basic tips, like ask the same questions to everybody, you know, make sure whatever you say is the criteria is the criteria that you hold everybody accountable to. I will say for us, for some of the jobs that are heavy in Excel, we've developed our own Excel tests to be able to get some of the back office support to figure that out. So it's kind of a riff off of like an inbox test of, can you follow these simple Excel instructions? Because everybody puts they know Excel or they know PowerPoint. And so until we actually like, and we decided not to steal from anyone else, we actually built kind of a similar table that the job would have and instructions. And they're pretty simple, like, you know, bold stuff, indent stuff, create, you know, create a chart of this kind of thing, you know, put a header footer on there and send it back. And it's not like they can't use Google to do it. You know, they can use Google, but it's timed. So even if they're using Google, they don't have two weeks on it, they have an hour to turn it back. So that's helped us at least be able to test a little bit, some of the back office skills. And then we also do a typing test. And so there's a free one minute typing test. I think it's, you just type in free typing test and we do, you get, you send in your, you send in three scores of that, of what was your typing test. And, you know, for a lot of our positions, it really, you really need to be at least typing, you know, around that 60, 70 words a minute. Like otherwise it's just not, you know, probably fast enough to be back office. So just setting some of those things. And again, you know, applying them to everyone. Yeah, I think those are great tips. I was smiling because when you talk about typing, when we were physically in the office, anyone that sat next to me used to always laugh at me. They're like, I could tell you used to type on a typewriter because you're so like, you hit your keys so hard and I'm a pretty fast typer. So it makes a lot of noise. Apparently if you sit next to me and when we're back in the normal office. But I'd be curious too, to share in the chat, a lot of problems that we hear about, where do you find your talent, especially providers? If anyone's had great success, I think it'd be great for you all to share or feel free to unmute yourself, kind of where you guys have had the best success finding home-based primary care team members. We, so like, you know, like I mentioned, we finally identified and found our first nurse practitioner to help get our program off the ground. And it was, it was tough. We recruited for a good three months and it was not easy. And we, you know, we used just our local website, LinkedIn or LinkedIn Indeed. And we just did not get quality candidates, you know. And I don't know if it's just because it's still relatively new concept in our area. You know, we got some folks with a little bit of experience, you know, it would have been a stretch, but as far as finding folks that had some really good experience or that could cross over easily into this line of the business, it was tough. So we actually partnered with the recruitment firm and that was how we found our first candidate. So it was a little more costly, you know, unfortunately, but long-term, you know, it should pay off for us and help us get this program off the ground. So yeah, we struggled. And so, you know, hopefully moving forward, you know, we've got a good relationship with this recruitment firm and so hopefully maybe as we move forward and grow, we can identify some candidates a little bit more quickly. Yeah, that's great. Thank you for sharing. I think one other thing to keep in tact is, or in mind is from a diversity, equity and inclusion standpoint, oftentimes we hire people that we know and we know people who are like us, whatever that might mean. So, you know, if we're white, we know other white people. If we're female, then maybe the majority of people we know are female of certain socioeconomic classes. You can easily find yourself out of, you know, maybe not mirroring your patient population. And so one way to think about that is always publicly post your position and then take, and then make sure that you have, even if you have an internal candidate that knows someone that you have an equal process that you're gonna do across the board. And you really, again, consider those ideal candidate characteristics. So we sit down with the HR every time we triple check the job description, we write down our geography, our degree of the ideal certificate or the ideal candidate. And then we go through, and those are the ones who make it to the interview. So, you know, and you're not gonna get diverse patients if you don't have, or diverse applicants if you don't have a diverse employee base. If you don't have a diverse employee base and you want a diverse employee base, you have to actively work hard at it, so. Yeah, I think that's a great point too, thinking about like what patient population you serve and, you know, what kind of culture and beliefs and kind of people are gonna mesh well with that. So for your clinical providers, the American Academy of Home Care Medicine and the link to this PDF is included on the slide, which reminds me, I did confirm with our team during the lunch break, all of the slides, including these slides from the non-clinical track, will be made available in the HCCI Learning Hub after the workshop. So you will have access to all of these materials. You should have been emailed instructions on how to access that, but if not, tomorrow they're gonna try and take a quick break and just show everyone in real time. And there will also be, you know, Betsy and Rachel, who are phenomenal and who are joining us on the call, are great resources for the practices that, you know, and providers that we work with and just making sure you know what resources are available to you and just staying connected with you. We really like to foster relationships and we're here to help and support you be successful after these two days as well. But clinical competencies, I think AAHCM and I know Dr. Cornwell, HCCI's founder, was really involved in creating these, really makes a lot of sense if you're looking at, you know, what's on the screen and thinking about the characteristics that your provider team needs to have. Kind of what the caveat that I would add is I think it's really important to be brutally honest, especially when you're hiring providers on what kinds of things they're gonna encounter, you know, having them go out on ride-alongs. You know, we had a candidate in my previous practice that was ready to, you know, sign all the contracts and get hired and then, you know, went out on a house call and was like, you know what, I don't think this is for me. I don't think I can handle this emotionally. And, you know, that's okay, it's not for everyone. So really thinking about that and understanding what your standards of care are gonna be and then sharing that with people when you're going through the hiring process. Amanda or anyone else, any other thoughts here on things you found helpful when you're onboarding or kind of vetting candidates during the hiring process? All right, so again, just kind of thinking a little bit more between what you're going to have in-house and what operations that you're going to outsource, you know, and understanding what core services you offer and what functions that, you know, kind of leads to and, you know, what are the benefits, costing, evaluating opportunities and risk, thinking about fully loaded cost and performance management, what really makes sense or what's, you know, sticking out to you from an expense standpoint and is there a better solution to handle that? Amanda, did you have any other thoughts here? Yeah, I mean, and I think Patrick's probably in the same boat, but if you decide to outsource something or you go with a hiring agency, just remember that, you know, typically they're going to take 25% at least of whatever the first person's annual salary is up front. Now, I've been able to negotiate the furthest, the standard here is like 25%, 26%. The furthest I've been able to go down is 23%. So if you're working with a hiring agency, you can always try to drag, I mean, I'm under the belief that everything is always up for negotiation. So you might get a couple of points off of it, but you know, if you're looking at someone who's $100,000, you're going to owe $25,000 for that person. And typically there's not a long runway for how long they guarantee they're going to work out, or they'll give you maybe some of your money back. So it's just, you know, again, you can, that's one outsourcing. Another outsourcing option is you can keep them as a contract employee. I can tell you in the state of Minnesota, our Department of Revenue and the Department of Labor have really cracked down on if you have a contract employee doing work that is typical work for someone else or would be standard work. It should be varied work if they're doing kind of contract work, either time-limited, variable, you know, like, you know, it's a three-month project and then it's done, or variable throughout the week as we may or may not need you. But even then you could eventually probably call them casual. So you just have to be careful with how you use contract employees and how long you keep them as contracting. Because remember, if you're keeping someone as a contract employee, they're paying the government because they have to pay taxes on it, but you as the employer aren't paying the government on them and that government's going to come for their money. So that's a problem. Yeah. And Chris brought a good point up in the chat about outsourcing at no cost to two lab companies that handle a variety of testing for them, blood, viral studies, you know, two radiology companies at no cost, and then using home health for lab jobs and wound care. And absolutely. If your patients have home health, send them the lab orders and things like that, and helping, of course, you know, wound care, you know, again, the social workers. And then, yeah, I mean, in the practices that I worked with, we had several different mobile phlebotomy and different diagnostic companies that we would use. And there was no formal contract or, you know, relationship other than, you know, we referred patients to them when we needed them and they, you know, you know, understood that and were pretty responsive. So absolutely, especially for labs and diagnostics. And for us, some of the labs here will be, if you have enough volume, they'll hire their own phlebotomist just to do your work. So you even have the same kind of, you say the same person doing that work, and that's nice. So you can negotiate that and say, like, yeah, I got a hundred patients today. I plan to have 250 by the end of the year. You know, make sure you hire up for that. And then, and then, you know, who those folks are that are coming in your, in