this case, you know, involve home health, you know, involve home care for some, some skin care slash wound care. Well, she doesn't have a wound but for skin care. Okay, let's go to now let's go to what was what was our number three? I forget what we had talked about home health to help wash up. Excellent point. Veronica, you know, we talked about medications, but also active mental health issues. Okay, let's let's go through. Let's go to medications. Actually, let's go to both but first with medications. All right, so you say you stopped several meds since the last visit. So let's take a look at your meds together. You have a lot to keep track of. Can you tell me how you get your medications advantage? He replies. Well, since I can't leave my house and my husband travels for work, my daughter picks up my medications. I try to follow the directions on the bottle. But to be honest, sometimes I forget to take them because I'm tired. Plus, I don't know why I'm taking them. I you know, I worry about all these side effects. So the next question is what additional issues did Betty's answer reveal? The worst and possible next steps. To me, it sounds like we need to start reducing some of her medications before she makes those choices for us. So that way we make good selective choices about what's removed out of the pill box. Excellent. And I like that point, doing it first before she does it for us. She's doing it. And I think Talisa makes an excellent point that we really have to be fair to her financially. We don't want to add something if she doesn't have the money and we need to start trying to see what we can do to save her money so she'll buy into the process. That's a great point. And Veronica had also mentioned, you know, can she read health literacy? That's important. Or can she even see? She told us about her blurry vision earlier, you know, health care literacy, but also just her vision. It might not be great and she might not be taking the right meds anyway. I mean, it might be an education issue as well. So what are some possible next steps? We talked about deprescribing. So that's one step. Dark basement needs lighting, right? That's an environmental improvement that would help her. And also probably help her mood while we're talking about that. Not just her vision, but her mood as well. Anything else? Any additional next steps? I think it's really important to a couple of things to educate our patients. Whether it's a social thing, a vision thing, literacy thing, and so on, you know, we're medical doctors. We write prescriptions. We can look at it another way that our scalpel, we don't have it, we don't carry scalpels, right? Our scalpels, it's our word. What we teach, how we educate, that's our scalpel. We need to be really good with our words, whether we're talking about a teach-back method with medications and so on, or you're talking about end-of-life goals of care kind of conversation. So I think it's really important for us to take time and talk to them about their pills, ask them if they have any questions or concerns, just say, you know, do you know why you're taking this particular pill and so on? And as I have learners here rotating with my practice, I tell them probably the longest part of the visit is about what? It's about, you know, going over their 18 pills and trying to answer questions about the pills that they have, right? So be patient and take your time. Don't try to rush through all of that because it is time-consuming. I don't know of an easier way to get through what we need to get through with these complicated patients. Great. Well said. Does anybody, down here in Florida, everybody has their blinds closed and usually they keep the area dark because it's hot. Do you run into that where you're at that I can't get them to turn lights on or open the blinds because it's air conditioning or light, it seems like, and it's frustrating, but I'm not sure what the answer to that is. Yeah, I haven't really prescribed light for, say, if you've got seasonal affective disorder or a sleep disturbance, that prescribing appropriate lighting within a certain number of locks may help with mood. I really haven't used that modality often with my patients. And you just brought up the lighting thing. I'm wondering if, you know, maybe we should have thought of that with Betty and see if we can help her with her circadian rhythm and also with her mood. Just an observation because the homes I go into, they're dark. They're all dark. And it's because they're choosing to try to keep the home cool versus letting it get hot during the day because it's so hot here. But anyway. Well, thanks, everyone. So please just make sure to fill out your care plan for Betty. And then now we're going to go see our new patient, MJ. So the information that we have is that he's obviously he's a new patient who was discharged from the hospital yesterday and he was discharged for belly pain. So we can review his case with the demographic details. We'll actually do this in the upcoming slides. So we'll go over each of these. So his demographic intake form, we'll see, you know, we see that there, you know, primary insurance, Medicare, Cigna, I think it says HealthSpring as well. Next slide. And this is his home. We see him and his niece Olivia for the first time. We view his systems and symptoms as well as his findings during the exam. So his systems and symptoms are increasing dysphagia, weight loss, increasing tremors, increased trouble walking due to his Parkinson's and arthritis in his knees. And his blood sugar is 195. Oh, yeah. And the case study is on page 94. Thank you, Sarah. Blood sugar is 195 and he's got a protruding inguinal hernia. I have, let's see here. Because I speak Greek and I know Greek, I can read that last, that bottom part, but I think it's blurry on my screen, so I can't really see, but I know he's saying, it's saying something on Monday, Wednesday, and Friday. So I think it may be warfarin, I don't know, but I have no idea what that really says. Okay. So yeah, here's another way we saw that. We talked about that and let's go to the next one. So so let's go over what we would like to do. Again, the three main topics that we would like to tackle. And yeah, as you'll hear or read on the case on page 94 of your workbook, MJ speaks primarily Greek but his niece Veronica helps with translating. You know, his household doctors were very interested in reducing ER visits and 911 calls, right? Why is he utilizing the high cost centers so often? I think that will be one of my interest in terms of what I wanna get out of this particular visit with MJ. Yeah, frequent 911 calls. Would you like to start there? Let's do it. All right, sounds good. Okay, so you say to Olivia, you've called 911 on several occasions. What were your reasons? And she replies, he has a hernia that sometimes bulges out. I was told that he could die if it's not put back in. So frequent 911 calls or ED visits even are common among home-based primary care patients. So what are things that you can do for MJ to avoid unnecessary use of ED visits or 911 calls? Education. Mm-hmm. If no pain, push hernia back in. Yeah. Show him how. Great point. Yeah, not just education by telling, but also by showing. That's a great point, Veronica. Mm-hmm. So there's a lot of fear, right? Just like the last case with Betty, there's a fear of my legs. I'm gonna die because I have gangrene. And Olivia is afraid that he's gonna die because his hernia is gonna get stuck, right? So again, as providers, this is another easy, again, an easy fix in otherwise can be challenging situation. Again, to build that bridge, build that relationship with the patient and their loved ones. And I also would like to say that, just building off on what you had said earlier, Dr. Cheng, was the issue of trust, right? If there's, you might make recommendations or you might say, oh, you don't need to call 911, but if they don't trust you or if they don't trust your process, your system, you can call us 24 seven, then they might still get in that habit of calling 911. So I think it's also important to build trust and build rapport. I think it's also important to tell them, just like Betty and Ralph and Reggie and so on, what to look for when things aren't going well. Of course, we hope that Reggie or Ralph, his breathing gets better. We hope that MJ's hernia never comes back. But again, I think it's important for us to be educators and say, hey, these are the things to be on a lookout for. In Ralph's case, like shortness of breath, weight gain and whatnot. In MJ's case, like if he's having worse pain, if he's vomiting or other symptoms, clearly put that out for Olivia so that she feels equipped to handle emergencies or urgent situations. And also that she has a number to reach you in case there's additional questions or if she tried to reduce it and she couldn't. Yeah, and I like Dr. Walker's point as well. Yeah, just use an alternative source to call. Excellent. So can we go to the main screen? Yep. So what else would we like to address at this visit? Falls and polypharmacy. All right, let's do the frequent