patients that medically need to be seen and maybe you can make the case for the majority of those patients, depending on their complexity.  But by law, you know, no one likes to say the F word, fraud, but the Medicare fraud and prevention program is looking at use of Medicare dollars and what they're paying people for, and it should be personalized based on each patient's health status and needs and the provider's clinical judgment.  You as the clinician will know how often you need to see that patient to keep them out of the hospital. But what else can you do? What care management or non-face-to-face interventions or other interdisciplinary team members can you mix in?  Does it, you know, if you're getting, this came up the other day, assisted living facility that was insisting a provider see the patient for a fall with no injury. Is it really necessary for them to go out there and lay eyes on the patient for that? You know, could they use their nursing staff and get some other, you know, information and treatment to that patient?  You absolutely can build an E&M code and a procedure on the same day, but you have to separately document both because you're going to have to use modifier 25. So let's say this patient just happened to be near the office, they needed a knee injection. That's something your practice does and you add them on just to go do the knee injection. And I look at your note and it's really, in your chief complaint, you're telling me you're seeing them for the knee injection and that's all I'm really seeing in the documentation, then that's all that should be billed.  You need to show me that you manage their hypertension or their diabetes or their chronic kidney disease or whatever it is. And then you also have a separate area of documentation for the joint injection and that that was separate and distinct work that should be paid separately. That's the key when you're using modifier 25.  And again, looking at your documentation, you know, when you do, when you admit a new patient and you're spending all that time doing that wonderful comprehensive HPIs that I see so many of us do, we don't need all of those things, you know, details on every single patient. You know, what happened from the last time you walked in the door to see that patient till right now? And how are they doing today with their chronic conditions? Or what did the daughter tell you about she's really concerned about, you know, change in sleeping habits or, you know, more  agitation, you know, focus on what's different or what's really going on and try and make your documentation different from encounter to encounter.  Hey, Brianna, can you clarify something for me?  Please go ahead.  Yeah, as many of us are thinking about giving our homebound patients COVID vaccinations, does this second bullet point here about minor procedure and billing for E&M code? If I'm just going out to give the vaccination, what's your recommendation regarding billing for that for that procedure?  Yeah, thank you for bringing that up. I should update the slide to the COVID vaccine, although we hope to have it. So again, if you're just seeing the patient, HCCI did a presentation in January that's on our HCC Intelligence Resource Center, where I listed out all of the things that Medicare considers billed in the administration code just for billing the vaccine, which they did raise to $40 from $16. But, you know, making sure the patient's eligible for a vaccine, counseling related to the vaccine, you know, unfortunately, you have  to sit there and monitor them for the 15 to 30 minutes. All of that is just vaccine administration. That's not an E&M visit. Now, we know you have to go to the home and you have to go see these patients. So if you're giving an injection and building that into your normal visit, and you have a full E&M visit, and again, they're separate and distinct documentation. Besides just that vaccine, you absolutely could bill both. But we also know that we have time constraints with these vaccines, you know, for the two dose one. So if you're really having to just make quick  visits and just see patients for vaccines, then unfortunately, really just it's just the vaccine administration, what I would say is you're probably not going to do a vaccine and an E&M visit on every patient that you see in the day, there's probably going to be some that are really just vaccine visits, but maybe you mix a couple other visits in there too. It's really going to depend on a case by case scenario or how your practice is setting it up. I feel like I know 5050 some practices that are fortunate enough to be giving vaccines right now are just doing vaccine  appointments on those days, just because of the time limitations and the travel, and others that are offering it as part of their normal visits. But you just have to understand that that just giving the vaccine alone and counseling just related to the COVID vaccine does not warrant an E&M visit. Any thoughts on that? Or is anyone anyone giving vaccines or doing anything? Feel free to put in the chat.  So I've been hoping to give the vaccine since we first got it. And, you know, there was incredible pushback on the temperature constraints for the Pfizer or the Moderna. And, you know, I was getting extremely frustrated because a lot of my families were like, why can't and in Connecticut, you know, we pushed really early that all older adults get it and and healthcare workers, you know, and now we're down to I mean, everybody's at, you know, 16 and up.  But we were at 45 and up. And, you know, our hospital was like touting all the vaccines we're giving. And we have all these vulnerable people at home that haven't gotten it. Because not every, you know, not everybody lives in an assisted living. So I actually reached out to the health departments. And they a lot of them are doing mobile vaccine clinics. And, you know, they're, they're picking up we have a website in our state where we sign people up.  And for me, you know, when I do my flu shots, you know, it's always like, you know, you only, you know, you only brought in this much money this month, well, because I'm only giving administration, you know, fees, I'm not doing the all the visits. And it's always kind of like a ding when you're giving vaccines in terms of how much revenue and the RV use aren't there and all that stuff that, you know, my organization looks at.  So, you know, kind of turfing them out and getting them quicker by health departments made more sense. Because we're finally just getting the vaccine. And now, of course, everybody's freaking out about the Johnson and Johnson after the fact. And, you know, it's almost more of a headache if you can get somebody else to do it.  Yeah, no, thank you for sharing. I mean, it is, you know, flu season is always challenging, too. And I don't want anyone to take this as you can't, because you absolutely can. Like if you can support a vaccine and an E&M visit, you could, you know, if you're going there to see the patient and to make a visit, especially during flu season, the challenge is vaccinating all of your patients, right? Like your assisted living facilities probably have flu vaccine clinics. So let your patients get them there. Same with the COVID vaccine.  We've been hearing a lot of local EMS programs in some states that are popping up to give COVID vaccines. In DuPage County, it's still, you know, very limited. I have a homebound family member still waiting for the vaccine, you know, on a wait list with the health department. I'm hoping that that, you know, comes out. But, you know, that's a great point. I think logistically, it's obviously very, very challenging. Check out that HCC intelligence webinar. Maybe Betsy or someone can help me put the link to that in the chat.  We had three programs that were giving vaccines talk about their strategies. One of them, they just partnered with EMS, and that was who was giving the vaccines for their patient. Because to your point, you know, especially with the time constraints, do you really have time to do a visit and, you know, give the vaccines and get them in the arms within the amount of time that you have?  I will say, too, I was talking to another practice that was pretty frustrated about this. They have a whole fraud unit just dedicated to looking at the vaccines. And they were doing a vaccine clinic and on, like, new patients they've never seen and established care for. And that's when I was like, you need to pump the brakes and focus on just billing administration because there's no way you're doing visits for how much volume you're telling me you're doing and for patients that aren't established with your practice.  So those are the kinds of things. You just want to think ethically and what's realistic and what are you actually doing and billing for?  All right. I'm going to move on from our tangent about vaccines. But thank you for bringing that up, Dr. Cheng, because that was a great question.  So electronic health records. It's hard to believe we're still kind of talking about this. You know, there's pros and cons. Are they friends or foes? You know, cloning was never a thing. If you think back to how we used to document on paper, I may be young, but the first medical office I ever worked in, I got lucky to be hired the day before we went live with the EHR.  So I got to go through all that integration and getting those paper records into the EHR and see how really difficult it was for the providers to adjust. I argue the biggest pitfall is our templates and how we sometimes misuse them. Because you're going to need templates for different things.  