your spots. And, you know, it's a lot easier if you know who they are all the time and they're consistent. Thanks. Absolutely. All right. So let's get a little bit more in the weeds on, and when I use the term front office, it's a very general term. I'm talking about non-clinical administrative tasks. And again, this isn't like a standard, you know, this is going to be different. I know some practices that have, you know, clinical staff members doing certain things. But just thinking very specifically, you know, who you're going to have answering the phones, or maybe you want an MA doing that, or, you know, what's the process, you know, of the information from, you know, when the person initiates the call to who answers the call to how those messages are routed. It's especially if you do have a nurse or someone in the office, you know, rather than just taking a message every single time, certain things getting worked out in real time, rather than just forcing callbacks. So having kind of triage protocols and even office protocols on when calls are going to be transferred to who when can really save a lot of time. Insurance verification, can't stress how much importance this is. Patients and their caregivers don't understand Medicare Advantage. You know, Medicare Part C is technically Medicare Advantage. I can tell you my own great-grandmother and her son would have no idea that she has a UnitedHealthcare Medicare Advantage plan. I know that. But again, really verifying that up front, you know, a couple of, I think almost two years ago now, all Medicare beneficiaries got new Medicare, you know, MBI numbers, new ID numbers that aren't their Social Security cards. If you don't have the correct number, you know, you're not going to be able to process that claim. So really having a strong intake process, I can't stress enough how much of a difference that really makes, and that you're getting that information, that demographic information, insurance information up front, and actually verifying it, and not just once. You know, ideally, your EHR should have what's called RTE or real-time eligibility that you can check for every patient visit that's scheduled to make sure there's not a change or an issue with insurance. And you know, there's a lot of paperwork and orders and things in the world of what we do, especially with DME. So who's going to handle that? You know, do you have an e-fax? Do you have electronic signing for your providers? What's going to make that more paperless and more efficient? Who's going to handle all the scheduling and planning provider routes? Appointment confirmation. Again, yes, these patients are generally home limited, but maybe the daughter has to be there to answer the door, or they go to dialysis on Monday, Wednesday, Fridays. You really need to kind of know all of those things, track that information within your EHR, and make sure that, you know, they're expecting and they're ready for that visit. I know some providers that even like to call when they're on their way, or have their assistant call when they're on the way, or just call the day before with the date and the time reiteration to make sure the patient is there and expecting the visit and it doesn't need to be rescheduled. And then again, depending on who you hire, you know, helping with medical records requests, maybe you get an office manager that has some billing and coding experience, even if they're not formally trained, what's their role in kind of monitoring that and making sure clean claims are getting out the door. Amanda, any other thoughts here? This is an overwhelming slide. It's like you need to be doing all these things, and I know you guys know you need to be doing all these things too, but I think it is, I think, you know, again, this is kind of in the how do you hire and staff, and it's just taking all the things you got to do and just putting it on paper and what buckets they're going to be in. You know, as our growth, we're a growth company, our growth company has been over the years, do you know how many org charts we've had? It is okay to change your org chart 10 times. It's okay to have new people assigned to new things. It doesn't matter if we have 180 employees, it doesn't matter if we have 180, it doesn't matter if we have three, you know, figure those things out. And this is what you're hiring for the broadest level of experience, depending on how you build it. Like who can adjust with me if I'm going to need to change my mind in a month? This is, you know, so like I said, I know it's overwhelming, but it's a good slide to have all on one page. Yeah. And Chris bought, you know, paperless is great and touchless laptops are a must, you know, thinking about what technology is going to make you most efficient as well. And, you know, the last kind of point I'll make here is just don't underestimate how much time that scheduling and appointment confirmation takes. I mean, even really having a process for your team of like, okay, what's your week going to look like? Or what days or what hours are we going to make those calls? And who's answering the other incoming phone calls when we're doing it with one person's doing that. So you really even need to think, you know, kind of more strategically, you know, and helping and signing documents, getting everyone certified on those 485s from home health, which you can also bill for if you're not for signing and the oversight of home health services, home health services, excuse me, the certifications and recertifications. I'll put those codes in the chat. But, you know, there's a lot that goes on. And so, you know, understanding roles and responsibilities and what that office flow is going to look like. So back office, again, just another general term that we're using to summarize, generally, like, you know, if you think in a traditional practice, your front office is probably your receptionist or someone you see when you first walk in the door that gets you checked in. Then once you're back, and you're seeing the provider, maybe there's a nurse or medical assistant or kind of, you know, the clinical support staff behind the scenes. So what are some roles and responsibilities that those people can do? Again, if you do not have triage protocols, and it, you know, when I say triage protocols, it doesn't need to be like an extensive, you know, hospital protocol and things like that. But what things depending on the relationship, can they act on independently without having to route that message to a provider for action? Things like simple wound care orders or continuation of home health and hospice. What are those top five things, you know, just maybe have a little staff meeting exercise. You know, that was how the old practice that I had developed our first ones of, okay, we just asked our providers during a provider meeting, what are the kinds of messages that, you know, you're getting constantly, that would be within our RNs relationship, and that we really just need to flush out a process that they need to act on before it's routed to you as an FYI. And then you can, you know, make additional decisions from there. DME, it's a lot. HCCI has a couple resources on oxygen and wheelchair and walker and different thing requirements and what it takes, but especially if you can have a couple people on your team that make relationships with your customer relationship reps for each DME company, the major vendors in your area, and get really good at it. And also kind of communicate how long that takes for patients and doing prior authorizations for medications and things like that and placing orders and referrals, it's just a must. You know, is there any follow-up after a referral is sent to make sure it actually happens? You know, what's your standard for prescription refills? Are you setting, you know, standard medications for 12, you know, 12-month refills for non-narcotic prescriptions or what's your standard there? You know, just getting less referral requests in is going to save your providers and your team time. Being that liaison, so you have, again, your community service partners, you need to maintain those relationships. If you have a couple, you know, do you have monthly care management meetings with them to ask how you're doing and how, you know, they're doing as a partner and how your patients are doing or any concerns can really make a big difference. And then when you kind of get into the nitty-gritty of inventory management, if you're going to keep, especially if you're doing immunizations, you know, do you have the appropriate fridges and freezers at temperature control with thermometers and someone's checking that? If you have medications, are they thrown out when they're expired? You know, there's a lot of different, you know, things that need to happen in that respect and kind of how can this clinical team all work together and overall just kind of reduce redundancies and promote efficiency and not have, you know, everything have to require the provider's immediate advice. Any questions or thoughts, or Amanda, you have anything to add? Again, this is a big slide, a lot of information, so. Yep, no, feel good. So, again, just why do we think about all these different relationships, you know, not underestimating the power of a great, what an RN can do, and then what a MA and an LPN can do, you know, and what's the difference and what's the immediate need? You know, again, the big difference is a medical assistant can't give medical advice without direction of a provider. But they can do a lot of things such as taking vitals and doing phlebotomy and those DME and things like that, so understanding the need and then the impact. But again, RNs come at an expense, so how are you going to account for that expense and make it still part of your sustainable model? Amanda, when did you decide, like, when are RNs, you know, any kind of logistical considerations that you think of when you bring in a nurse? You know, for us, it's about maximizing their licensure, so to do true triage, and that's a new model for us. We were doing LPN intake before, so no protocols, so true triage, we have RN. And what we do with our RNs is they are partnered with our practitioner, whether an NP or a physician, under any managed care product, where they can see acute visits. So they'll go out and assess the situation and do all the acute visits, and so it's not billable because we're fully at risk for those patients, but then they can keep the providers informed of what they need, they can do a lot of stuff on site, they'll do a lot of clinical stuff on site. So that's where we've mostly used RNs is we have total, total top of licensure work, is they're actually doing hands-on care, you know, and really, really what I would call truly acute care visits. Yeah. Yeah. All right, so this slide was created because I get so many questions around scope of practice, and so again, just to kind of put things together for you between