falls. So I saw from the notes that he's had a few falls, he said to Olivia, so tell me more about that. And she says, he's fallen a lot. It's terrifying. Last time he fell right after I left for work. He wasn't near a phone and couldn't get up. When I came home, there he was. I felt awful. And he replies, don't worry about my falls. So MJ has a walker, but he doesn't use it properly. So how would you assess and manage MJ's numerous falls? And does he need to move to a more supportive environment? So the question is about orthostatic blood pressure, polypharmacy. That's a perfect answer about the orthostatic. All my residents know now when they come, like, yeah, when there's a fall, Dr. Shane wants orthostatics. That just become like, yeah, they all know. That's what I'm asking for. Again, we're looking for that easy, simple solution that could have an enormous impact on this guy's life, right? We could be preventing a hip fracture and a prolonged stay in a nursing home, but even maybe death. So little things that we can do. Don't underestimate that. Yep. Valerie, good points. Veronica as well, get PTOT assessment for fall risk, environmental assessment. Excellent. What about Olivia's guilt? Look at that last sentence or last comment. I felt awful. Anything we can do to help alleviate some of her worries and her guilt and so on. Assuming we've optimized his meds, we got PT in there and so forth. Yeah, she sure sounds like she's under a lot of stress and burden. Laura makes a good point with the med alert system. Some sort of alert device. Mm-hmm. I like Valerie's point. Address interventions she can have control over. Yes. Yeah. My patients and families are very creative. Some of them, one of them actually installed one of those ring doorbells, except they installed it on the inside of the patient's bedroom. So that Olivia, when she's at work, if she wanted to see the video of the patient, that she could just use that as a way of having be, because you can talk through the ring doorbell as well, as well as having video. So that was, I thought it was a very creative way of monitoring mom or dad when they had to go to work. Yep, baby chems, I see. Yep, that's a good point. Did you wanna go next to polypharmacy or caregiver stress? Polypharm? Let's survey the group. Polypharmacy or caregiver stress, one or two. And we probably have time for both. I'll share for this one. All right, let's do caregiver stress and then we'll do polypharm. All right, so you say to Olivia, caring for a loved one with conditions like your uncle's can be difficult. How are you dealing with the stress? And she replies, not well, I'm exhausted. There really is no one else that can do it. I haven't had any time away for nearly two years and it's 24 seven. And just as an aside, how often have we heard that phrase? So you say to Olivia, tell me about a typical day and she replies, so we're up at 7 a.m. MJ can get out of bed himself if I help him dress and get cleaned up. I make breakfast, but he can feed himself slowly. During the day, he sits in a recliner and watches TV. I work in the middle of the day, but leave lunch in the fridge. Sometimes he eats it and he's back in bed by 8 p.m. So the questions, just also as an aside, there's also significant financial stress because of costs of caring for MJ's wife, because she has advanced dementia and she's living in a facility. So that's adding to the complexity of taking care of MJ. So how do you assess Olivia's stress and what resources are available to assess and manage her stress? That's a great point, Laura. She mentions that if he's hospice eligible, they may qualify for additional resources and even if he still lives another six months and beyond, I mean, that might be a great resource for them. Sorry, is MJ and Olivia, how connected are they with their church? I was thinking, perhaps, does the church have any kind of a day program or a friendly visitor program that could come and be with MJ? That's a good point. Go back here. There is a spirituality thing we could look at. You might be a good candidate for a PACE program, Dr. Walker says. And there are some programs over in Massachusetts that Dr. Bender was talking about. We might need Medicare Advantage. And this is where the Aunt Bertha site comes in, too. Sometimes that might pop up additional suggestions if you've exhausted a lot of resources. I believe we have five minutes left, so let's do the polypharmacy, and then we'll adjourn before our break. So, MJ is on multiple meds. You review his medication list, including OTCs. You reconcile, you justify them. You ask MJ and Olivia how they organize his medications to try to make sure he's always on schedule, and she replies. Oh, there's no reply. I'm not sure why there is no reply. Okay. So how do you approach MJ's polypharmacy on a first visit? I was going to just see if I could pull up his med list. Here we go. Yep, right there. Can we zoom in a little bit? Sure. So it looks like he's on lisinopril, atorvastatin, magnesium oxide, insulin, glargine, furosemide, spironolactone, omeprazole, aspirin, warfarin, tamsulosin, trazodone, metoprolol, cinnamet, latanoprost, eye drops, insulin, lispro, ibuprofen, and timolol. Quite a lot. Yeah. So let's see. Are there meds we can get rid of? So statin, furoselactone, lasix, fumidin with the falls. And it seems like there's duplication of medications or possible low yield, low benefit medications. The statin, for example. One of the things, whenever I see omeprazole, especially in patients who are, is was omeprazole in the med list before they went into the hospital? Very frequently, it's one of those checklist meds that never come off the checklist. So, and think about that as well. Okay, great, so there's, stop the sliding scale, great. Aspirin and Coumadin. Especially, you know, I would say, you know, and I think this is, I think we've talked about this a lot over the past couple of days, you know, risks and benefits of all medications. Taking these medications, do the risks outweigh the benefit? And for this patient, I think I would say yes, especially with these balls. So. Okay, well, I think we are close to time. So what I'll ask everyone to do is to fill out your care plan at the, for MJ on, like, you know, blinking out on the page at 1.30. And, or sorry, maybe it was 1.04. And then we're going to be going on a break soon, right, Melissa, and then, you know, we'll come back for the debrief and coding. We'll do coding for each one, two, three. Right. Three patients. So we are scheduled to return from our break at 3.20 central time. So in about 15 minutes, you get a little extra time. All right, and we'll debrief and we'll talk through those care plans with the larger group. Okay. Thank you. Thanks everyone. Hello, everyone. Hopefully you are refreshed and ready for the debrief, which will start in just one minute. Okay, I believe Melissa is going to be sharing her screen with us again. Are we good to go? Everybody good to go? Dr. Della Giannidis, you feeling good? Yeah. Hi, guys. All right. Costa, do you want to go ahead, and I will pull up workbook pages. Or here, you know what? I'm going to do something else. Okay, so, Dr. Dela Giannidis, we have a plan for our debrief today, right? Can you all hear me now? Yes. Okay, great. Sorry, I couldn't get off mute. I'm sorry about that. So yes, so welcome back, everybody. And I just wanted to just go over just the overall clinical scenario. So we had three patients that we saw today. We had Ralph, who was a follow up visit. We had Betty, who was also a follow up visit, and a new patient, MJ. So what I'm going to do is I'm going to ask Talisa to present Ralph first and go over kind of like, you know, the different, you know, teaching points at the end of the case presentation. So take it away. You'll have to forgive me. I'm actually switching between screens here so I don't have everything fully at my fingertips but Ralph is a approximately 70 year old widowed male who lives alone independently in his own apartment. Poor neighborhood, some gang activity. And today he came to us as a follow up visit that we were reviewing on the last case but previously new to the practice has oxygen dependent COPD, congestive heart failure, ejection fraction about 40%, coronary disease, peripheral vascular disease, falls risk. I believe he has a fib. Lots of medications. And I, you know, I think the big issue for me was a lot of the social things that were, you know, affecting his care so living in a poor neighborhood. He's dependent for medications and for his food and so, you know, diet restrictions are difficult for him to adhere to. And then, you know, does he get his medications, he has had frequent exacerbations of his COPD and his congestive heart failure. So those were always concerns. Use of his oxygen and, you know, his living environment so smoking with his oxygen concentrator. Those were all concerns for all of us as we were reviewing the case. Some social isolation. He's widowed, recently lost, I think it was his brother. So that was also a concern with depression, along with all of that social isolation. Just