But if your everyday standard progress note has so much in it that your providers are having to do so much clicking and so much, you know, click through, that sometimes I'm looking at notes and I'm like, gosh, I know they're providing great care, but it's really hard for me to tell what actually went on because I have all this generalized documentation or these things that are just blank and smart phrases because I can tell the poor providers are having to click through so much. And it's not meaningful. It's not succinct.  There's an article when I'm not talking I'll put in the chat that was on note bloat and talking about, you know, how we've kind of mishandled EMR use and how we can kind of work to get our progress notes back to being more meaningful and more focused, you know, almost like problem focused visits going back to the soap note, if you will.  And I think we just need to be really careful with that and I'd encourage you to go back and look at your templates and even a couple of your progress notes and see if there's anything in there that surprises you that you didn't realize that's just getting carried over and isn't really any value add.  So, in summary, just keep your templates meaningful and succinct and anything that you don't need to a lot of times there's boxes, you can click or uncheck if it doesn't need to be there if it's not pertinent to that encounter, then don't include it.  Next slide.  So this should be more of a back end billing process hopefully all the providers don't have to be too, too intricately involved in this but again, home assisted living and group homes, they each have different what we call place of services, and you also build a different CPT code, if you do, if you're seeing a patient in a private home or an independent living versus an assisted living and a group home you're billing the domiciliary CPT codes.  Autopopulates good. That's great. I'm happy to hear Prima's doing that, where you get into trouble though is some of these buildings that have multiple services so on intake you really need to understand, are they truly in an independent living setting, or are they, you know, getting custodial care services that makes you have to build a domiciliary code that's what you want to watch out for because there's a slight for whatever reason domiciliary codes pay very, very slightly more.  So you're going to want to make sure you're just building the right code.  Next slide.  So modifiers, the infamous modifier 25 that I was speaking about where you heard me talk about how your documentation needs to be separate and distinct. This is why because that's really the definition.  But if you're going to bill your E&M visit and an annual wellness visit on the same data service you can if you do both services and they're separate documentation, but you would need modifier 25.  Same thing if you're doing advanced care planning. Again, I need that time and that documentation for the advanced care planning conversation.  So, again, if you're having a goals of care conversation talking about patient preferences, you may or may not be completing a, you know, DNR form or things like that for your patients and making decisions if it lasts at least 16 minutes, just on the ACP conversation, nothing else to do with what you did during that visit, then you could bill for both, but I need to see that that work and that time and that documentation.  Maybe put in the chat if you guys are doing any procedures in the home, things like those joint injections or other services, you may need modifier 59 in those situations. And then also the infamous hospice modifiers GW and GV.  So, you can continue to care for a patient that's on hospice if they elect you as the attending provider. So, if you are, then Medicare Part B, you know, will only cover that for the attending provider. Otherwise, everything goes to the attending provider.  So, if you're seeing the patient and you're providing care for their other conditions, that's not their terminal diagnosis, and you're not affiliated with the hospice, I know we have two programs here that are hospice and palliative, you guys are using GV. So, kind of ignore those terms.  But if you're a home-based primary care practice that's independent from the hospice and you're continuing to be the attending provider and provide care to your patients, generally, you're using GW. Now, if the patient elects a nurse practitioner on the hospice, then you're not affiliated with the hospice. So, if you're seeing the patient and you're providing care for their other conditions, that's not their terminal diagnosis, and you're not affiliated with the hospice, I know we have two programs here that are hospice and palliative, you guys are using GV. So, kind of ignore those terms.  But if you're a home-based primary care practice that's independent from the hospice and you're continuing to be the attending provider and provide care to your patients, generally, you're using GW. Now, if the patient elects a nurse practitioner on the hospice to be their attending provider, or you're seeing the patient related to their terminal condition under hospice, then that's when you're going to use the GV modifier.  Bottom line with these is if a patient is enrolled in hospice and you don't use one of these modifiers and you bill an E&M service, it'll be denied. So, that's why they're important.  Next slide.  So, thinking about, you know, we've hit on the intake process, making that medical reason for the visit. Dr. Chang brought up a great point earlier, too, is your intake staff, when they're confirming appointments or if a patient's calling and asking for appointments, asking why, what's the major concerns, what's been going on?  That'll help you have a more specific chief complaint. And they can also be the ones that bear the burden of figuring out, okay, is this an independent living building? Is this a group home? You know, are they licensed as an ELF? All of those kinds of considerations.  So, making sure that information is asked and documented within the medical record. It's also a service to you because if all of a sudden you get a message about all these concerns a patient's having, you know, maybe a clinical staff member or a sooner visit needs to be arranged.  Next slide.  So, here's what I mean by specific chief complaints. And so, I try and give very specific examples. Again, it's not wrong. I see follow-up on chronic medical problems all of the time, but it's not specific enough to tell me what conditions you're going to be focusing on today.  And if there's a specific problem, you can say seeing patient today for management of their diabetes, dementia, and hypertension. Absolutely. That's what you're following up on. But just be as specific as possible. Avoid that new patient follow-up medical problems. You know, even if it's a follow-up visit, there's generally something that you're going to be focusing on or a condition that's exacerbated that you know you really need to focus on. Make sure you explicitly call that out.  Next slide.  Here's what I mean by bulleted documentation. And I would challenge you. I think most providers are comfortable with the narrative way. Sometimes this is an EHR limitation. But when we think about HPI and the 95 guidelines, you either have to give me a very detailed chronological description of an acute problem that's going on, or you have to give me the status of at least three chronic conditions.  If you give me the status of three chronic conditions, and this is based on kind of what you're learning from the patient and caregiver asking how they're doing when we're talking about HPI, then that qualifies as extended HPI credit. But you have to be able to, I have to be able to tell the status. You know, what are some recent readings? Or, you know, maybe they're saying their blood sugars have been poorly controlled. You know, things like that.  Just rather than that long narrative telling me, you know, their entire history every single time, if they're follow-up visits, think about, you know, would this save you time on documentation if you went to a bulleted method? And again, just HPI status of three chronic conditions, that would get you extended HPI credit. Or, if I have one to three elements describing an acute problem, that would be a brief HPI.  If I have four or more, it's extended. So if I look at the lower example here, radiating low back pain, it tells me the location of the pain and it describes the pain.  It tells, patient reports the pain as a seven out of 10. That tells me the severity of the pain. It tells me it began two days ago, duration. And it tells me anything they've tried  to make it better or worse, Tylenol. Like that's how detailed you need to be if I'm gonna give you extended HPI credit for an acute problem. So just keep that in mind.  That's why for most of our patients, the bulleted, just give me the status of three kind of conditions. These are very detailed examples  because I'm always gonna give you a very good example rather than a subpar example, but it doesn't have to be that detailed every time.  Talisa, were you gonna say something?  All right, we can move on.  Review of systems, oh, go back one.  Oh, is this an accident? Okay, past family and social history or review of systems. Either way, we're gonna talk about both of them, I promise.  Review of systems is the second part of the history. It's really intended to be based on the patient's presenting problem or their current conditions.  