an RN or an LPN or a medical assistant, but you do have to know your state scope of practice lines, your state board of nursing is going to have a website with that information available for you if you don't know. Another way, especially during the pandemic that I've seen RNs is the RNs are facilitating the telehealth visits with the provider, which is still a billable visit because they're connecting, you know, the provider is billing the E&M visit when done on two-way video, or, you know, just not sending a provider out for an injury with, you know, a fall with no injury for your ALF, or your assisted living setting or things like that. So really thinking creatively, how can everyone work to the top of licensure? How do you need to shift roles and responsibilities? I'm a big fan of, too, like any team exercises, like, you know, using a whiteboard or a paperboard or whatever, or even just Post-it notes, you know, what is everything that your staff says they're doing every day, and then looking at each person and seeing where their overlap is, or, oh, why are three people saying that they have a role in, you know, intake or the specific thing, and maybe that's not what you had an idea of. So that can kind of be a fun little exercise as well, if you're trying to optimize your team and really understand what everybody is doing. Well, we're right at the point where we're about to dive into staffing models, and we said we might take a, you know, I don't know how long you'll give us here, Brianna, but we might take a short break. Should we, because the next slides are kind of all lumped together as really big staffing ratios, so. Yeah, there's staffing ratios, so two options. It's what you guys are. We can either finish the staffing model section and then pause kind of before we get to quality, or is everyone ready for a break now? Because I know it's been quite, it's too, we've got plenty of time. It's, you know, do we want a five or ten minute break now? What do you guys feel like? Let me see the chat. Yeah, a little break would be nice. Sounds good to me too. So Chris, I will talk about the billing and coding. I see your message too for home health orders and things like that, but why don't we take, it is 158 central time. Sorry, I know I'm saying central, and a lot of you are probably eastern. Want to come back at like maybe 2.07-ish. Is that enough time or 2.10? What do we, Amanda, what do you think? Yeah, how about just 10 minutes? All right, 10 minutes. All right, 10 minutes from now. Thanks, y'all. Bye. Hi, Rachel. I'll give everyone a couple more minutes to 10 but thanks for being here with us. I am sitting in a not cute position which is why my hair is kind of out of place today and I don't want to offend anybody. Do you guys have most of your meetings on video? We just don't. We have not spent our time on video. I've just been having phone calls for the last 15 months. We do everything on video. I feel like even like when we use Microsoft Teams, again, we're not at like a practice. Most practices I know are back in the office. I don't know. Are you guys? I'm sure or I don't know. Are you guys? What are you guys doing? You have a lot of remote employees or how do you guys communicate? Well, I mean, if you're asking me, like we're not, we're certainly not back in the office. I brought, I'm a CEO. So I brought myself back. That's kind of it. Everybody else, they don't want to come back. They're done. They're done. I don't know what we have 7,000 square feet here and then office space and it's our least stuff in like 18 months. I don't know. We're not going to need this much space even for 180 employees. So. So, yeah, I never I'm never on video like before I start coming back into the office, you know, like I was. Then I started showering every day, you know, for being honest, like it just wasn't every day. What about you guys? Lots of Zoom. Yeah. Which I wish to your point, I wish we would break it up a little bit and just, you know, do some calls. Zoom, you know, just in front of the monitor so much, you know, they think a call is just as effective sometimes. Oh, for sure. Well, and it's part of the reason I'm like, let's be on camera because I never see anybody. You understand where I'm coming from. So no pressure for me, for sure. That's funny. All right. Well, welcome back, everyone. Thank you. I think that that little break was was helpful, too. So we're kind of in the homestretch here. You have about an hour left with Amanda and I before we go back to our main session. And so we're going to kind of keep chugging through this content and then we may we'll see how timing works out. We could even potentially save some additional things to talk about tomorrow or again, you have the option. You don't have to. But during the putting it all together session tomorrow, if you would like to break out again just for informal discussion and questions. That's an option you guys can just think about and let us know tomorrow how you feel. All right. So can everyone see the slide? All right. So now, you know, we have various different staffing models, real staffing models that we pulled together just because, again, I think this is one of those burning questions. And again, you'll see there's no one size fits all because all of these are very different. It's actually kind of interesting to to look at the different structures, but wanted to share some examples with you. And then would love to hear from from each of you or anyone that's comfortable sharing kind of how your current teams are structured from a staffing model perspective. But this is a particular program in Illinois that's under a health system umbrella. So they have a census of about 800 patients health systems. You know, you generally have that part FTE of practice administrator time and their other office manager time is bundled in that administrative FTE. But you could see they have 1.1 FTE physicians, three full time nurse practitioners, 1.5 of an FTE of RNs and then 1.5 medical assistants. And so kind of these are going to be, again, slides that you have to reference. So you can kind of go back and do the math on caseloads and and just kind of compare and and think about your own practice and how this compares. I like this particular example because it shows the pod system. And this is kind of what Amanda was mentioning at either where certain nurses or certain medical assistants or whatever the position is, is cared with or is paired, excuse me, with set providers and set panels of patients. And I think that does wonders for continuity of care. And also just the relationships that you have amongst your team. Again, this was a very, very large practice that also I will share has some value based contracts and some more revenue to play with, because you can see they've got a pretty robust teams with RNs, social workers, care coordinators, schedulers. So keep that in mind. But I do think that there's a lot, you know, even the chaplain and the DME specialist, referral coordinators, you're not going to have all of these things depending on your practice size. But I like the example of kind of putting in pods. Does anyone else do that? I'm curious, you know, do you have, you know, set providers or clinical support staff paired with, you know, the same people? No. We have two different teams that we work. So mostly medical assistants and the PCPs. And do you break them up that way because of geography? Yes. So also important to realize, too, I think the independent practices, you have so much more flexibility, right? There's pros and cons to being under health systems or being under, you know, I forget what Dr. Chang calls them, mom and pops or something. You don't always have the flexibility and some of the pros that you might think. But this was an independent practice, a little bit larger census at 1900. Three part-time physicians that make up 1.1 FTE, and they actually have 12 providers between nurse practitioners and physician assistants, but only making up 9.2. And again, this was a practice where they felt scribes were a huge benefit. You'll notice they don't match. Not every single provider has a scribe every single day. They rotate the scribes, and then their expectation is two more visits a day if you have a scribe. And then their patient care coordinators are non-clinical office support staff. And then additional some kind of not administrative, more receptionist type roles. So just another kind of different example for you to compare. I'm not going to go into detail, but, you know, the difference here is an RN manager, triage RNs, reimbursement specialist, something new on this team. And you can kind of see the FTEs and how that breaks down in accordance with their patient census. And for us, you know, it's not going to look exactly like this, but we have so many patients at risk, especially under our dual program, where we have two RNs hired. And maybe it's the same idea with the reimbursement specialist, but we have two RNs, not coders, RNs that have been hired just to risk adjust all of our value-based patients every year. And so they mine all the data for all of our risk-adjusted patients. And we have, you know, I don't know, 1,500 total patients. Of course, they're coming and going, but, you know. That's a great point. I think I've seen a lot more. There's a lot of, even in the payer side, like RN auditors now that you see. The MACs love to hire those. But I had another program, too, that was big. They were under kind of like a family residency program. So, like, when they had residents, they would have them prep their charts and help with things like that because it was learning. And then it helps them with, like, you know, cleaning up their problem lists and more specific diagnosis coding. So there's kind of a lot of creative things you can think about. So, again, this particular program, just the difference with the staffing model, you'll see some social workers. And everyone, I was always like, oh, my gosh, analytics. But, you know, you can do a lot with the different team structure and kind of how that's broken down. And then New York. Again, kind of this is pretty similar to the last one. But really just trying to give you guys some numbers and some data of some very well-established programs so you can kind of see the difference and think about how that compares to your own staffing model. There's definitely some similarities. But, again, there's no one-size-fits-all. Does anyone want to share? You don't have to share, like, as specific FTEs, but how their team is structured or kind of how what your staffing model is? So we are going to be starting out with a nurse practitioner and a CMA paired together and trial that for, you know, probably these first 12 months and see how that works as far as, you know, quality and volume and efficiency. And then probably, you know, three to six months in, as our volume grows, we discuss looking at, you know, an RN navigator. I'm