seemed to have a lot of very little support. And so, you know, and then falls risk, along with all of that so I'm not sure if there was anything else you wanted me to go through. So, the, you know, I. So when we did the, when we did the visit, and his visit became, you know, initially was a follow up visit but then there was an acute issue that came up. How did you prioritize like what you were going to address because they were like, I don't know we had six different things that we could address and and kind of like, how did you choose to pick which ones or which ones were the top three that you're going to address. Yeah, so initially he was a follow up visit family had called that his oxygen saturation was really low and that he, he was really short of breath so upon arrival we, you know, the first things that we are doing are sort of, okay, you know, does he have oxygen is it plugged in and delivering oxygen, and then, you know, we sort of did this acute setting vital signs history and physical exam altogether. You know, did it was he taken his medications that day or previous week, we found out the brother had just died. So he hadn't received his, you know, the food that he normally had so he was eating Campbell soup and. So, you know, we were prioritizing the acute issue along with the social issues that went with the acute issue. So the shortness of breath. You know, likely secondary to congestive heart failure, because of the recent diet changes because he wasn't able to get out to the grocery store, or didn't have family to get out to the grocery store and shop for him. And then question of whether he was actually taking his medications. So we prioritized the acute issue and then the social things that came went with it. I think it was, it just goes to show you know we talked about the, you know, the four M's or, you know, five M's, you know, with that multi complexity. And, you know, how, you know, it's not just a disease process, you know, in isolation, you know things mesh together so you know the social aspect affects the. And the medication management, which also affects the health conditions the CHF and COPD and everything so there's, they're all intertwined in that, you know, that adds a layer of complexity. My, my, my question that I had that I had for you as well was, you know, in terms of the, the care plan, kind of like the things that you had, you had come up with. In terms of a treatment plan and the care plan. You know, what did you include in. Why did you include them in them at that visit. And then, and then I have like a follow up question after that. In terms of the acute issue it was did he take his medicine that day. Do we need to sit here and help you know make sure he has his medicine, going through the pill bottles to make sure they're even one are they being taken and are they were they taken that morning, making sure that his home was a safe environment so the smoking, obviously when he is there with an oxygen concentrator instructing to make sure he's not smoking with the oxygen concentrate are going to wearing the oxygen. And then I think to me that was a big, the biggest issue at that moment in time was, you know, and then I think also, you know, talking to him about, you know, if this type of thing happened again what his resources would be for, you know, call the office, could you call you know someone else for help, depending on the local resources there. So I think those were the big things for the acute visit. Yeah, and, and, and, and that was that's well said, you know, it's, it's, it's important to involve resources, you know, to enlist the help of resources like, you know, the, if the concentrator isn't so for example like I mean, not just for him but for anybody if someone's on a concentrator and there's no concern about equipment. And, yeah, so just, you know, knowing, knowing the resources and enlisting their help. And then I just another, another question I also have for you was what factors. Did you consider in the, in the. Sorry, what what factors in the visit with Ralph were different in the home setting than what normally would have been in a office setting. So, one you get to see where he lives and what the living environment looks like his safety, his equipment their medications. That was one of the things that always drew me to home based primary care was the fact that you, you know, sometimes these patients that would walk into a clinic, that would be the only time in three months that they would leave their house and that was the only time they ever showered. And so you know you get to see these things you get to look into the refrigerator into the cabinets and see what they're eating do they even have food, do they have working electricity and working water. So, being in a, in a home setting, you know, you see all of these things that you would never get in a clinic. And that's that's one of the one of the great things about, you know, seeing patients in, in their true context, and not in a artificial facade that it might be in an office setting or, you know, clinic setting hospital setting one, or what have you. So thank you, thank you for that to Lisa. So, now I want to ask. Let's see. If we can go to MJ. Actually, can we can we skip forward to MJ a little bit. And Laura, Laura, can you can you present MJ and bring up kind of like the teaching points for his case. Yes. Just getting the file up in here. Okay. So MJ was another case that we reviewed. And this was actually a new patient visit. He was referred to as post hospitalization. And he's an 82 year old male from Greece, who's currently living at his niece's home. It turns out that hospitalization is a frequent problem for him he's been hospitalized six times in the past seven months, and oftentimes has not been able to see his PCP because of the frequent hospitalizations and calls to the EMS services. We do have some home health care, and we actually did get a handoff from home health, where they called and reported some of their concerns to us. And this most recent hospitalization was due to some abdominal pain. It turns out that he has a large left inguinal hernia that frequently protrudes and causes him to seek emergent care in the emergency department. Because he's a poor surgical candidate due to multiple other health concerns, but there's a fair amount of anxiety surrounding this recurrent hernia issue, because his niece is under the impression that this could be a life threatening problem. If his hernia were to be protruding. He has multiple other things going on a history of stroke, hemiparesis, diastolic dysfunction, diabetes, atrial fibrillation, Parkinson's disease, hypertension, osteoarthritis, and more. He is living with his niece, Olivia, who works outside the home. And that's been a stressful circumstance because she has been required to go to work, and then he has fallen while she's been at work, and that has caused her to feel very upset because she wasn't there for him. Additional stressors include that his wife lives in a nursing facility due to dementia, and that's caused financial stress on the family. Review of systems is positive for a variety of things. I mean, he kind of has lots of symptoms related to his chronic conditions. Most remarkable is fluctuating blood sugars, he's weak, he's falling, his gait is impaired. He has some leg swelling, difficulty sleeping, some dysphagia, with a recommendation from the hospital that he should be following a modified diet for aspiration precautions. And then his medication list is quite long. Most notably, he's still fully anticoagulated due to that history of the stroke and the atrial fibrillation. He's on insulin, on statin, proton pump inhibitor, lots of meds on his med list. And then in terms of some of his screening questions, he has a positive PHQ-9 with a score of 10. His home environment is well kept and clean. Clearly, his wife is a, or sorry, his niece is a very devoted caregiver. The fall risk seems to be connected to the fact that he has a wheelchair that he's not using. He has a walker that perhaps he's not using appropriately. In terms of his social history, he has a Greek Orthodox Christian faith that's really important to him. But as his health has declined and he's become more homebound, he's not able to participate in his faith services. Very reliant upon his niece for her assistance. He may have some communication challenges. He does speak English. He's been in the US since the age of 14, but his preferred language is Greek. And I think we talked about some of the financial concerns. The fact that he's essentially homebound other than when he's going back and forth to the hospital. Physical exam showed that he has some Parkinson's findings, a bit of a flat affect. Not much else noteworthy there other than he's a little bit orthostatic on his orthostatic blood pressures. He is fortunately a DNR. And so there's been some planning made for that. And he prefers not to be re-hospitalized. So as we kind of talk through this, with a case like this, I think one of the concerns is there's so much going on. You kind of have to try to