What are the positive or the abnormal findings or any other system findings that are affecting the patient that day? You can always just document the abnormal or the positive  or if there's any pertinent negative findings and then just say all of their systems were reviewed and negative. That's gonna get you complete ROS credit  without having to list out all 14 of these every single time and be just seeing negative, negative, negative, negative in your documentation. Again, thinking about efficiency,  document what matters clinically to you and then consider the approach of documenting all of their systems were reviewed and are negative if you did.  But if there isn't an abnormal finding, it needs to be specific. Sometimes I'll see positive joint pain. Okay, could you have told me what joint, where was that pain coming from?  Give me a little bit more information.  Next slide.  So the past family and social history really becomes important with new patients. Again, if you're missing any of this on a new patient,  I automatically almost always have to drop you a level and downcode you because the history requires all three of these for new patients.  The family history template is a lot of something a lot of practices I think don't realize the level of specificity that needs to be included with that  not just the family member and their disease, but if they, their health status, meaning if the family members alive or deceased and their approximate age that they expired.  If there's ever a patient where the history is unobtainable, it's a clearly demented patient. There is no family. These things happen, right?  You have no way of getting this information. You just have to give me a reason why. So if the history is unobtainable, you need to say, you know, unable to obtain family history  due to patient's cognitive status and no living family members or no, you know, has independent historian available. An auditor can never fault you for that,  but you have to give a specific reason why the history was unobtainable. For established patients, we can review things and, you know, just document changes  as long as you're reviewing and the information is available within the record.  All right, next slide.  So here's the physical exam. I'll tell you why I'm a fan of exam templates that go on body systems and not body areas and systems. And again, every EHR template is different,  but almost every provider, if you don't know if you use the 95 for the 97 documentation guidelines, excuse me, it's almost always 95.  They're more general and more favorable to providers. That's typically what I audited. You can use either, but the 95 is just more general. It's more favorable.  It's generally what we see. But organ systems only, a comprehensive exam, I need eight organ systems. Great that you tell me head findings and other kind of body areas,  but those don't count as systems. And generally the kinds of things we're documenting in the physical exam always relate back to a body area system.  So if you can list systems in your exam template rather than body areas, that would be my recommendation here.  Next slide.  So medical decision-making is another kind of where we have multiple factors we have to consider. And I think a lot of people think that MDM is the same thing as medical necessity.  It's not, and it's also not just the overall level of risk or one of these factors. And this is why documenting every little thing you do matters.  So first I'm gonna consider the number of possible diagnoses and management options. And I'm gonna show you how auditors actually score MDM  because I think it's only fair that providers get to see that side of it and they know why. But I will tell you, I'm not looking at your problem list.  I'm looking at your assessment and plan and I'm seeing what you meaningfully assessed and you documented a treatment plan for and not a notation of,  let's say diabetes managed by endocrinologist or cancer managed by oncologist. You're deferring treatment to another provider.  And unless you tell me how you considered that condition and your care of that patient, I can't give you credit for it.  Second piece of information that we look at would be the amount and complexity of medical records and data. So if you reviewed and summarized hospital records,  if you ordered or reviewed a diagnostic or a lab test, if you had to talk to another healthcare professional such as a home health nurse, or you had to get history from the POA  before you saw the patient, all of those things matter. Again, I can only validate it. I can only give you credit for it if you tell me you did it in your documentation.  And then finally, we'll look at the overall level of risk. This is where that table of risk and CPT comes in  in play here. But this is again, descriptive words. If you're debating that the patient needs hospital level care, I need to understand that complexity  in order to kind of score that.  Next slide.  So this is a screenshot of a standard audit tool template for MDM in particular. I can put a link to one in the chat. And again, I'm going to your assessment and plan,  and I'm just gonna show you how all of these things add up. So in your assessment and plan, can I tell if it was a new or a chronic problem to the patient?  And do I know based on now you doing your physical exam and your clinical impression, what's the overall severity or the status of that condition?  Really important for me to be able to tell that from your assessment and plan.  Second piece, if we go to the next slide.  This is why I'm saying that data matters, right? The bolded are just more common things. It doesn't, talking to it within your own team, it has to be a healthcare provider  outside of your organization or a specialist. But if you're doing those things in relation to a visit, just make sure you make a note. I don't need a huge long summary,  but just note that within your documentation  and that you're considering that. And that that's adding to the complexity of you caring for that patient, then that contributes to your overall level, excuse me,  of medical decision-making.  Next part.  There was a question, if we had a checkbox in records, would that work? No, unfortunately not because it's review and summarization.  So like a sentence or two about what you reviewed, you know, if it were the patient was admitted, you know, to X hospital last week for CHF exacerbation,  their edema seems to be improved. They were on Lasix, you know, whatever milligrams, something like that. But just a couple of sentences.  I have seen some practices that have had like, they queue this as like an MDM template, like each element for their providers, but the provider would need to be specific.  Like what labs did you review and were they normal or abnormal or what testing was ordered? I've seen that go bad. I actually recently did an audit for a practice  where they thought I was gonna be so proud of them. And it was so like, I felt so bad because I was like, I'm so glad you're using this MDM template, but it didn't tell me anything.  I just see general template documentation without specific, you know, consideration to that patient. So just be careful. If you think a template, you know, for MDM,  just kind of reminding you to document those things would be helpful, great, but it has to be specific to the patient and it can't just be kind of like a generalized checkbox  or a template in that respect.  And this is the last piece of MDM. Again, I just think this is the most nebulous. That's why I just really want you to understand how it's scored.  If you're doing any sort of prescription drug management, even if it's just evaluating the effectiveness and continuing a current medication,  almost all of your home-based primary care patients are gonna fall under this moderate. This is from CPT. It's called the table of risk. You don't have to have all of these things.  It's just one of any of these areas and it's not meant to be all inclusive, but you can see that high is a pretty high bar, but that's why we don't have to just rely on this  for a high level of MDM. You can get to it from other factors. Laura, were you gonna ask a question? I was just gonna comment. Sometimes those MDM calculators  that are part of the final step of dropping the codes in the electronic health record could be helpful for that reason, because if you encourage the providers  to run the calculator to see what code to drop, then that sometimes is that trigger to think, oh, I need to be sure that, well, yes, I did this, but I didn't actually document it.  So then to go back and add that note before you finalize it. Yeah, have you had success? Do you have you found, have you used that in your own practice?  Have you found those helpful? Yeah, for when I was a family doc in rural practice, we would use that within the Allscripts application,  especially as we were just learning to use the EHR and having to do our own coding for a change. And I found that really helpful. That's great, thank you for sharing that.  Yeah, there's also a lot of the Macs, like I know First Coast does have interactive E&M tools where someone from your team, like your billing or your auditor,  or even ask your practice manager to do it for you could just check a couple levels of service and it'll let you check boxes for MDM and then it'll tell you the level  so you don't have to guess. So there's some, if you look at your Mac website and you look at, usually each one has like an E&M spot. Sometimes they have an E&M documentation tool,  they call it or interactive guide that'll kind of give you an MDM calculator and actually look at the whole thing too, like HBI exam and tell you the level of service.  