sorry, let me back up. Nurse practitioner, CMA, and then having an office coordinator shared with our palliative medicine program to help with some of that intake scheduling, referrals, maybe some billing support. And we're trying to find an office coordinator that's also got some CMA experience that can maybe pinch hit if our CMA is on vacation or, you know, out sick or something. So that's kind of the, you know, first step. And then second step, looking at an RN navigator, three to six months, again, depending on volume and then also, you know, social work down the road. And so that's kind of how I would envision our program, at least the first 12 months, maybe. And then, you know, grow from there and then add more as our caseload increases, kind of like you've got laid out here. Yeah, that's great. I love what you said, too, about the office coordinator that's potentially an MA. And I have seen that a lot, you know, in thinking about, you know, again, how they can best support or, you know, you either have kind of to an office person that's more clinical, or maybe your office coordinator is also, you know, doing some administrative stuff. But I have seen the MA model work quite well. Yeah, I've just, I've had a lot of success with that, you know, and just the brick and mortar, you know, physician practices, just having that cross training. So hopefully, you know, it will cross over well to this setting. It's always great having people that can pinch hit either with surges in volume or, you know, fires that come up or just vacation sick calls, you know, what have you. Absolutely. Well, thank you for sharing. Sometimes, you know, we, we started this, I don't know, I don't exactly know how it's going to work. We're a couple of two years into it a year and a half into it. But we have a large number of LPNs, and we're like, we think we're going to need more nurses. So then we were like, we offered like a 18 month or two year window where someone could sign up to be in a nursing program that we would pay for up to a certain amount. And then they'd have to give us two years of service after that. So as you grow to you might have people who started some of that work or come in with some of the education and they just need a little bit of help finishing it. And then you can tie future employment to that. So, I'm not exactly sure how that's going to work. We only had a couple of takers. I'm not quite sure why either but, you know, keep in touch and I'll let you know. Yeah, now that's a great point. I forgot to mention earlier when we were talking about scribes. I know a lot of programs that have really good success with medical students that like they're wonderful scribes and they need their hours. And so that I mean thinking about your local colleges and nursing programs or medical graduate programs that are in your area. I have one person in particular that I'm just like phenomenal scribes because they're all medically trained and they need hours because they're going through school. Or future medical students, absolutely. So, kind of shifting gears and thinking about your clinical model, and how do you kind of tie this all together to really make sure that you have the right pieces that you need. And again, I think, especially regardless of what happens on the legislative side and what kind of billing opportunities may or may not exist whenever the public health emergency is officially declared over. We're at least going to continue the PHE through the end of 2021 so all of the what's called 1135 telehealth waivers that we have right now allowing us to bill, you know, our normal home and domiciliary codes for video visits will remain in place at least through the end of the year. But, you know, how might you balance that and Chris I was thinking of your program, especially when you were talking earlier about the rural areas, and I've really seen some good efficiencies mixing in. You know, I don't think there's one standard I know some, I had heard one program told me they were going to do every third visit as a telehealth visit, or every third visit in person. So something like that you'd obviously have to adjust based on the clinical scenario, but thinking about in person care versus virtual visits, or if you're using remote patient monitoring where you're getting you know blood pressure or glucose or pull socks on your patients how does that data kind of inform decision making. From there, you know, who, what's your on call schedule look like, you know, I know one provider that they each only take one week a month and then she also offers like compensation for that on call week for their providers and, and that is very much appreciated by her team for, you know, making sure that it's fair amongst your team so people aren't getting burnt out. I think especially with today's regulations if you're not like if you're don't have a patient portal, and it's not active. You really kind of need to get behind using that and not every patient is going to use it but their caregiver their POA might. But especially I mean even in chronic care management it's a requirement that you have that kind of, you know, interoperability or that real time access electronic method maybe that's even, you know, I know some practices that use different platforms than maybe a portal but you have some sort of means of electronic communication options for your patients. And then thinking about partnership communication and opportunities and relationships with specialists we actually just had in a previous conference we did there was a homebound dentist. I'm trying to think of what other ones. Anyone else have any other home specialist they love. Yeah, I think it's very region specific I will say I'm not trying to say that there's, you know, all of these specialists but I think even if they won't do home visits, especially with telehealth I've seen a lot, especially in the psychiatrist role or the behavioral health role a lot more specialists are willing to do visits if you can help facilitate a telehealth visit maybe that's a way for your patient to get care. So, again, just remember there's no one size fits all solution. It's really important to think about the team composition that works for you, and what your practice and organization's standards and needs are obviously your payment model structure is going to, you know, play into that there are ways that you can maximize fee for service revenue and you can be sustainable. But I also think we need to take advantage of the opportunity that we have at hand with these payers recognizing the value of community based, you know, services. And I really think you know we're transforming to value based care. I really do believe that's the way of the future and so how can you kind of prepare for that now and understand your patient needs. At the end of the day, whatever you do or put in place to saving someone money, it's just time you get some of that money back. There's really nothing you can do in geriatrics, that doesn't improve quality and lower cost, you know, those things really go hand in hand as you make interventions, by and large, by and large. So any questions that anyone wants to pose or kind of thoughts before we move on into quality. I just have a question. For team members if you hire them in like social workers, etc. Is there, I mean I usually use home care for that. But is there a mechanism for them to be billed for in primary care home based. Not necessarily like primary care but if they're an LCSW so if they're a licensed clinical social worker and depending on your state, where are you located again what state. Connecticut, Connecticut. Okay, I don't know offhand but I can I can double check the regulation there for you. Most of the time they can bill under Medicare they do have to be credentialed. They need to have their own NPI number they need to be credentialed as a Medicare provider, what they can bill for is in person counseling. So psycho there's certain CPT codes for psychotherapy. There's also, and I can put the link to the resource in the chat and the telehealth during COVID-19 tool and tip sheet that we have. There's a code for phone calls and a code for communicating on the patient portal or something like that over seven days that there's, you know, certain other qualified healthcare professionals that licensed clinical social workers are able to bill for so there are some reimbursement opportunities it's not huge. But there are some and I do know some programs that you know will employ social workers and then have them do the in person counseling and bill for it. So, and that would be under the umbrella of the practice not, they wouldn't be like a subcontractor or anything. Amanda I don't know if you have any thought you have probably set up a contractor relationship, but they would still, they have to be billed, you know, under there, they have to be credentialed with Medicare to bill, but then set it you know under the practice 10 correct. Correct. Yep, yep, you can you can you can still collect revenue your contract will be with them as a contractor, you'll pay them some amount of money in exchange for their services. Yep, and then that will be billed under use of left to be fully credentialed under your 10 and MPI as well but yeah, you could set them up as a kind of, you have to check every state is in a different spot on, you know, their Department of Revenue cracking down on how you think about contractors. So you know I certainly check your Department of Labor and your revenue department, or your state revenue department just to check into how they view those. Because if you just put them on contract, you know, I wish I kind of if you just put them on contract because you don't want to employ them. Even if you employ them at a really low, low FTE where they're not eligible for benefits. But if they are doing things that look like a full time employee or regular scheduled employee would do, then Medicare is not getting Social Security and their tax out of deal from you, they get it from them because they have to report that in on their own personal taxes so that's the only catch with a contractor. Like, also, you know I use home care for PT, for example, but is there an option for PT under Medicare Part B through, like, under the practice umbrella or would that have to be like a separate entity. Physical therapy is a hard one. Generally it is, you know, only paid under the Medicare skilled home health benefit there is like, there's, this is more popular in the Alps like there is some Part B outpatient therapy options I've never seen them necessarily employed in the practices the closest that I've heard is, I don't know if anyone's ever heard of the capable model. But again, it's not like a Medicare reimbursed, they get a grant funded where they actually have occupational therapists that come in for so many visits and then, you know, dollars for handyman's and things like that. So I've heard of