prioritize in a patient-centered way in terms of finding out from the patient and his niece. What are the things that are the most urgent and concerning to them at this time? And then trying to kind of hone in on those so that we can offer some tangible and useful information on this first visit as we're just trying to get to know them. And so I guess our first question kind of centered around, what is it that's leading them to call the ambulance, going to the emergency room? What's kind of behind these frequent hospitalizations? And when we found out that there was maybe some lack of information surrounding the definition of a true emergency and necessity to go to the emergency room compared to something that might be communicated or dealt with in a different way. We talked about how offering the niece that education about life-threatening illness, why to call 911, what might be something that could be directed to a different agency, like a call to the home health service or a call to the home-based primary care service, so that there weren't as many misdirected attempts to seek care in an environment that really was not the best fit for him. So we talked about that a bit. Then we also discussed his frequent falls and trying to kind of get into a better understanding about what could be causing the frequent falls and what could be tangible things that we could do in response. So we talked about home safety, education, reviewing his medications, considering home occupational therapy or physical therapy for fall assessment, optimizing treatment of his Parkinson's disease. We also identified caregiver stress as a real issue, considering his niece was definitely feeling the strain of caring for her uncle, and talked about some suggestions we may have for her, such as considering a hospice referral, considering a med alert-type system, so if he were to fall, she would be aware of it, or some of the other technology, like a baby cam, where she could keep an eye on things if she has to be away from the house, talked about how there might be resources in the church or the community or other family members that might be able to help her out, and then also just talked about how we could be part of the solution in terms of supportive presence in the house and a source of information and support for her. We worked on polypharmacy with him, looking through his med list, trying to identify some medications that were high risk for him in terms of his geriatric risk and the medications that may actually at this point be causing more potential harm than good, talked about potentially discontinuing his anticoagulation, his proton pump inhibitor, adjusting his medications to prevent orthostatic hypotension. And then we also kind of talked a little bit about plans for the future in terms of where to go from here, recognizing that we didn't want to be an overwhelming presence with, you know, too much information, but also the importance of following up because there were a lot of items that we also recognize is important that we did not address in detail during this visit just for time constraints and then also kind of information overload. Thank you so much. And, you know, I think, you know, I think one of the things that I think you, you had answered, you know, some, you know, answer the questions I was going to ask and follow up the, I mean, very similar, similarly, you know, to the question I asked Lisa was, you know, how would, how would a visit like this in the clinic look differently and result in different outcomes than in, in, in, in the home? Well, I guess it just is so, this is so much richer in terms of the information that you get about his surroundings, you can kind of picture the circumstances of how he's there by himself and how, when, when she's not there, what it, what it would be like for him to be alone and, and, and trying to kind of fend for himself. I think too, there's that degree of, of, of trust and helpfulness that comes from, from offering them a service at home that they probably have not had access to before in terms of, you know, the case mentioned, he's hardly able to get to his primary care physician appointments because he's so commonly in the emergency room or the hospital. And so I think that the presence of the team at home coming to them where they're at and, and proactively looking at his circumstance in a collaborative way probably just sets up a little bit different dynamic where they feel like they're, they're, they're discovering something they didn't have before that I think would hopefully be pretty helpful for them. Great. I agree. I think, you know, and, and, you know, Laura and Talisa, both of you were just, you know, just saying, you know, how, how much more information we get at the home. It's such a richer experience. It's, you know, it truly is. And, and, and it allows and, you know, it allows, it allows for real life plausible solutions to thinking about solutions in a vacuum, you know, and, you know, it might, it might be, for example, you know, the baby cam, you know, for, for his house, it might work for another house who might not, you know, so it's, it just, it depends, but you won't know unless you actually see the home. So I totally agree. And this might be the lines a little bit, but the home health nurse did a tuck and visit and then calls to kind of do that handoff. And I think now which would share he have done that if this was just a regular PCP kind of appointment, I think it's sort of that strength in numbers approach of, of, I could imagine as home health nurse, when she's coming into this environment. She's probably overwhelmed just as we would be of holy moly. There is a lot of things that need to be worked on. So I think that that potential for collaboration there and, and passing the baton and, and working together on some of these things could be just, just building from there. And then I think that also demonstrates trust for the, for the patient and his family that, that now there's, you know, two resources that are coming to the home that are going to collaboratively be of assistance. Also, it's interesting, I think this is the first time. Did you have a volunteer that can present? Laura, what were you saying? I was just going to say that, you know, as I was reading the case through a moment ago, he prefers not to be rehospitalized. And it's just so interesting because, of course, that's exactly like the path that they have been on has been one hospitalization after another. And yet their true goal is to not have that happen. So that's kind of exciting, too. Alignment of goals. So do we have, can I get a volunteer in terms of presenting Betty and her case and the teaching points? If not, I'll go. All right, I'll go. See here. I don't know. I don't know her stats here. She, I believe she's in her 60s. And she's, she has, we're seeing her for a follow up visit. She has multiple, multiple medical conditions, including obesity, type two diabetes, major depression with anxiety. She has migraines, PMR stage three CKD. I believe she also has COPD. And basically she, she's in. She's in the basement of her, of her home. She has chronic, chronic pain. She's unsteady on her legs. Partly because she's, she has numbness in her on her legs, but also has, but also has generalized weakness. She is in the basement of her home dimly lit basement and depressed has some social issues with her husband being away most of the time. Her daughter and her daughter is her primary caregiver, but they don't get along all the time. And maybe that's putting it lightly. And, and she's in the update is that she had, or actually at the last visit, the first visit, she had an abscess, which we took care of at that first visit. When we see her on update that abscess has not come back. It's completely resolved. But she brings up a concern in follow up that she's her legs appear black to her, and she's afraid that she has gangrene. In addition to that, she, her mom just recently died, and she's having some visual hallucinations. She also has blurry vision. Her blood sugars have been all the way, you know, from 40s to 400s uncontrolled. She hasn't showered. She's not eating well. And, and it kind of like the teaching point that I found was that there was a lot like when we when we had our kind of like, you know, our screen where we can choose different different problems to address. You know, I think Ralph had six. Betty had I think 16. And, you know, and I think we all felt it, like, where do we begin. And I think the, the easiest way to begin was, you know, begin with her chief concern. And, and that was the, that, you know, that was the concern about her legs. And if it was, you know, if she had gangrene, fortunately she doesn't have gangrene. She had some stasis dermatitis, and also some hygiene issues that she needed cleansing. She needed bathing. And one of the, you know, one of the things that came up with was came up during our discussion was, well, you know, if we just made the recommendations, oh you know, go ahead and, you know, go to the shower and bathe. You know, that might not, that might not