If you want a spot, check a few records. You don't have to do a ton, start with just the last five encounters or something and just see how you're doing.  Next slide.  So again, this is a two out of three. So maybe the patient wasn't really that high MDM alone, that highest risk is really a patient that almost needs hospital level care  or is really, really unstable and maybe you're going to hospice or something like that, but you have to tell me that to get there. But there's other ways that we can get back.  So I'm gonna consider all three of these things and I need two out of three. So maybe you didn't get to high risk, but I had, you access probably like three or more,  three or four conditions in your assessment and plan and you had a moderate level of data based on talking to healthcare professionals, reviewing a lab and a diagnostic order  or something like that. That'd be an example of moderate for column B that would get you to your overall MDM level. And this is just kind of showing you how MDM is tied together.  Also important to realize for established patients, 99350, which is a level four, it's the highest level home visit code. It matches with the 99337  for the highest level domiciliary code. Both of those only require moderate or high medical decision-making. Again, I'm considering the overall medical necessity.  I'd wanna see some sort of unstable problem or active management going on, but you don't always have to get to this really high bar. I think sometimes providers are scared  to code that high level. If you're managing a lot of active conditions and it's not a really straightforward visit, you can probably make a really good case  for that high level of service.  So thinking about your assessment and plan, and again, Amanda shared that dust by a thousand clicks. I think sometimes when I struggle with assessment and plans,  it's because the providers are so burnt out. By the time they've gone through all the other clicking in the template and they get down to the assessment and plan,  that's where I'm sometimes lacking that detail. And I really think this is the most meaningful part of the note. So each problem that you list  that you're gonna put in your assessment and plan, this is what HCC validation uses too. It's an acronym called MEET. The M is for monitor,  E is for evaluate, A is for assess and address, and T is for treat. So how are you monitoring that condition?  How is it evaluated?  Are you ordering any labs or commenting on labs values, assessing and addressing it? Are you treating it with any medications or any specific follow-up instructions  for the patient and the caregiver? Again, making sure I know if it's a new or an established problem and what the severity of it is. All of those things kind of need to tie together  for that level of risk.  Kind of a strategy for HCC coding too is to prioritize your assessment and plan. Sometimes it's tempting to just list the first diagnosis that pops up in our diagnosis list.  But really, what did you spend the most time on? Was it the CHF every time or was it a pressure ulcer? Is it their diabetes? Consider prioritizing your assessment and plan  on what was the most meaningful to that visit. And that'll help with this MEET documentation too. And it shouldn't be the patient's problem list unless you really evaluate it  and have a treatment plan for every condition every single time.  I'm just going to pause for a second. Any other thoughts, even things you found helpful in your own templates or questions that anyone wants to share?  I know this is a lot, especially to take in from a clinician standpoint, but this is where just having an understanding, having someone on your team that can help you  do some internal auditing and monitoring and give you some insight and give you some real-time feedback. Or even your clinicians, do you do any sort of peer-to-peer auditing  at least once annually? That might be something that you consider that would be beneficial for your team.  But again, just remembering, it's not just listing the condition, stable, continue. That's really kind of a red flag. If I go down and the majority of the problems  are just CPM, continue present management, or stable continue for that. Even if they are stable, even if they are stable, I mean, not every problem is gonna be problematic  every single time, but what's going on? What did you consider? Are you telling them to monitor blood pressure readings every so often for hypertension?  Are you encouraging good diet with diabetes? What kinds of things are you doing that's telling me your overall clinical impression  of that diagnosis and what your specific treatment plan is? And again, just really painting that picture of complexity.  And if it wasn't actively managed and treated that day, save your time on the documentation. Just don't even put it in there.  Next slide.  So again, thinking about treatment options, the thing that you have to be careful about with this is so when you're ordering referrals, and this can, the home health partners  will appreciate this too. Like if you're ordering home health physical therapy or occupational therapy, are you explicitly stating why?  Like are you, what is the goal of physical therapy? Or what is the need for occupational therapy? Those kinds of things  your home health partners will appreciate anyways, but you also need to understand the reasoning and kind of the necessity, if you will, for the referral or treatment.  Again, it just makes your case for your documentation and your overall level of risk for that patient.  Next slide.  So if anyone would care to share, and this isn't, you know, not gonna think one way or another, but maybe in the chat or if you wanna share, hopefully you're building,  you're choosing your levels of service, and maybe you have a billing company that's doing this for you or something, but are you billing on a combination of time  and documentation and complexity? Or do you know?  Combination, yes, that's what I wanted to hear. Thank you, Talisa. Combo, okay.  Good, all right. You guys are all way ahead of the game, compliant documenters. You should be way ahead of the thing. You can't bill on time every single time.  That's sometimes the problem that I run into. That will be number one audit, huge red flag every single time if you're billing every encounter on time.  But for those lengthy encounters, like I'm gonna show you some examples of, it is to your value to bill on time sometimes.  And especially when maybe there wasn't a whole lot of active management going on, but you just had some really difficult discussions. That's when you can,  all of those other E&M elements we talked about go out the window if you're billing on time. What I care about is your total time spent. But this is what I meant when I said earlier  about a compliant time statement. And if you don't have all three pieces of these things, one being what was the total amount of face-to-face time  that you spent with that patient and caregiver? That's all I care about for the outpatient setting. That greater than 50% of it was dominated by counseling and coordination of care.  That's number two. You have to say that. I need the words. Greater than 50% was dominated by counseling and coordination of care. And then you have to describe it.  Give me, again, it doesn't have to be a novel, but some specific details, such as coping skills to deal with social isolation and emotional stress.  What was the nature of the counseling or coordination of care? Or spend extensive time trying to get a hold  of a behavioral health specialist for the patient and talking, counseling through their anxiety needs in the meantime or something like that. What was it specific to that patient?  If you're missing that third part, it's just as important. Sometimes I'll see total time in the 50%, but then they just leave it at that.  Now your documentation, if it's really clear, like your assessment and plan just had a whole paragraph about the counseling that occurred, that's fine. I can use that.  It doesn't necessarily have to be all together, but it's just a good practice to get into, even if you just kind of summarize your note in a couple of sentences on what the nature  of the counseling and coordination of care was.  Any question on time-based billing in general?  Okay, so the next four slides, I'm not gonna go over each one, but these are kind of like cheat sheets, if you will. And if you're not real familiar with this,  this would be something to kind of look at. This is the one for new patient home visits. If we can actually go, let's go to the established patient domiciliary visit.  I know we have a lot of assisted live-in practices here. Go one more, I'll tell you when to stop.  There we go, perfect. So 99336 is probably the most common looking at just averages. So what does that mean? That means that I have a detailed history.  What does a detailed history mean? It means I either have four individual HPI elements or the status of three chronic conditions  that you gave me at least two to nine review of systems and one element of that past family and social history. A detailed exam is two to seven areas or systems.  Detailed can be body areas and systems. When we get down to comprehensive, only systems and I have to have eight. That's really the big difference  between the detailed and the comprehensive exam. And then moderate and moderate or high for the level of medical decision-making. So you can see that 99337.  