partnerships with you know occupational therapy and physical therapy I know there is a way that they can bill for it technically as outpatient therapy but usually that's when like they have, you know, PT in like the assisted living building or something like that. Yeah. Okay, thank you. Great questions. Actually, one more question. Um, there's a couple of codes and I unfortunately don't have them off the tip of my tongue but they're supposed to be case coordination codes or care management codes or something like that. Yeah, do you ever use those or. So I really believe that you have to be billing for some sort of care management service so tomorrow. If you look in your workbook to there's two resources I would look at one there's, if you go to the appendix and you look for or in the coding activities the HCCI super bill. I put everything on that but for example like chronic care management. There's several different codes that would be you know traditional chronic care management is 20 minutes per calendar month of provider and clinical staff time but it comes with a lot of other requirements you have to do a comprehensive care plan, you know, have get consent, you know, the eligibility requirements are two or more chronic conditions that place them at risk of life, all of your patients are going to have that. There's also care plan oversight. That has to be all of the billing practitioners time and 30 minutes per calendar month it's highly audited so you really need to understand, you know, the kind of documentation that you would be looking at is each date, the number of minutes and then the number of hours of like eligible clinical clinical activity like a short description you know generally you're kind of documenting that anyways. But you just need to make sure you understand all of the documentation requirements but take a look at the super bill and the advanced coding opportunities and then we can dive in to some more details on that I don't know if you're registered for the advanced application workshop that follows this in June, but we go into a lot more detail on those codes in that course as well. Okay, great. Thank you. Any other questions anyone wants to pose, we'd welcome, you know, any other questions you guys want to discuss. And I make a plug for Brianna for her coding discussion tomorrow and in the advanced course like I said those are always the two most popular courses, and people bring a lot of really specific questions to those two. Tomorrow we're going to focus more on kind of documented what I call documentation basics really understanding the E&M requirements for home and domiciliary setting. What are red flags, what is quality documentation look like you know how do you avoid pitfalls. But, you know, we'll talk about Amanda and I today are reimbursement and sustainability, and then again we get more detail in the advanced on talking specifically about like TCM CCM and things like that but we still provide you the information and those resources you can reach out to me. HCCI has an HCC intelligence hotline. If you go to our website it's just help at HCC institute.com and I field coding questions all the time I would be happy to follow up with anyone. All right. So let's dive into thinking about quality improvement and demonstrating your value in the lens of a home based primary care practice. So, for those of you who may or may not be familiar. There's an initiative called the National Home Based Primary Care Learning Network. It's a wonderful initiative there's two and Dr. Christine Ritchie, who have really dedicated and gotten grants, a good chunk of their careers to meaningful quality metrics for home based primary care and how does that be get endorsed at the national level. So what they do right now is they have certain cohorts of practices you have to submit an application to apply and then you have to do at least one quality improvement metric, and they kind of guide you through that process on the formal process and then you kind of share your results as a group and Amanda's practice is actually participating in the current cohort but a link to the website it's just improve house calls.org. I know there will be another application period coming up in the future you just have to kind of stay tuned for that but it really is a great opportunity I know a lot of practices that have had the opportunity to participate. I got to listen into the kickoff call. Amanda, did your team share anything with you or any other thoughts on why you wanted to even participate. No, I described it to my team kind of like being in college, and when you go sign up for a trial, either for cash or pizza or a free t shirt. You know, that's really what they're doing is my, my perception of the situation right like they are using all of us as guinea pigs to collect information and then we get access to information like minded practices how we improve things, and then they're going to use this information to really change, you know, Medicare regulation drive quality thinking. So, I mean it's certainly an honor we were we we applied with our assisted living practice. Our cohort includes were the only assisted living practice in our cohort most are home based medicine. You know, more traditional home based medicine practices, and most are really small so if you're thinking you're kind of a small group I mean most, you know, have like 70, you know 70 patients, certainly get access to you know again you're going to have some data we're early in this process but we know we're going to either have manual, whether it's extracting some of it, we're still have to manipulate a little bit or, or actually you know maybe making tick marks on stuff but this could have big impacts for future and that will impact things like how we all get paid for bonuses how they set reimbursement structures how they set quality initiatives and goals for us, maybe even how they set Medicare measure star measure so I think it's going to be really valuable. It was a two page application it took almost no time and for anybody again interested in just getting better data out there this is, I think this will be will be key so I'd encourage everyone to at least look into it. So that's what I know today about it. Thank you. So this is kind of speaking on kind of what you can do for the field. So they're requiring all the practices to at least report on one of these measures cognitive assessment and care plan or functional assessment. And the reason why is because through the work that they've done. These are actually the only two quality measures that are endorsed by the National Quality Forum, you know, being Miss eligible and kind of, you know, looking at it at a broader level, they're constantly the National Quality Forum is constantly evaluating measures and if they don't get enough practices reporting data on these measures, then they're at risk of, you know, no longer being endorsed for lack of a better word. So, again, just to highlight these two specific measures I think are great ones if you if you want to kind of start looking at a quality measure but you're not sure which one. So, again, just to highlight these two specific measures I think are great ones if you want to kind of start looking at a quality measure but you're not sure which one. So, again, just to highlight these two specific measures I think are great ones if you want to kind of start looking at a quality measure but you're not sure which one. And this is something that's it's been going on for a while now independence at home. You know, you can't actively participate as a new practice if you're not already an IH practice but they did actually just extend it for three years which was a really huge win that we looked at for a long time so this model will be going on at least until 2023 enrolling 5000 more new Medicare beneficiaries, I forget how many I think there's 14 home based primary care practices that are participating as well. But you can see, these are the measures that they're evaluated on and is directly tied on how much, you know, shared savings or quality bonuses that they receive. So again, when you're trying to figure out what can I do to show really the ROI and care that I provide because I think with home based primary care we really have to recognize it's not just going to be numbers you need to show the value that you're providing and the cost avoidance. And so what are some really meaningful ways that you can do that. And so, again, anytime we can cite an evidence based model, IH saves about on average $2,000 per Medicare beneficiary and had 81 millions in its first five years so it's really been a great example of the value of home based primary care and they have white papers to if you're looking for something to have leadership really understand what you do. Dr. Cornwall on our website also has a great white paper called the perfect storm. I love sharing things with like, like that with people and especially executives that aren't as familiar with this model of care. So earlier in the presentation we talked about the primary care first model, and they're the first cohort there was a sip or a seriously ill population component, and that's not an option for participation right now but again these are what I look for is trends like advanced care plan which what they're looking for is that you documented annual preferences at least once a year every patient that you have has an advanced care plan documented within your record. Once per year. That's a big one, you know, and especially I think the pandemic has heightened goals of care conversations and that's kind of a way to measure what you're doing. And the total per capita cost is a claims cost measure that they look at. And then they also look at patient and caregiver satisfaction for the primary care first model they call it a patient experience of care survey. It's a little bit different than a traditional, you know, satisfaction survey or if you're familiar with the chaps that consumer assessment of healthcare provider and services kind of standard survey that they do. And then another huge one is days at home. And so what they're just looking at again another claim space measure how many days at home outside of an institutional setting and not in a nursing home. Do your patients have. And so, oh, go ahead. I just, you know, the last couple slides and even the next slide that we're going to talk through, like, for me, these are just examples of things that you can use so what we said collect some data, you know, if you're thinking about a primary care first or value based contract in the future, you know, understanding a couple of these points even days at home like we've been working with our EHR to be able to track that that that piece of data like is there any way that we could just have that because we're going to need to keep it. You know, the IH, you know, sometimes I'll extrapolate and say, well, you know, we know a national program