go over well. Just to, you know, put it that way because, you know, is it, she's like 480 pounds or so she's, you know, does she even, you know, does she fit in the bathroom. Number one, number two, she has unsteadiness in her feet, she doesn't have a shower chair she doesn't have grab bars, is she a fall risk going into the shower. Can she even, you know, make it and walk it, walk into the shower. So, you know, so we had to kind of come up with ideas of well what can we do. What were quick wins. And I think that was the phrase that we we use what were quick wins that we could improve her legs, so that she, so that she felt like things were moving in the right direction. The other thing that kind of like is compounded to that was the polypharmacy cheese, as you can see on her screen. She's on a lot of medications. And the question was, given her kidney function. Is she on medications that we should be prescribed. And, you know, there are some that that we felt like she, she should like metformin, for example, that we should, we should start cutting down. And the question came up. Well, was, you know, if we don't de prescribe, will she will she de prescribe on her own for us. And it's, it's a, it's a really good point because, you know, there's one thing, you know, it's one thing where we can have like a strategy to de prescribe. And then another, you know, and the other scenario might be the patient to say, you know what, I'm just not going to take half of my medications because either I can't see them because she has blurry vision, or I don't know why they're why I'm taking them, or they're too expensive, or I forget all the different dosing somewhere one once a day somewhere four times a day, you know, all of that. Keep by keeping it simple and by reducing the pill burden. That might be a quick one for her, and it might help her financially and it also might help her symptomatically. So, so those were, you know, it with with all of the different things that we could address some were some had some were the proverbial low hanging fruit that we could we could pick and we could address. And some were if there were some solutions that if we did them. They might yield a benefit to the patient but also a benefit in the therapeutic relationship between the patient and the provider. Then we felt like if we do that, it'll just gain momentum so that we can address more long, long standing issues that that needed addressing. But the other important part for her was also involving resources. Physical therapy occupational therapy, home, home health for her for her skincare. I think those were the ones that we had come up with from from from the group any anything else that I that I missed. You know, for when I saw Betty. And I don't know if I said this before I probably have. When when I saw Betty, she, she's, she was overwhelming. And like I said I really had to take a deep breath and get a little bit of time for myself to focus and and to think about you know what I want to do next. It is absolutely true. So true. If there's if there's a quick fix, you know, taking care of the issue that the patient was most concerned about. All right, and addressing them, whether it's to access the first time or the follow up, you know, she's worried that she's going to die because she's got gangrene in her legs. So taking care of her concerns. I think there are two reasons. One is a therapeutic reason, whether we're talking about just cleaning her legs, or we're talking about training access, but I think more importantly, it builds that trust that relationship, which is so important in taking care of patients who are complex like MJ, Ralph and Betty. We need that trust from them, because we're going to start making changes, whether we're talking about medications and so on, or even talking about more serious things like end of life decisions and goals of care discussions, they need to have that trust with us. So I think it's so important for us to recognize, you know, for me, for me, for me, home based medical care comes down to essentially three things. One is recognition. And two is connection and three is implementation, recognition, you know, when I bring students here and residents, I said, I need you to have all your all your senses on, you need to be fully awake, fully engaged, your eyes, ears, your smell, whatever. And your intellect, obviously, gather as much information as you can about the patient as you're walking through the door, as you're listening to the interaction between the patient and the family, recognize what what are some of the pressing issues here that I need to address. And when you make that recognition, you can make that connection with the patient and the family, you know, I recognize your need for this, I recognize your fear like Betty, I'm going to die. I recognize your fear behind your question. All right. And so you can make that connection with with the patient in a deeper level. And finally, as Costa said, you can then implement a care plan that's consistent with the patient's goal with their concerns and their problems. And in a way that's plausible, I often used the illustration like, you know, you need a Hoyer lift, but the apartment is so small, the Hoyer lift is not going to work. Right. So I encourage you to to recognize both, you know, medical things and social things as you walk through the door, trying to make that connection to your great, compassionate, caring manner that you you you go about doing a home based primary care, and then come up with a plan, really, that's tailored for our patients. And it's really consistent with their overall goals of care. But with a case like Betty's, one of the things that is so hard about it is even just reading about it, never meeting her in person. As a, as a, as a clinician, you feel your blood pressure starting to go up and you start to feel a little anxious, because you're thinking, Oh my goodness, there is this is this is not a good deal. And, and then I think about so what strategies do I have for that sense of being completely overwhelmed and not knowing where to start, and trying to sort through something that's so complex and then of course all the self doubt comes into play where you think, you know, what am I doing here what am I going to do about all this I, there's no possible way that I can be everything I need to be to this patient. And I think that it's just that I think it's just that come down to the simple things that writing down the pressing problems, writing down the plan for the pressing problems and even if your plan for the pressing problems is, you know, skin lotion for the dry skin and that's your plan, then at least you've kind of started to tease out some of the things that are manageable and start to create some sense of order in the chaos, which I think then helps you think more clearly and feel more confident and project a sense of professionalism to the patient rather than looking like you're, you know, don't know what you're doing. Great comments. I think it's good to number one take like I said take a deep breath, and just calm yourself number two remember you can't fix all of this in 123 tries remember that PD plan. Implement, adjust and reassess that complete set you got to keep going back and do that cycle over and over again. I think one of the tendencies when we have when we, when we see a patient like Betty is, oh I don't want to take up too much of your time to see patient I don't, I don't, I don't want to see her back for like three months. But that's exactly what she doesn't she does she needs a lot of high touches right and frequent touches for for you to gradually chip away at some of these issues that that needs to be addressed. And your comment about you know who am I be careful with that. Think about what kind of care. She would have if you didn't exist. If you didn't go to her house. What is she left with our fragmented broken healthcare system, and the emergency room. Right. Is that, is that the kind of place you want to send her, honestly, we know we all know that's that's not the solution. Don't underestimate yourself, one step at a time, you're doing more good for her than you can possibly imagine, because the alternative is pretty dire. Thank you. Really, really wise, really wise advice and. And thank you all. And thank you all for participating in the, in the case review and putting it all together, and so Lisa and Laura Thank you for the, the presentations as well. I appreciate that. And so I just wanted to. First of all, encourage you all if you have any questions, you know, feel free to put them in the chat. And we're going to go to the next stage of the putting it all together. I think we're going to turn it over to Brianna. Okay. So on the screen we're going to look at each of these, the progress notes might be slightly different just a little forewarning for the coding activities, but we're just going to talk about how we would code each service, kind of before we end our time together and I just want to highlight a few resources again, especially with the coding thrown a lot at you on where you can go