Again, think about where you might be undercoding because it makes a big difference to your bottom line. Generally, I see comprehensive exams,  especially now again, not every patient, every single time. I'm not telling you to go bill every visit at the highest level. But if you're doing a lot of work,  it's not hard to reach that 99337 bar.  And then the typical time of course associated with each code. When we get to the coding activity, I'm gonna pull up a grid for prolonged services too.  So you notice the highest bar is 60 minutes.  How many of you might spend 90 minutes with a patient? Pretty easily sometimes. You should be billing E&M and prolonged services. Absolutely, for an established patient,  the threshold bar is 90 minutes. So there's a prolonged services face-to-face code. And then we have some prolonged services non-face-to-face codes too,  but those are bundled with chronic care management if you're doing that.  But if you're spending more than 60 minutes, you wanna check and you wanna just have a cheat sheet or a reference sheet and we have those  and you can use ours of when you can bill prolonged services in addition to your E&M code. The only thing with prolonged services is you saw that reference of total time.  Prolonged services like start and stop time. So consider adding start and stop times to your record if you're gonna do that would be the only other caveat.  Can we use timestamp on the phone? So the prolonged services face-to-face code, which is I have on a super bill for you guys, it's 99354, that has to be face-to-face.  So the telephone time would not count. 99358, and I'll put these in the chat, but they are in resources for you. That is non-face-to-face work.  It has to be directly related to an E&M visit. So it could be an extensive telephone encounter is one of the examples it gives. If you're talking to that family member  in relation to the E&M visit, and it would have to be at least a 31-minute conversation is the other caveat, because it's a time-based service,  just that non-face-to-face work would have to be 31 minutes in addition to your visit. Then yes, you could bill prolonged services non-face-to-face and the E&M visit.  A lot of practices that don't bill that is because they're counting their time in other ways, like chronic care management or things like that. If you already kind of have a method,  then you don't wanna go down that road because it could be considered duplicative. But if you're not, then you might consider using prolonged services non-face-to-face.  I think one of the issues that I come into is like to bill a 99337. You know, you spend 15 minutes talking with the staff, you know, then you spend 15 minutes  on the phone with the family and then only see the patient for 30 minutes or whatever that visit may be. So is that when I do the 99337,  is that a better use of, I don't know. So you'd probably be better off, and this is where like not including the time. The other thing is like,  if you're not intending to build the encounter on time, then don't put it in your documentation. Because if we as auditors see time, then we wanna bill it on time, right?  Then that's what we're thinking is should be the driving factor.  Especially in the ALF setting, I hear you, because you have to spend so much time with the nurses and then the family who might not be there at all of that.  And, you know, if you're billing just on time, the only thing that counts is face-to-face time with that patient. But if you didn't tell me how much time you spent,  you could probably get to a 99337 based on your level of history exam and medical decision-making. And for established patients, it's two out of the three.  So let's say maybe I had a brief history, but you gave me a comprehensive exam and I can see clearly from your assessment and plan, you support a level of moderate or high MDM,  then you can still bill the 99337. Does that help? Okay.  Oh, thank you, Sarah, for the Superville worksheet. The worksheet too, I just want to make sure, there's some that are included in the coding activities  that looks like it wasn't the updated one, but the one that has the 2021 prices on it and the codes, that really like every service  that you could possibly be billing for is on there. So I encourage you to take a look at that and just see if there's anything that jumps out at you  as new and kind of go from there.  All right, next slide.  So again, I didn't spend time going over each piece of these E&M grids, but they're there for your reference. Just know, obviously new patients,  you need to meet every level of history, exam and medical decision-making. Established patients, it's a two out of three. And so if that's kind of a new concept to you  or you're constantly remembering like, is it 60 minutes or is it 45 minutes for that level, then maybe having some cheat sheets like that in your office would be beneficial.  It's definitely a complex activity. It requires study and practice. I mean, even if it's just professional development once a year for your providers,  you're not trained in coding and billing like this. That's why we try and kind of make these talks much more extensive. So invest in your staff,  because ultimately it's your licensure on the line. Or if you can add staff to help you with this at some point in your practice, that's always a great way.  Is somebody giving you real-time feedback or letting you know like, hey,  did you do something like this or could you add, did you add your time to that goals of care conversation to bill advanced care planning?  Is there somebody that's able to help give you some education and real-time feedback on your billing and documentation habits? And absolutely, every practice that's participating  in the Medicare and Medicaid program is required to have a compliance plan and monitoring program. That was enacted by the Affordable Care Act. There's some lawyers that say,  well, they didn't give a hard date so you could get away with it, but you need to be compliant. Healthcare is highly regulated.  Even if it's just annual, internal, you do some of your own monitoring, whether you're formally trained or you're at least looking for trends and things like that,  or you hire someone to do that for you, or your providers do peer-to-peer audits, just make sure you're doing some sort of annual internal auditing and monitoring.  And like Laura mentioned, some EHRs may have MDM calculators or things like that that can help you, but there's also Mac tools. So the audit tools actually make it really easy  to kind of score your E&M visits. Just pull a very, very small sample, like three to five notes per each of your providers and assign somebody to kind of go through that exercise  and see if there's any major concerns.  Any other questions on billing and coding?  Just a question. Do you think that we're gonna see any changes to the billing and coding like we did for office? I actually hope so, because I meant to make a mention  of this when we were going through HPI. So what the AMA said, the AMA rec committee and CMS has said they are considering those guidelines for other services in the future.  And actually I serve on a couple of regulatory task force, one with the American Academy of Home Care Medicine, and we commented on this in support  of the new documentation guidelines that the office visit has for the home, because I personally hate scoring HPI. Like, I don't wanna have to sit there and go,  oh, how many HPI elements did they? I don't think that should be a big driving factor. It drives me crazy even as an auditor to have to score that.  So, you know, the office can now count all that non-face-to-face time like Talisa was talking about too. There's not all these requirements.  I hope we have that someday for the home. I think they will, because also like, there's a lot of providers in different settings of care, right?  Like, especially if you do inpatient or inpatient palliative or, you know, multiple different things, you know, I just feel bad. It's such a headache to have to remember,  oh, I'm in the SNF setting. Oh, wait, I'm in the inpatient setting. Oh, wait, I'm in the office setting. So I think they will have no choice because of the feedback and pushback  that I'm sure they're getting. I know HGCI was heavily involved in commenting on, hey, we need documentation burden relief too. Simplify things for everything,  especially thinking about providers who serve multiple settings. I don't have a crystal ball, but I do think I've been keeping an eye and educating myself on those guidelines,  even though they don't apply to the home in the domiciliary setting, because I think they might one day, and I hope they will. I am definitely in favor of them  applying to the home one day.  Any other thoughts?  Coding changes come out once a year too. So if somebody on your team isn't looking at the Medicare Physician Fee Schedule final rule fact sheet  and kind of keeping you up to date on the new codes, little things like that make a big difference too. HGCI generally does a webinar every year too.  So if you subscribed to our newsletters, I do a ton of coding resources and things like that. But just make sure you're staying up to date because like when we come back,  I'll share my screen on the super bill. There were a bunch of changes to some of like the online audio and digital E&M services and things like that. Sometimes codes do change.  So you just got to keep an eye on that.  