say $2,000 per beneficiary for Medicare annually. We have, you know, to that, you know, we have x number of beneficiaries you know we have 200 beneficiaries in our program and that's what the savings is translating to. So, you know, for those that either spend all their time and kind of financials or business stuff it's maybe not that uncomfortable for those who it's still like I'm still kind of getting used to some of those things, you know, extrapolation is the name of the game when you're telling a story and you need to figure out where you don't, where you are saving money that can be really difficult so you know take take the stuff that's already published, you can point back to and say this is this is this is why we need this metric, this is the amount of money this metric is saving. If we do this right here's how many days we've done. Here's how many days at home, and we've been able to find the metric online that the average days at home if it's over 250 is this much of a savings, whatever. So you'll see a lot of these other studies and, you know, you can absolutely extrapolate them for your own for your own use. Yeah. I like the extrapolation part I'm glad you brought that up Amanda because it's always the challenge of the technology and the EHR and the infrastructure of, you know, how do you get this meaningful data on your patient population. But again, there's a lot of ways and systems and companies that can help you do that if you're not able to do it on your own. That's a good point like there are certainly other groups but you know you don't have to go, especially if you're starting out or you're trying to grow, you know, and I think, you know, Patrick as you're starting out. Pick just a couple a handful, you know, readmissions is one that always gets looked at, you know, that's it that's a good one admissions and readmissions just to be able to grab have on hand, you know, you can just set it up from the beginning of this is the that we track today. And here are another a number of others Brianna will talk us through them too but, you know, deaths on hospice if you're not partnering with a hospice or home care group today, you know, number of deaths on hospice. They're going to want to partner with you when you turn over that number for sure. Low or high if it's low there's an opportunity high they want your business. So it's just how you spin it whatever data you get figure out how to spin it towards what you need. You got a high cost utilization, you've got a not a great readmissions number to me that's just an opportunity. Here's where we started now we're going to focus some energy and effort and it's going to come down and we're going to track it. So, yeah, I mean I think you can you can always start somewhere and just kind of want to reiterate Amanda's point about we're giving this a lot of different list of metrics, not at all expecting anyone to do all of these things these are just to give you ideas of what other programs have found effective so you can tell your story, and really demonstrate your value. And, you know, just for example so the National Hospital readmission rate is about 20% you know there's one particular practice that shared some data you know they were at 15.1% rate when they started out so all you know they can already say they're lower than that they had a 4.7% overall hospitalization rate per 100 patient beneficiary months which compared to 19% nationally. They can say that 76% of their patients died at home, rather than a nursing home or a hospital setting. That's a really powerful number to be able to say and they can also say that 77% of their patients died on hospice at the, you know, and the overall hospital mortality rate so when you can say things like that. After a while that's a really really powerful story and case that you can make for different kinds of partnerships and payment structures. I had one other thought on metrics and then I know we can move on here but one thing, again like days at home deaths at home. This is a metric that is important in geriatrics you're going to hear a lot in geriatrics but you're just not going to hear generally. So, you know, I'm not the smartest in every room, you know, I may be rarely in the smartest but I certainly want to hold my own. And so what I try to use is what's the talk and then what, what is my distinct platform that's different. They're going to go in payers and partners that don't ever think about that number and you say, this is an important number in geriatrics boom, you're the expert in geriatrics now and then you say this is the number we're at. They don't have any context for any of that they don't know what that means yet but they know that you said that this is really important in geriatrics and that you are good at it and you track that and so I think it's, you know, I think this is all spin on how you use it. But capturing a couple things that are really important in our field, continue to give you the authority to be at the table to keep moving forward. Great. Does anyone else want to share anything that they're tracking in their practice that maybe we didn't mention on any of these slides that you found really impactful. If not, that's okay. If you think of something, feel free to throw it in the chat, too. But again, just kind of more, but what I love that someone brought up is they measure their collaborator satisfaction, too. So, again, being a good partner, and they actually survey not every single, you know, agency or partner that they work with, but their major, you know, facilities or home health or hospice agencies, they actually will send annual surveys out and measure that and have those kinds of conversations and ask for real-time feedback. And I think that's pretty novel and really impactful to do. And then polypharmacy is another one that you can think about. You know, I know that there was Dr. Chang's practice did a study with a pharmacist, and on average, they showed that 13 medications was the average per patient. I mean, you think about all of these high-risk patients, and you add the high-risk medications and the interactions and all of that, you know, that will, you know, definitely tell a story and kind of have a reduction of that in partnering with the pharmacist. They did a pilot where the pharmacist actually was able to make deprescribing recommendations, and then they were kind of tracking that over time on how much they were able to deprescribe. And then, again, patient satisfaction, and then also don't forget about your staff satisfaction, but HCCI does have a sample form, and again, we'll make sure you have access to all of these handouts in the HCCI Learning Hub. If you haven't, and Betsy can put the link in the chat for you guys, visited our HCCI Intelligence Resource Center. Also, a lot of these forms that are in your workbook, but that we reference, we're constantly adding to our tools and tip sheet page, and we have a variety of sample forms available there for you as well. Does anybody have an EHR that tracks deprescribing? That's next on my list, is to figure out how to not manually track that, you know, how do you capture from admissions, you know, and then, anyway. I don't necessarily know of one, but I'd be curious, anyone, let me check if we missed anything in the chat here. I just talked to a pharmacy group that said that they can do it, you know, like they can kind of snap these pictures of, you know, and I'd love to see, you know, almost like clinical pathways of, you know, antipsychotic use, deprescribing, you know, what are we band-aiding, what's truly on label for antipsychotic use, and then how do we, you know, what's being used off-label. So, there's some, like, interesting things, I think, you know, beyond just how many did you, how many, instead of doing it manually, how many medications did you come in with six months later, three months later, whatever it is, how many do you have today? Because I think that's a huge opportunity. I think that the two largest raising costs are MedA, SNF days, and pharmacy costs. So, I think if you could get polypharmacy numbers, especially to payers, that would be wildly attractive on deprescribing. Hey, we're going down from 14 to 9 on average, and be able to bring those back, and it's not like I'm just scrapping vitamin D. Like, we're actually getting rid of meaningful prescriptions that aren't adding any value. I'm, that's high on my radar, just for what it's worth. Yeah, absolutely. I mean, I think that's so important, especially, I remember my younger grandma, she went from, like, being on two medications her entire life to now having, you know, a pill box at 94, and having all of these meds, and, you know, is constantly asking me why she's taking all of them. So, luckily, she's got a wonderful home-based practice that has to answer those questions, because I am not clinical, and I am not qualified to answer any of that. This was just a screenshot of the Patient and Caregiver Satisfaction Forum, and again, we make these in Word, too, so you're welcome to actually use that. I know a practice that's taking a couple of these and rebranded it, and also, if you have some suggestions on what meaningful questions are missing, we would love to hear from you. So, we talked a lot about clinical quality metrics, but you also, you know, we touched briefly on it earlier, but really, like, how are you taking a pulse on your practice? Like, what kind of data or things can you measure that will help you decide when you do need to hire, or how your team is really actually performing as a whole? And some of these get into more outcome metrics and things like that, but I would just kind of encourage you to think about maybe something that's not necessarily a clinical quality metric, but that would show you the performance of your practice, and what value, you know, could that be in your program? Especially, like, you know, one that I've, like, you know, wait times for, you know, new patients, I think can be, you know, if you know how quickly you're able to see a new patient, or you know that you have a wait list, you know, what can you do to close that gap and get to patients more quickly, or time to TCM visit, you know, things like that. Chris shared cost per patient, you know, have a very high acuity on patients that are consuming, yeah, absolutely. I think also, I mean, if you really can figure out the cost measure, you know, how costly are they when they first come into your program, and they're probably really need to be stabilized, and not that they're ever going to get all that much better, but, you know, once you kind of stabilize that patient, I know some programs that with more advanced kind of capabilities that can average or estimate their total cost of care on intake, and then kind of more six to 12 months after they've stabilized a patient, and what that cost of care looks like. You know, and as you kind of put these things together, like, it's not that