back and reference this information. So let me go ahead and share my screen I am going to just pull the cases up so we can just look at them all together but if the HCI team maybe wants to pop in if anyone wants to follow along in their workbook where, where that information can be found. I think they already did look at you guys. Thank you. Okay, so this is Ralph, I'm just going to kind of scroll through each section of his note. And so we can see here, you know, ongoing complaints of shortness of breath and this was a hospital follow up visit. This is really great information in this HPI you know last time four weeks ago that he called 911 because of shortness of breath but I will tell you this would be considered a brief HPI, because of the, the actual elements that are going, but that doesn't mean that's a bad thing and there's still a lot of really information obviously some recent cigarette use with the oxygen is something, and him saying he can't be breathe can't breathe excuse me we know what we're going to focus on today. This is a review of systems here. His past medical history. I want to get down to the bottom of the note for my question here but just kind of encourage you as you as you guys are looking at this and thinking of your own notes and your own documentation style kind of how this differs or how this compares. What other things you know you might include, or might not include, as we're kind of seeing what kind of history and things are included in here. Certainly the medications are always important. I always love hearing that the stories of the bottle by bottle medication review and, you know, you know, Dr Chang, I think you probably did yesterday your demonstrate talk about you know I remember hearing Dr Chang used to throw her pills and peanut butter and not know what is what so I mean again just what differs in the home is pretty traumatic from what you're going to get in the office. All right, what I want you guys to look at and answer a question for me is looking at his assessment and plan you see obviously the shortest of breath being the primary concern we have a lot of information there. Also, you know, some other factors such as the fall risk and the instability. And at the bottom of the note it says that an hour and 45 minutes was spent. Anyone want to tell me how they would code this visit or anything that jumps out at them. Let me check the chat to you're welcome to use that. So thinking about thinking back to kind of the coding talk that we did earlier, we talked about you know what kind of information we need to build on time versus, you know, billing on documentation and complexity. This is definitely a visit an hour and 45 minutes where I would build on time. And yes, ding ding ding. And you can see you got the magic codes there the 99350 plus prolonged services. So, to kind of demonstrate this in visual form I'm going to have this other document pulled up so here we have our high level established patients we know that Ralph was an established patient for this visit. So that's where we're looking at here. We know we can just consider time for the encounter because it was clearly dominated by counseling and coordination of care. I have the total time, I have that greater than 50% of it was spent in counseling and coordination of care. You could really see that from the shortness of breath comments up there but it also explained that and it has total time in and out which we need for prolonged services. Again, time based billing is always a billing threshold. Here was the, the threshold for the initial code, a full you know 30-31 minutes needs to happen so you've hit that 90 minute threshold. And if we look at the Super Bowl activity, which is in your worksheet. This is where you'll kind of find these codes but you can see this prolonged services direct face to face that code that Talisa suggested we add. This is off the Medicare fee schedule the national it may vary by locality but 129 extra dollars for your really extensive time you spent almost two hours with this patient. So just showing you the kind of financial impact that billing appropriately like this can can have on your practice. Anything else or any other comments about, you know, time based billing or how you kind of approach, you know, are there certain strategies that you take on window approach time usually it's you're spending that extensive time or focusing on things, you know, especially new patients sometimes really long and new patient visits usually, you know, you can pretty easily and home based medicine especially make the case for why it was dominated by counseling and coordination of care just because of the extensive care you all provide. So, you know, any strategies there. Yeah, Costa brought up tobacco sensation. So, anyone bill for smoking sensation services. We have up here. He spent nine minutes discussing smoking sensation and benefits that he could realistically expect going into the details. There is a code. If we go to. Let's go to the Super Bowl, it'll be easier to find but if we look at this advanced coding opportunities handout. This is the other resource that I would point you to there's a lot of information on pretty much anything you could possibly think you could bill for in home based medicine, but we have codes for what smoking sensation counseling services. Again, it's all time based billing it's not a huge payment. Four minutes or more is the threshold greater than three so that's why I'm saying four minutes. You know, if I really wanted to be picky I might want to be a little clear that that wasn't bundled into the other total time that we were talking about at the other visit. But one thing to know about smoking sensation services is you have to use a qualifying ICD 10 code. So you would need like nicotine dependence or one of those codes otherwise the service will be denied. But if you're, you know, having a smoking sensation conversation with a patient. You also do need to document some other things you know the total time, a brief description of the counseling, you know, were there any behaviors or resources that you talked about and provided to the patient so again this is where you would have that macro or the template and then you would fill it in just with a little bit of patient specific details, but doing all these things adds up over time. I see a question in the chat. Yeah, so someone who has private pay this whole process seems outlandish and hard to imagine. And I totally understand where you're coming from. I mean, these are all Medicare fee for service kind of tips and tricks on how you be sustainable. I mean, if you're caring for patients that, you know, is totally out of pocket, you know, you don't have to, you know, self pay situations, you don't have to quite worry about documentation and compliance standards. You wanna focus on quality though, and, you know, reflecting the care that you provide, but absolutely. I mean, this is really a means to how are you gonna have a sustainable business model and really get paid for all of the care that you're providing. And if you do understand your tools, if you will, like let's say we consider these codes tools for all of us, and we have templates and we kind of say, okay, you know, here's my billing model. We're gonna focus on, you know, billing appropriately our E&M services, remember prolonged services when we have time, and then maybe we're gonna do really good transitional care management visits or chronic care management. You know, keep it simple, but just know what tools are available for you. So that is Ralph's coding case that you'll find in your workbook. He was an example of a time-based documentation just to kind of tie that together. So Betty, I'll kind of go through again and give you a minute. You can see this was her follow-up on the depression, anxiety, weakness, and pain. This visit, if you look through, I don't have any time, so we're gonna have to bill on documentation and complexity. You can see her HPI. You know, again, if we're trying to kind of pull together what we thought, you know, she's focused on her legs, states they are very dark colored. This tells me where the problem is, the severity of pain, a 10, you know, that's always gonna be some of those HPI elements. Anything that, you know, makes it modifying factors better or worse about getting a little exercise, associated signs and symptoms. She's saying she's depressed and lonely. Oh, thank you. Sarah's just putting the coding practices in. So we have a good HPI. We have our review of systems here as well. Again, past, full past family and medical social history, really important for new patients. You can always mark as reviewed for established patients. And then I would just, you know, kind of highlight too these assessment and plan examples really go into, are great examples of the detail that you can go into, you know, telling me it's a problem, chronic problem that's worsening. So I know how to score it appropriately from a medical decision-making standpoint. You know, things like that. Again, depression is severe, you know, using those