Janine, I believe, or Melissa, I believe I ended on time. Would you like to give us any kind of thoughts before we break up or clarification on what we're doing  and who's going where? Your timing was perfect, Brianna. Thank you so much for leading us through all of that. So the workbook, yeah,  might not reflect the latest and greatest super bills. So if we can plan to screen share those when the time comes, that would be great. We are going to move into session 11,  which is the start of the putting it all together. And then when it's time for breakouts, we will go ahead and add people to the non-clinical.  If you could just tell us one more time, I'm gonna stop sharing my screen for a moment. Tell us one more time in case you haven't already in chat what group you would like to be in,  whether you'd like to stay with the clinical main group for the case studies, or if you would like to go back into the non-clinical. I've got a partial list of requests.  So I, again, will stop sharing so I can check that.  Thank you, everyone.  You know what, while Janine is getting people moved into their breakouts, this is kind of the rough time of the afternoon.  We're going to keep going for another little over an hour until we have an official break.  So if you want to stand up and stretch and walk around, refresh yourself, get a glass of water, a snack, whatever you need,  this would be a good opportunity. And then when you come back, we will be starting our clinical and non-clinical tracks for this afternoon.  Okay, breakout room invites have gone out. So if you accept.  And as always, if you end up by accident in the wrong room, just speak up and we'll rearrange you.  Okay, people are starting to accept their invites, so I believe we have everyone who requested clinical in Maine with us, and I will go ahead and share some slides again,  and I will hand it over to Melissa when it's time for our actual – Here, actually, Jeannine, I can go ahead and share now. Jeannine, I can share. Okay, great. Thank you.  All right, everybody should be able to see my screen.  Uh-oh, you're probably, are you, you're not seeing the right screen, are you?  Let's try that again. All right, there we go. All right, can everybody see the slide that says putting it all together?  Yep. Okay, yeah, I couldn't hear anybody. All right, all right, and Costa, you are going to lead this. Excellent. Yeah, and I know you,  we, I think we may need to try and just do this in the one room, if that's at all possible,  because we're not set up now for, I think, I think, that's okay. Okay, yeah, I don't have another person to drive right now. That's good. Well, so, you know, I just  wanted to say thank you all. I know this is, you know, this has been an information-packed  set of a couple of days, but we are going to be putting it all together, as the title says, and I'm really excited to just, you know, have this experience for you all over the next,  you know, over the next session and the following session. So, can we go forward?  So, one of the things I did want to say is, well, let me go over the objectives first and then  bring up something else. So, the objectives are, you know, we're going to go through three patient  cases and we're going to prepare for and conduct them. And we're going to discuss the impact of  home-based care on, you know, patient outcomes, you know, in the light of these three cases.  And then at the end, we're going to demonstrate optimal coding for the three simulated house calls. So, we're going to be pulling in, you know, our clinical experience and also our,  like, you know, coding and billing experience from earlier. I did want to say, though, before  we start our case, can you please go to page 102 in your workbooks? That should have, like, a planning worksheet for three patients, Ralph, Betty, whom we met yesterday, and MJ,  who's a new patient. And there they are. So, I'll give you some time to load up on page 102,  I believe. Yeah. And then, kind of specifically, you know, when you're going to be  listening to the cases and participating in the simulated house call, I'm going to ask you  just three questions to keep in mind. One, why is it important to review charts ahead of the visit?  Two, and specifically for each of these patients. Two, what equipment and supplies are needed for  each of your visits today? And those, if you want, like, a sample list, that's, I believe, page 130.  And then, the third question is, what's most critical to address in each patient?  And thank you, Sarah, for putting in the questions in the chat. That's great.  All right. So, if we can go to the next slide.  All right. So, preparation. We're going to review the files, plan your day, and think about what  equipment and supplies you may need. So, if we can go forward one more slide. All right. So,  we're going to see Ralph. And specifically, I'll go over the details here. We're going in for just  a routine follow-up visit for him. As we talked about yesterday, he's our 76-year-old African  American man with COPD, heart failure with reduced ejection fraction, pulmonary hypertension. And we've been seeing him for several months now. So, we've fast-forwarded some time.  We enjoy seeing Ralph, although sometimes he appears gruff and, you know, dismissive. But  you've noticed over time that he's been building up trust and rapport between the two of you.  And during the last visit, Ralph opened up a little bit more. And, you know, his worries and, you know, he talked about his worries and his sadness about his brother's illness.  And then, you know, the morning of the visit, the office advised you that Ralph's brother just recently passed away sometime last week. So, now we're going to see him.  And if we can forward one more slide.  And already, like, your plan in advance, your plan for today's visit is, because it's a follow-up, we're going to follow up on his chronic diseases and his medication management.  We're going to go over a fall risk and an emergency plan. You know, who is he going to call if there's an urgent issue? And then revisit some goals of care and discuss his brother's  recent death and talk about depression. So, if we can go. So, you see Ralph's home. And you remember  Ralph's nephew, Reggie, who's over there, who's his caregiver. And let's go to the next slide to  see. Oh, wait a second. There's something urgent going on. Not unlike the, you know, real world,  right? You go in for something urgent and then something routine and an urgent issue comes up.  So, Reggie meets you at the door and he's anxious. So, I'm going to talk for him. Ralph really can't  talk now. He's sitting in the TV, in the TV room, short of breath. His pulse ox right now, when I  got here, it was 78%. I asked him how long it's been going on. He said for about three hours. So,  I called your office right away. They said that you are already on your way for a regular checkup.  So, you see Ralph from the hallway. He's sitting in his favorite chair. He's got his nasal cannula  on and he's really short of breath and he's looking like he's tired and having some work of  breathing. But he's alert and he kind of like really, you know, gives you like a brief wave  when he sees you. So, let's move forward. So, now, given that information, remember Dr. Chang's  lecture about the sliding doors, you know, what would you do if you did not call 9-1-1? So,  we have two scenarios. You can call 9-1-1 or you can assess Ralph and the situation. So, which one,  let's, you know, type it up in the chat or say it out loud. Which one would you want to do? 9-1-1 or assess Ralph and the situation? Yep, I see two.  And keep in mind, the last time we went to his house, his oxygen was not turned on.  Hint, hint.  All right. So, good. But, I mean, I joked about that, but there's also, I mean, there's,  I, you know, it's not completely, you know, in a joke because you have that as a history, right?  And so, you know, in the back of your mind, it's like, well, if you didn't know Ralph, I mean,  this is the benefit of a longitudinal relationship. If you didn't know Ralph, you know,  your pulse might go through the roof and you might call 9-1-1. But because of that history,  as Megan said, it might be something to say, oh, let me check my own pulse and let's calm down and let's assess the situation as everyone voted. So, let's go to scenario number two.  No, relax. There we go. So, you decide you have further time to evaluate Ralph and to discuss, you know, determine if there are things you can do to improve the situation. So,  let's go into what you would assess at this time. So, let's go to the next slide.  Now, here are some choices. Which one would be your first choice, your second choice, and your third choice priorities-wise to choose from this list?  You can put your answers in the chat or just speak up. So, first choice, O2 delivery. Anybody else?  I see O2 delivery, I see exam.  Oxygen. The history exam while getting vitals and listening.  O2 delivery first.  I see two, one, and four. So oxygen exam and med reconciliation and diet and tobacco cessation as well. Okay.  Maybe consensus for oxygen delivery first. Yeah. And I mean, honestly, I think there is in this acute moment, very often, like we're assessing two things at the same time,  you know, as we're doing an, like we're putting a pulse ox and we're listening to the lungs at the same time. So it's kind of, you know,  kind of the kind of two things happening at the same time, but let's look at Ralph's oxygen delivery system.  Let's do that first.  All right. So he has his nasal cannula on obviously, and the portable concentrator is set at three liters. So what are your next steps?  