big of a jump. Medicare publishes by county what your multiplier for your RAF score should be, so that you can kind of get what you should be spending, what you are spending. All of a sudden, you've created something pretty magical. You know, here's my average HTC is a 2.5. On average, my multiplier, or good around number is $1,000. So, I'm spending, I should, I'm collecting on revenue for someone, even if it's not me at risk, $2,500 per member per month for that Medicare beneficiary. Great. What am I spending? Where are they going? And just take a couple of sample patients. You know, even, you know, sometimes we think, oh, well, it's a big, it's a big group. No, it's like to have one person's practice and one MA, just track movements of people for one month and see what happens. And then try a couple months later, one month and see what happens. Then look it up and say, what's the average cost in my area for hospitalizations? How many hospitalizations did I have? How many provide, you know, your provider visits, how many home care? Get those averages, build it out and say, boom, look, I'm saying I'm making a ton of money. I'm making someone money, or I'm really overspending myself here. So one other thought I had here is this adoption rate of new processes. You know, especially in any time, whether you're starting or you're in the growing phase, as you have new processes, what's your evaluation for this? And we, earlier there was a slide around reducing red tape and the bureaucracy of stuff. That, even if you could just put in place a really simple PDSA, you know, I use, for some of the small projects that we do, we just use an SBAR form for our team of like, here's the situation, here's the background, here's what we, here's our assessment, here's our recommendation, we're going to try it, and then we revisit that form to say, you know, did we really root cause, did we solve what we were trying to solve? Did we get to the things we were trying to get to? If we didn't, a month later, let's try something else. So there are kind of, you know, cheap and dirty ways. You don't have to adopt lean, you don't have to train everybody in doing that, but if you're going to put in a new process, make sure you've figured out your root cause and you've solved it, and you, again, can show everybody, hey, we solved it, we're moving on. This is the, we're moving on, we're moving on, moving on out. Yeah, I love that. It's funny, I was like, SBAR, I haven't thought about that in a while. But, yeah, there's lots of little tricks. And I know, Chris, you shared, you know, time of enrollment, time equals money. You know, yeah, your average lengths of stay for your patients, you know, again, knowing that these are geriatrics for the most part, so you may have a younger, you know, chronically ill population, but, you know, thinking about those kinds of things. And I would just, and high employee satisfaction, I think in healthcare, we're so good at taking care of others. But do we take care of each other? Or do we have informal check-ins? Or, you know, outside of just annual performance reviews, you know, do you really take time to check in with your team? You know, in my old practice, we used to have a, well, Dr. Chang has morphed it now into different kinds of jars, but we had called a cotton in the app box. And it was not anything bad. It was when you wanted to recognize your colleague for just doing something awesome or helping you, and we would read those at staff meetings and bring candy and little gift cards and things like that. But just take time to celebrate the wins and thank one another, and just realizing, you know, everything that everyone does and making sure that your team feels appreciated, because, you know, retention is important, and turnover is expensive. So, we talked a lot about data and numbers, but there's a lot more to be said. And I was listening to a woman that's had extensive payer experience, and she starts every payer talk with, don't talk to me. Don't start your conversation with cost or metrics. Start it with a story. Tell me, you know, in a different light, the difference in the quality of care that you provide. And what an absolute difference that can make. So, you know, for example, this patient was taken on to the practice post-discharge at the hospital, you know, 65-year-old female. Not uncommon for many people. You see 12 chronic medical problems, 16 medications. Her social history was challenging as well. She had two pretty uninvolved adult children, lived alone, relied on frozen meals. She was never married. Home-based primary care got involved. They got home health involved. They had telehealth involved. They got her the DME equipment that she needed. Pill package delivery was set up for her, medications to help with med management, and they also involved social worker and PT through home health to really just get her the support that she needed. She went from having 11 hospitalizations to one hospitalization the following year after they had resumed care. And I think, again, like these kinds of powerful stories will also demonstrate your value. And really what you want is, you know, I use this method too. I do a talk around contracting, and I always talk about, you know, how you have your patient stories, but you really need all of your leaders to have, you know, probably three patient stories just on deck that anybody could tell at all times. And they got to be short and succinct and ready to go and ready to prove whatever point you're ready to prove because you never know when you're quite going to need it. You know, if you're talking to a payer, you don't need to, like, you don't need to quantify the savings of money of hospitalization. You need to quantify that, you know, hey, I put a ton of health care interventions in place. If you're talking to your neighbor, you're like, gosh, that person needs a lot of work. And you're like, I don't know what the other side, if you're talking to a payer, they know what the other side of that cost structure looks like. They know that what you're saying is cheaper. Um, so, you know, that the super, super powerful, there's a comment to here. I think it was about, um, pill package delivery, um, and, you know, are people using their local pharmacies or, um, Amazon? That was an interesting comment, um, that you're using. I know there's some, like, I've heard of DiviDose is another one, just, um, like they actually pre-package, um, like AM and PM and things that come from meds. So anyone else have any specific suggestions that they're using for pill package delivery? Yeah, and a lot of the local pharmacies, um, will deliver, um, you know, within reason, um, for your patients as well. So, I mean, even if it's a Walgreens or a CVS or a local, you know, pharmacy that's been in the area for a long time, it's definitely work, worth looking into. Um, but Chris, you're using Amazon for this. Yeah, we have some patients that are, when I say in my area of Alabama that are so far out, the local pharmacy is not the option, which we always try to use someone local in the area. But Amazon is someone who is, they're going to anywhere and anything, and it's cutting down on med errors. The patients, they don't know to take out the pills and put in their pill packs. You know, it's just so confusing for them. I even have to show them, you know, a few times. It's just a hassle. So Amazon has that option for the patients who are so far out. It already comes to them and there's, there's no gap, no medicine errors, anything like that to cut out. It's just an option that I've found on a few patients of mine that I, because I'm, again, I, I feel like I go out to the trees, you know, out past the boom to get some of these patients. Is that, is that part of their new, cause Amazon got into kind of the home-based care space with their, I forgot, like Amazon care app that they're expanding and they have kind of, they formed a new coalition with a bunch of other people to help payment and policy around home-based care. Do you know if that's, or just in general, Amazon? Well, it's just in, well, just in general, Amazon, because one of the pharmacies, and this is, let's say in one County, one of my patients, their pills come out of a Amazon pharmacy out of Texas. The other one comes out of Maine in County. It's just hard how they have that set up. Are they utilizing their insurance? Yes. Wow. Okay. Yeah. Thank you for sharing that. As I always think it's interesting to see the trends in healthcare. And I thought it was interesting that Amazon and, and some of these other people are, you know, dipping their toe into medical. All right. This is a really great story. This was one of Dr. Cornwall's patients, actually a younger patient, you know, Amanda, not to not our Amanda, but, you know, it was 35 years old, you know, when she came in and was waiting for a transplant that she needed and, you know, diabetes, CAD, you know, chronic pain. But again, looking at the story at the bottom and what they were able to do HCP stands for home care physicians. So that's just essentially talking about when they took her on to, you can see from 2017 to 2018, what a difference it made having that kind of care in her life. And this picture in the upper right-hand corner was actually after she was stabilized and was actually able to get out and go to a fall craft festival. She had been homebound for many, many, you know, just in and out of hospitals and, and gone through just a lot of extensive treatment before home-based primary care came in and was able to really make a difference in her life. And that's why we say, just have a couple of these stories because you don't need a, you don't need a ton. You get, you get two or three of these slides, you get two or three of these stories, you know, you've done your work here. So there are a couple of pieces of data you'll want some, some groupings on, and then this, you go in to depth on just a couple. And that's, that's a compelling story. I know other people aren't coming up with that. Absolutely. And the VA is another place you can look for outcome data. They've done extensive research because their home-based primary care program was at risk at one time of being shut down. And they were able to kind of make the case and show how much cost savings, you know, even though on, you know, in the PNL statement, it looked more expensive, but really the value of their care. So people always ask me, you know, what's the best white paper or place to go? And the VA really has some great data out there as well. I think we talked about this again, you know, just highlighting these stories. This was some of these numbers that I was referencing earlier and really just overall lower cost of care, how impactful that is. And why there's so many partners. And this slide came about, Amanda and I were talking about the different kind of census numbers. Like I, you know, when I'm talking to programs, I always want