descriptive words in your documentation and really telling what specifically did you tell the patient to do? What's your treatment plan? And any other kind of guidance that was provided. In this case, it was kind of a referral situation. Anyone have any thoughts on how they would bill this visit? I know it's the end of the afternoon. We're in the home stretch, I promise. I'm just gonna show you a couple other tools and tricks. So again, we don't have time. So we're gonna bill on documentation and complexity. And just based on documentation and complexity alone, if you were conservative, you could make the argument for 99349, but this does support a 99350 based on the level of medical decision-making, you know, the multiple unstable problems. The nice thing about the Superbill too, just so you all know, if you're kind of thinking about prices, we do, I did update this using the CMS fee schedule, has a calculator. This is the national fee schedule, but you can also filter by your MAC. And then it shows obviously the 85 allowable for nurse practitioners, physicians, assistants, and things like that. But this is the document I was referencing earlier where we kind of called out, you know, could be a cheat sheet, or maybe there's some other services on here that you haven't thought of. The final case that we wanted to review is MJ. And you heard them talk about it, but you notice this is a transitional care follow-up. Ralph was as well, but it wasn't quite documented that way. Kind of just a few points as we're chugging along here. You've mentioned me, you heard me mention earlier the kind of bulleted documentation, and this would be kind of an example of how you could do this. And, you know, yes, it's meaningful, but also if this will save you efficiency and save you time, maybe think about, you know, have you ever tried bulleted HPI or documentation in this way? But also thinking, you know, remember transitional care management, technically is a 30-day service period, but you bill it the day that you see the patient for that post-discharge visit, you can bill it as a TCM visit. We know that there's going to be some documentation that we're going to need in our progress note outside of just our typical E&M. So if you go down here, we've actually provided, you know, example, smart phrase or macro. The things you see in bold would be the smart phrase or the macro, and then everything else would be personalized by the provider. There are certain both face-to-face and non-face-to-face requirements of TCM. So what this is doing is really tying it all together. You'll also see up here, it mentioned that the interactive contact call or the call placed by the office, I might've gone too far, by, for MJ was completed, which there'll need to be separate documentation of a telephone encounter for that. But you could see here, you know, Cindy Smith RN spoke to the family yesterday, and then it's tying every other TCM requirement together for the provider in one macro. And why would we want to do something like that? Well, again, I mentioned TCM reimbursement has increased the past two years. So we have two level of service choices here. One is if you've seen the patient within 14 days, but it requires moderate medical decision-making. We have another TCM CO if you see the patient within seven days, and if you've gotten to high medical decision-making. But remember, it's not just the amount of days that you've seen it. I need to look at your assessment and plan and everything else within your note and be able to get to the appropriate level of medical decision-making as well. And correct, seven days and 14 days. So that is the requirement of the TCM codes. If you've seen the patient within seven days and you meet high medical decision-making, which actually looking at this particular note we could do, then you build this code right here is 99496. It's the higher level of TCM. It pays $281 is the national fee schedule rate. Even if you build the moderate TCM within 14 days is pays $207. And compared to even the 99350, you can see is $178 is the average national fee. And I think it was Patrick that shared in the chat earlier, how much revenue was increased for a practice he was with just by billing on TCM visits. So TCM is what you wouldn't need to bill on time. You would literally just need to have the documentation requirements, but you also have to meet the pitfall that I see with TCM is not meeting the level of medical decision-making. So if it's still moderate medical decision-making, even if you saw the patient within seven days, you would still need to bill the moderate TCM code. But take a look at this template that we used in the coding activity. This is what you would need to do in your documentation is supporting that it was a TCM visit. And I don't even need to know time. That's not a factor, but I would refer you to this advanced coding handout. It looks like this in your workbook. And the reason I say that is because we did a very specific, much more comprehensive job of going over what TCM are, what are the codes, what kinds of things need to be documented, but also just kind of a benefit here is take a look at this macro on this template and see how it compares to the actual code. Take a look at this template and see how it compares to your own documentation. Or if you're not billing TCM, certainly something you want to consider in that case. How many people, anyone want to share in the chat, are billing TCM currently? I see heads nodding, that's good. It's paying off a lot more this year than it has in past. Last year and this year, we're really the difference makers for TCM. And again, I think it is what you make it. I hear frustration on the documentation even for those interactive contact calls, but if you can have your clinical staff asking some really meaningful questions and working on getting you the information you need before you see that post-discharge patient, that's also going to save you time as the provider from an efficiency standpoint. You know, as I remind my providers when I go through the super bill that Brianna has greatly disassembled for us, I tell my provider, I'm not telling you to document more. It's about getting paid for the work that you are already doing. So finding the code that best fit the complexity of your visit that day, whether you're talking about smoking cessation or you apply the Uniboot on their legs or cleaning out earwax and so on, all of that, it takes time and you should be reimbursed for that. So just be smart when it comes to billing, especially like us, like our practice that we are under fee for service. We are just fighting for every penny, every dollar that is out there to keep our practice going. Yeah, absolutely. And because it can seem overwhelming and cundersome and frustrating, and that's why I think you really have to get buy-in from your team. And, you know, Dr. Chang is a great clinical champion for his team too. So they hear that from a peer, like, hey, it's not just, you know, the billing department hounding us for doing that. This is why, and we're going to be able to take better care of our patients. And Megan too, don't shortchange yourself. Don't leave money on the table. It's unfortunately, it's hard enough. I hope someday it's much easier for us to get paid way more. I think the whole payment system for home-based care should be revamped in ways that we're not even anywhere close to yet. But we, you know, you do a lot. You're not like that visit with Ralph. Not every visit is 145 minutes, but there's a handful that are. So are you remembering to bill prolonged services when it is that long of a visit, when it is 90 plus minutes? Patrick, your point too about the interactive contact. Yes, that's a requirement of TCM too. There would be separate note from the nurse or, you know, that, or someone that called the patient. And we have a template for that too in some resources. And that's why you saw the reference to kind of the, you know, the call, the provider noting that there was that other documentation when the nurse called the patient. So in a nutshell, if the patient's discharged from the hospital or a sniff to home, even situation or rehab to home, all of those are qualifying admissions. You have to have a licensed clinical staff member to contact them within two business days of when they were discharged. And then you have to see the patient within seven to 14 calendar days. And that's when you bill it, that post-discharge face-to-face visit instead of your home or your domiciliary code. That's then when you're billing the TCM code and you're adding that documentation, like that template I showed you to show that all of the non face-to-face work, because Medicare technically considers the TCM a 30 day period, service period. They want to make sure that patient's not readmitted. Now you can see that patient again and bill, you know, a normal E&M visit if you need to do a two week follow-up, if it's medically necessary. That's another myth I sometimes hear. Can the MAs do the call? It has to be a licensed clinical staff member is the problem for TCM. CCM can be