And that's a question for our learners, right?  What are you going to do next? Is he getting oxygen? Is it delivering?  That's a great point. Right. The machine might be on, but is it actually working?  Okay, good. Increase O2. Right.  Excellent. Okay.  So let's see about any,  anyone else have a question? Sorry, any other answers? Oh, there we go. Neb treatment. Yep. Good. So yes,  like to see, check to see if it's working. If it's not, finds his portable oxygen tanks and set that up.  So afterwards, you're going to check his pulse ox serially  to see if there's an improvement. And if there isn't, then you can consider 911.  So fast forward, his pulse ox actually goes to 92%. He feels better.  So once he is stabilized, you check the other electric outlets. So, you know, this is a little bit of detective work. You know, if, you know,  if one outlet isn't working, you know, maybe is it, you know, is it a problem with that particular outlet? You know, we'll check and check the other outlets.  And then depending on the assessment, you know, contact the home office to, you know, either call the O2 company to fix the concentrator,  the electric power company, depending on what the electrical problem is. So anything else?  Actually, we talked about nebulizer treatments, Megan. Megan brought that up. So that's another good point.  Now, what else?  If there's anything else from the group.  If there isn't, we can go back to the initial. Yep, listening to the lungs and heart, which goes into the exam part. So let's go to, if we can click to the exam.  Okay, so we're gonna go to this? Yep, focus history and exam.  All right, so Ralph is alert and attentive. He's able to nod yes or no. We check his vitals. He hasn't, he hasn't any chest pain, fevers, chills.  The shortness of breath happened suddenly this morning.  Now, we talked about vitals. His weight is up five pounds. He's afebrile, blood pressure is fine.  Pulse is fine, respiration is 20, and he's using the accessory muscles, but less so now that his oxygen is working.  However, his breath sounds are diminished with a prolonged expiratory phase.  No crackles, bronchiorals. He has bilateral pedal edema though. It's a three plus, and that's new.  Good question. Has he taken meds this morning and in the last few days? Good question.  Well, what,  other, well, let me pause a moment and say,  ooh, changes in diet, too much salt, excellent.  I was gonna say, what's in your working differential? I won't share my thoughts, but can anyone else  discuss the differential, and based on the differential, what you'd like to ask about and find out more about? Thank you.  I see that Dr. Cheng had mentioned changes in diet, too much salt, so I'm going to extrapolate, you know, possible CHF exacerbation because he has CHF as a history.  Has he taken his meds again? Is that CHF?  Another possibility I was going to say is, you know, could this be a COPD exacerbation?  You know, given his history of COPD.  Yeah, you know, Ralph is depressed. I'm worried that maybe he's eating inappropriately. Maybe he's not taking his pills because he learned that his brother died.  Maybe he just got him into a tailspin. Maybe that has affected his compliance with his pills and with his diet and so on. He certainly can have COPD exacerbation  and maybe CHF, maybe he's got both.  And the final thing is we teach our residents here, you know, shortness of breath and leg swelling. We still think PE.  That's always in the consideration, especially in our patients who are sedentary. They don't get around very much. And I don't think he had a fever, right?  That makes it infectious a little bit less likely.  But, you know, in the era of COVID, yeah, sure, you know, can, you know, throw COVID in there, I suppose.  If there was COVID exposure or fever or other symptoms. Yeah. Yeah, and that's true. And, you know, there's a mix because we,  Megan and I think you, Paul, as well, had mentioned the, you know, if the death in the family and, you know, could he be depressed and him not taking his meds  or not eating appropriately? You know, there's also, because he's reliant on Reggie for his meals and for his meds,  was Reggie, if it was a recent death, was Reggie involved with traveling, you know, to the funeral and, you know, couldn't come back in order to take care of Ralph.  So there's the direct, you know, impact of his brother's death and the indirect impact as well.  So great points all around. Can we forward the slide one more?  Great, and this is very similar to what we had talked about earlier. You know, give nebulizer treatment, increases O2 concentration and more specifically, you know, before that,  make sure that the O2 concentrator is working.  Consider EKG and chest x-ray at home.  I just wanted to say though, you know, very often I see stuff done instead of an exam. And so if, you know, if there's JVD, if there's three plus pitting edema,  you know, you don't necessarily need a chest x-ray to diagnose, you know, CHF.  So, you know, that's why we say consider EKG, consider a portable chest x-ray if it's going to change your management.  Especially with no fever and improvement on replacing oxygen right away. That's a good point.  Assess medication and diet adherence, which is what we had talked about. Consider diuresis for exacerbation of heart failure or consider initiating treatment for COPD exacerbation  like short course of oral steroids.  In another scenario, if you're, so I don't know which practices use community paramedics,  but for our practice, we have community paramedics who can do acute visits when we're not able to. And with, you know, with online medical control guiding, guiding them.  And so sometimes if we have COPD exacerbations, you know, they can give neb treatments, they can even give IV, you know, dexamethasone or solumedrol  to help with COPD exacerbations as well. So think about other resources as well to help our patients get the care in a timely fashion.  So if we can go back to the original selections, yep. And let's go to number four, cause that was the next thing, assess medication reconciliation.  All right. So as we mentioned, Ralph's weight was up five pounds.  You know, when we asked how his diet's been with my, and he says, with my brother dying, my sister, Reggie's mother, went to the funeral down in Georgia  and stayed to put things in order. She's the one who shops for me and knows to get healthy, low salt food. I've been eating my Campbell soup. It's not good.  It's got good nutrition, right? So how do you interpret that?  Okay.  Increase the NACL in diet. Yep.  Increase, maybe too much salt.  It's time for meals on wheels.  Yeah. I would say, you know, at this point, you know, consider your resources.  And, you know, get them involved.  Meals on wheels, any other type of food delivery systems, those would be, you know,  those would be great resources to use.  Can we go forward one more?  I think we have one more slide. Could SN with HH help?  Oh, skilled nursing with home health. Sorry. Thank you. Yes.  That's another thing to consider. So, and I think, you know, this is, you know,  in terms of next steps, I think, you know, remember that illustration I gave with the refrigerator biopsy from yesterday. So, you know, very similarly, like ask  if you can take a look at the fridge and the cabinets and see, you know, what foods are accessible to him at this point.  Take a look at his medications. And we remember with the med management, make sure that, you know, making sure that the bottles, you know, taking a look at the pill box, you know,  making sure everything's clear and checking the bottles,  making sure that the meds are, the med list, his med list is up to date. Your med list is up to date. And, you know, and review strategies for, you know,  when he can take meds and how to store them. And then you take a look. So this is also when you're Sherlock Holmes and you take a look at other clues  and you see that his ashtray is kind of full and there's a cigarette, but that's pretty warm. So you can, you know, he's started smoking again.  Now it says when he is stable, begin a discussion about cessation. Is now the right time to talk about that?  To talk about quitting smoking?  Aside from using it, making the point that you can't use it with your oxygen delivery system. I would probably bring that up.  I don't know how everybody else feels. I like to remind him it doesn't mix, but.  I don't know about you guys. I'd be happy if you were eating properly because then maybe he might mentate better and remember to keep his oxygen on  and try to do all the instructions we give him. Yeah.  Yeah, I wouldn't want to overwhelm him with information, but I definitely would mention it.  Yeah, yeah. So I think the important part is the safety, you know, the immediate safety about, you know, not smoking, especially when you're having oxygen on.  But, you know, but to your point,  Talisa is, you know, about making sure that we prioritize strategies. And if there's, you know, what one thing or two things can we work on, you know, at this point.  So we tackled all three. And so I'd like to go to the next patient case.  But before we do that, if you can fill up,  and maybe fill up your care plan for Ralph while you listen to me read about Betty.  All right. So Betty, we're returning to see her for a routine home visit. You know, she's our 60 year old, morbidly obese Caucasian woman with multiple medical issues.  And she's been under our care for, just like Ralph for quite a few months now.  So before you see her, she called and said, you know, I'm newly concerned about the areas, the darkened areas on my legs. And I'm worried that I'm going to lose my legs.  So if we can move forward. So our plan for today's visit is again, to follow up on chronic diseases and med management.  Obviously to examine her legs and revisit the goals of care and further assess the safety concerns that we identified last time around.  Oh, yep. And just as a quick note, thank you, Sarah.  You can document all your notes, you know, all your care plan notes on page 102 of your notebook.  All right. So we are at Betty's home.  There's a lot of information here. So I'm just going to go over  some salient review systems and symptoms. I can advance to the next slide, which is a little bigger. Oh, excellent. Great, thank you.  So she has, she's got a pain in the neck that's worse with movement and it goes to her shoulder. She has an occasional cough and wheeze and shortness of breath.  She has orthopnea, so she sleeps in a recliner. She has dyspnea on exertion. She has heartburn at night when she reclines in her chair.  No GI bleeding, she has a rash in her skin folds.  Now her extremities, she thinks her skin is black and she has edema bilaterally.  She has diffuse aches and pains. She's got numbness in her feet. She has difficulty getting up out of the chair. She's depressed about her overall condition.  And she has some visual hallucinations. She's seeing visions of her mom who died recently.  Her blood sugars have been all over the place. They're between 40 and 400.  She's not really going through any specific diet. Mainly her sugars are in the 300s.  And then we can go over her exam at this visit.  So she's cooperative. She's in a recliner. She's disheveled though.  Her, let's see, her weight is 465.  Her blood pressure is 134 over 78. Temperature is 99 too.  Her visual acuity is like 20 over 70. She's got poor dentition. She's got halitosis.  Her lungs, you hear that she's got expiratory lesions on both sides, but no RALs.  It's hard to hear her bases.  She has a red, wet rash in her skin folds of her abdomen.  And she has chronic venous stasis changes.  There are some rough brown colored skin plaques scattered in her lower legs from the knees down.  They're tended to palpation and they're dry.  Neurological exam. She's got some difficulty raising her hands over her head because of some stiffness.  And she needs a lift chair in order to stand up.  She appears depressed, but she's cooperative and appropriate. And she's not having any active hallucinations.  And those are pictures of her home. And in the previous slide, you saw the picture of her dog.  All right, so the following slide.  All right, so let's pick three things that we'd like to address.  From this list. And as you can see, there are many more priority. Sorry, there are many more problems in the problem list than Ralph had.  I'm just happy to see the abscess is gone.  She did have an abscess that seems to have improved. I would make sure to point that positive factor out for us if she's got something to look at. Yeah.  And I have to say, so Megan, you bring up a great point. Very often we think of just problems that need solving.  But it's important to remember the successes that we've had and not just for us to remember, but for all us to talk about with the patient about the successes that they've had  and build up on those things.  Absolutely, to reward her for that. I mean, she's stuck in the basement, doesn't have much social interaction. I usually try to fixate on some of those positive things  that are going on to give them more of a goal for what they can still accomplish.  Well said.  So where do we want to begin?  So the primary concern, exam and medications.  We kind of already did the exam. I fast forwarded a little bit. So, but we can talk about the exam. I think it's important to do that.  So Melissa, can we take a look at the primary,  So Melissa, can we take a look at the primary concern? Yeah. Thank you.  All right. So we ask, what concerns do you have? And she replies.  So my legs, look at them. Why are they black? Do I have gangrene? All of my bones ache and I've got a splitting headache. My head hurts so bad that my vision is blurry.  Do you think they're related? Am I going to die?  So how would you respond to,  how would you respond to that? Like what things are first and foremost on her mind?  I think we have to address her question of, is this gangrene? Now, to give her some reassurance that it's not.  Yeah, I agree. It's the gangrene. But I think there was a comment there. As I've learned from my patients, I should say there's often a question behind the question, right?  The question is gangrene. But behind the question is this fear of, I think I'm going to die. I wonder what makes her think that. Is it a headache that she thinks she's going to die?  Is it the gangrene that she thinks she's going to die? Or is it that I have no future, that I'm going to die? Kind of stuff. So the question behind the immediate question,  I think it's important for us to find that piece of information as well if we want to take good care of our patient.  Well said. And I think along that line is, if we find out some information about that, like why does she fear that she's going to die, and it brings up  some additional concerns, anxieties, depression, it might shift. We talked about three priorities that we're about to talk about. But with that answer, it might say, OK,  we need to shift priority to active mental health issues or something else, or social issues.  OK. So let's go into physical exam, unless someone was going to say something. They made it a real point to talk about the blurred vision, which  could be from the hyperglycemia, the headache. She's got kidney disease. Are we over-medicating her? If I recall, isn't she on metformin? I think we mentioned it yesterday.  So she's got so many opportunities. Maybe we're just killing her with medications. I mean, she's got medical problems. But I think we've got to also really look at maybe  we're hurting her, too. Yes. Well said, yeah. And I think somebody also put down their PMR, polymyalgia rheumatica. Certainly, the case is teasing us.  She's got the stiffness, got the pain, can't raise my arms. Now she's got the headache. Does she have a TA on top of her PMR? Then you're thinking, am I going to give her prednisone  on top of her hyperglycemia? So that's just adding to the complexity of our consideration in this poor lady.  So just going into the next thing with the physical exam. So on your exam, Betty does not have gangrene. Her legs are black because of poor hygiene.  And I believe, yep, and it says in the further down, she does have changes of chronic stasis dermatitis. She has no open ulcers or cellulitis. Her abscess has healed.  And her neurological exam is unchanged. So now, how would you address the issues and maybe her primary concern again, like going back to her concern about gangrene?  Yeah. Reassurance. Yeah.  And what advice would you give her about her about her legs?  I think we also have to keep in mind she may not fit in the shower.  That may be, you know, so I would tread carefully on how I would put that to her. I would try to look into what what is the bathing situation  for her. Is there opportunities or is that a problem?  Yeah, it's a great point.  Either is she, can she not fit or is she too unsteady because I believe that mobility was an issue as well. And if I remember there wasn't a shower chair or maybe that might  have been Christina. But I don't think there was a shower chair or grab bars in the bathroom.  I really like the comments about reassurance and alleviating her fears and then just really getting on her level and just demonstrating to her like, you know, look, you know,  your skin is fine. You're okay. Again, you know, using this, just like her, what does she have,  just like her abscess, we're looking for that. We're looking for a quick fix here in this  patient who doesn't give us a lot of quick fixes, right? So we're going to take this opportunity  to do a quick fix. Again, building that trust, that relationship with her upon which you can,  you know, work with her and say, you know, let's work on this next step. How can I help you? Are you open to trying this, that, social worker, meals on wheels, whatever it might be.  So using this opportunity to alleviate her fears, take care of her primary, one of her primary concerns. And then I think that probably as important as anything is building that,  gaining that trust from the patient.  And you see here, Laura said, focus on the simple things that can be proactively done.  Hygiene, elevation, compression, stocking, skin.

Video Summary

I apologize for any confusion, but the provided summary does not include any specific video content or credits. It appears to be a transcript of a discussion or presentation covering various topics relating to healthcare, including strategies for handling durable medical equipment orders, the role of home-based primary care, marketing opportunities, state licensure standards, population health management, community outreach, and partnerships with home health and hospice agencies. The summary also mentions the importance of addressing immediate concerns and building trust with patients. Can you please provide more specific video content to summarize?

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Essential Elements April 16 Video 1 of 2
Main Session and Clinical Break Out Sessions
*please see Video Time Sheet for breakdown of video sessions*