an MA, but the MAs aren't licensed is the only problem there. So I think with that, feel free to pop in any other thoughts or questions and coding related. Like I said, I encourage you, the Superbill and that Advanced Coding Opportunities handout, definitely are great two resources. TCM in particular too, if you look at our HCC Intelligence Tools and Tip She Pays, we have two resources just on TCM that also kind of go over those templates. One just focused on that interactive contact call and then one for the provider. And Janine or Melissa, if there's no other questions, do you want to lead us in our wrap up? Yes, I'm going to pull up my screen and we are going to have Paul just talk through a last couple of slides about the HCCI Business Plan and Budget Template. And then I will take us to our closing. Thank you so much. First, I just want to say thank you for spending two days with us, investing your time and your energy in shared learning. So thank you for that. And thank you for being out there, taking care of our patients, for your passion to do this kind of work. Next slide, please. Now, our objective for the next couple of slides really is to help you launch a successful HPPC practice and to be able to share with others, like what's special about you guys? What are the values that you can bring to our hospital system and whatnot? And help you review some of the experiences and the knowledge that you heard from either the faculty or from each other, and think about what you may want to do in terms of next steps. And finally, we really want you to complete and submit the HCCI Learning Plan to help guide your progress and also help us fine tune our classes for the future. Next slide, please. This is just a sample of the HCCI Business Plan budget template for you to take a look at. It's something that you can work from to help your practice grow and thrive. Next slide. Even though our session is ending, the learning continues. We want to continue to engage with you. We invite you to come back for the Advanced Application Workshop, where we talk even, yes, even more about billing and coding and some clinical stuff too, where we teach you how to do like joint injections or tracheostomy to change or G2 change and many other clinical dilemmas that we might encounter. And also visit our online library, consider the House Call Practicum if you want to come out and be with some really seasoned providers and see how we go about doing house calls in our world. And of course, there's webinars and virtual office hours that's available. So we invite you to come back and don't forget the tool and tip sheets that you can visit anytime to get some additional help for your practice, whether we're talking about clinical or practice management. Next slide, please. Before we get to Tom, just a couple of comments. We want you to, I want you to succeed. ACC, I want you to succeed. Any way that we can help you, whether it's billing, coding, whether it's a clinical issue, whether it's self-care. You guys are important people in the transformation of healthcare. We need to take care of you. We need to equip you. So you can go and really make a difference in the lives of our patient. I just have one quick patient story to share and I hope it can resonate, it will resonate with some of you. I was, a couple of weeks ago, I was out visiting a patient it was a referral from the hospital and the daughter was kind of upset and I'll get into a little bit of a reason why in just a little bit. When you walk through the door, you can sense there's some, I don't know, frustration or anger in the way that she just presented herself. As the story unfolds, this gentleman has been to the hospital now as well. It's April, he's been in the hospital three times already this year. He's got multiple conditions that we talked about already, CKD, CHF, COPD, anemia and so on. He's on oxygen. The frustration for the daughter and the patient, not only the multiple hospital trips, the patient's now having shortness of breath, his legs are swollen, he's desaturating. They call the PCP, the PCP says, well, that sounds like a hard thing. You should contact your cardiologist. So she calls the cardiologist, the cardiologist says, you should go to the emergency room. And the daughter's trying to find oxygen, maybe a portable oxygen for dad. And the lung doctor says, well, you need to come into the office so we can assess your pulse ox and document that. So she was running into roadblocks after roadblocks in terms of trying to help her dad. We have, in my years of doing this, we get referrals from different doctors. I think this is the one patient where three referrals came on this one patient. So I think you can sense there was a lot of frustration on her part and the patient's part and also from the specialists just needing help from us. So we did the visit. We tell them, we tell patient and the daughter about how to manage the leg swelling, how to use diuretics, how to manage shortness of breath. We document the oxygen saturation on and off, oxygen and so on. So appropriate paperwork can be pushed and so forth. We talk about morphine, the proper use of morphine in terms of relieving her shortness of breath. But the most important thing was, you talk to the patient, what's important to you? He is sick and tired of this revolving door. We've all heard this, right? He says, I'm ready, I am ready to go see my wife. And you can look around his bedroom, there are pictures of them together. He's ready to go see her. He is so tired of the hospital. He wants to be kept comfortable and be at home. So we craft a plan that's consistent with that, supporting the patient and taking care of the daughter. And at the end of the visit, I often do this, I close the computer, I look at the daughter and just say, how are you doing? And this is, the shoulder just, the body presentation just changed, the lips quiver and the tear starts to flow because we have been there for her to help her through some really difficult situation, to answer her question, to help her take care of her father, which is her passion. So I know you have all experienced stories like this, right? So I want you all to go out and fix the broken healthcare that we're living in now, right? And really be part, you are now part of the transforming force that's coming in this country. And I'm really excited to be partnering with you. And with that, I'll turn it over to Tom. So how did it go? I hope the workshop was everything you hoped for and more. I hope you feel my same sense of awe and amazement at the dedication, the knowledge and the generosity of our Center of Excellence faculty. They are incredible experts in home-based primary care. I hope you are headed home with a deep understanding of the valuable work you do and a growing confidence in your practice's ability to deliver extraordinary care using a sustainable business model. I hope you understand the potential you have for a lasting, transformational impact on healthcare in our country. As you know, there's a tremendous need for home-based primary care. And right now there are not enough people doing it. I would like to ask you to help us spread the word and build the workforce. Tell your colleagues on your network, tell everyone about this program and encourage them to get involved in this very special field. From all of us at HCCI, thank you for embarking on this learning journey with us. We wish you much success and a rich sense of fulfillment in the important work that you are doing. Now get out there and transform healthcare in our country. Thank you everyone for being with us these last two days. We appreciate your time and energy so much. Appreciate your time and energy so much. Thank you to our amazing faculty. The resources that you shared were phenomenal. Your expertise was just beyond anything I've experienced prior to this. So I got to be new to this curriculum as well and it was a wonderful experience. Again, to our learners, we value your input. You're going to receive an email shortly about claiming your CME credit. You do need to complete an online workshop evaluation. We also ask that if you have not yet, please do complete that HCCI learning plan and return that to us. That will help us follow up with you on any resources or open questions that we think will help you as you move forward with your plans for home-based primary care. Access to the recording before we go is going to be available to you as well as the slides within the next 10 days. So again, just thank you to everyone. Let's continue the conversation. Please reach out to me. We'll be doing some follow-up with you all. If we can help you in any way with additional resources, we are so very happy to. We hope you have a great day. Thank you, everybody. Thank you. Thank you. Thanks, bye all. Take care everyone, bye. Thanks, be well everyone.

Betty's case

comprehensive approach

home health services

daily activities

mental health

counseling

medication management

depression

anxiety

diabetes

blood sugar levels

medication side effects

eye doctor

eye issues

home-based primary care