to kind of understand their active patient census. Like how many patients are you currently serving? And you have to think about turnover and how often these patients pass away or are discharged or whatever. But, you know, challenging you to think of active census versus total lives served versus your average daily census. And Amanda, what did you guys end up with? What kind of census data are you guys tracking? So we do, we do some version of an average daily census. It comes out to be more like kind of an average monthly census, where we do a snapshot to see what's our census. And we also do total lives served. And now that one's new to us, but by the end of this year, we'll be able to say we touched 1,500 Minnesota lives or something. So, because we, you know, just depending on the service line. So I think there's value in doing what's my current panel, because you got to know your current panel for your staffing, for your support, for your budgets, et cetera. So, you know, that what's my current panel, you know, who has what, who has capacity, et cetera. And then I think there's a lot of value in how many, how many lives, you know, in your state, in your area you've touched. I think that's going to mean something to people too. So, and you use active patient census too, but we use, we use the bottom two the most. Yeah. And the only other thing I'll say about this too, is it's a lot harder, you know, if you don't figure out a way to track your panel and your census from the start, it's a lot harder to figure out once you've started enrolling. So, you know, if you're looking to your EHR or whatever mechanism you're going to use so that you can keep a pulse on this. So just kind of to leave you with some framework. So we talked a lot about measures. Okay. Well, how do you actually go approach, you know, starting a quality improvement initiative or when you pick one of these measures? So just, you know, again, back to some kind of foundational principles of quality improvement, thinking about an AIM statement, you know, again, developing this with your team. What population are you going to do it? What percent and by when? So for example, you know, all right, we're going to strive to complete cognitive assessments on 95% of more of all new patients by Labor Day 2021. It doesn't have to be your entire patient population. Maybe cognitive assessments is going to be part of your HPI enrollment process, and you just want to measure and make sure that that's actually happening on every single new patient or the majority of them every single time. So you can break this down kind of into more tactical steps. And, you know, this is kind of the framework and things like this, the tools that the learning network we mentioned earlier will provide you with. But again, think about what population, what percent by when, and then just take it in steps and, you know, don't try and measure too many things at once or all at one time. Some barriers, definitely team and provider engagement, you know, feeling like you have limited resources or your staff is already overwhelmed. Why are you going to give them one more step or one more process or one more report or something that they have to do? But, you know, that's where I think it really comes down to, you know, identifying the why and getting that engagement and making sure everyone understands, you know, okay, we're asking you to do this process, but this is the impact that it'll make. And here's, you know, some ways that, you know, come to me when you're struggling and let's, you know, look at an option to make that more effective for you or another person that could maybe take something else off your plate and making sure that you're monitoring progress. But if you're monitoring it and not sharing it, is it really doing the team any good? You know, if you want to make sure they feel like they're a part of that success and those results. And then the other thing the Learning Network was, you know, highlighting is PDSA. You know, it doesn't have to be, you know, plan, do, study, act. Maybe you just look at a two-week period or a one-week period or five patients and see how you're doing. You can have a small sample size just for evaluation purposes to then kind of figure out what you need to tweak and adjust. So, logistical considerations for quality improvement. Again, you need to identify some standard tools you're screening. You need to be able to extract the data one way or another through your EHR, practice management system. You know, understand what processes need to change because you may be having advanced care planning conversations, but if it's not being documented in a way that that can be extracted, then, you know, there's some training and education that needs to happen. And you can kind of create some action plans. I like to, you know, think about SMART goals. Okay, what needs to happen within the next two weeks, the next month, the next three months, the next six months, and then really just kind of, you know, assign a team to kind of own that project management and go from there. So, we wanted to kind of end this quality segment with just, you're welcome, any questions or any discussions or kind of anything that you guys have tried, even in your other service lines that you've, you know, had some learnings you want to share with our group or a success. Just so you guys know, we're almost at a break. It's 309 now. At 315, we're going to be going back to the main session, and then everybody will get a break. Amanda and I are going to be taking a little bit of a break, and then we're going to be Amanda and I purposely decided to kind of pause on the marketing and branding content that we have. We can do that tomorrow together during the putting it all together session, and then use the rest of the time for Q&A, or during the main session, we do get into marketing during the economics. So, see if that answers your questions. If not, we can break out at the end of the day during the putting it all together, and we'll spend more time going over that. But any thoughts, anything that you guys have measured and come out with successful or tips and tricks you want to share? No, as a practice, we're realizing how much revenue has been left behind in old charting that was not getting billed, so thank you. You're welcome. I mean, honestly, it really comes down to, like, getting paid for the work that you're doing, because I know it's hard, and I've had such a different perspective on things since I've been very blessed to have the opportunity to work with so many clinicians and understand their pain points and their struggles and really try and relate to that as much as I can anyways, but, you know, again, it's like, okay, but for you to be able to provide the care that you need, like, there's simple ways that you can just get reimbursed and not be so stressed from a financial standpoint, and it's really just getting paid for all of the work that you're doing, like, all of the chronic care management, like, that is my favorite code in the world, probably, because you have so much non-face-to-face medical and care coordination management, why not get paid for it? Yes, every time that phone rings, I'm like, how can I bill for this? Yeah, I mean, we have to, unfortunately, and less things drastically change under fee-for-service. I mean, you've got to survive. I mean, you're providing a meaningful model of care. But, you know, just to note, even under value, like, you need to maximize fee-for-service. Like, we still, you know, we have 80% of our revenue comes from value contracts today, so only 20%, but, you know, 20% of not a small number is, you know, still a big enough number when COVID hit and we weren't going into sites because we didn't know what we were dealing with the first month or two. You know, we took a big hit, and then we had to adjust, and it wasn't, this is going to sound insane, okay, and I get it. But when COVID hit, we had a really banner managed care year, so fee-for-service was really hurt, but from a managed care perspective, people weren't consuming healthcare. So we, you know, like, so far, I mean, it won't settle for a few more months, but so far, we're seeing probably the best managed care year we've ever had. From a cash flow perspective, because managed care money is not going to come until 18 months after you start, you know, we were immediately in trouble because of fee-for-service. We just did not have the cash flow anymore, and it's only 20% of our revenue. So it always matters, and there's really no, there's nothing else that you would do. There's no other consumed business that you would take part in where they're going to give you something for free. I mean, you know, your best bet might be you go in to get, you know, something on your car fix, and maybe there's an extra Coke sitting there that they're going to let you have, but that's about it. Nothing else coming for free. Well, you brought up a really good point, too, because even the practices that I work with in the value-based space, I mean, that's how your patients are attributed is, you know, fee-for-service billing and those look-back periods, too. So I think, you know, we have to focus on it more just from a pure survival standpoint. If your payment model is majority or 80% of your population is fee-for-service, but I mean, quality documentation encoded in matters regardless of the payment structure that you're under, unfortunately, but if we can make your lives easier and just have you focus on more clinical care, you really, once you figure out your billing model and you do the education and the training and you get the processes in play, it's a lot kind of smoother sailing. And, you know, you can adjust if something's not working or, you know, different code or different things. You know, I feel like most of the startup independent providers that I hear from for care management service might start with care plan oversight because it is mostly their time and things that they're doing, and that's a little bit higher reimbursement. Chronic care management is a lot less restrictive. Like CPO, you have certain, a list of billable activities that you can count time for, and it's only like talking to home health and hospice nurses and that kind of thing, and then things you can't count time for, like talking with families and caregivers and prescription repos, whereas chronic care management really looks at a broader, it has to be medical in nature, clinical staff for your providers, but looks at really any medical and care coordination time. Again, it just comes with a lot of other requirements, so that's why sometimes you need a little bit more infrastructure to get away with that, but there's a lot of opportunity. And Brianna, when do you cover CPO and CCM? I think that's in the advance, but I might go into a little bit detail during our reimbursement and sustainability, or we can talk tomorrow. We can talk coding anytime, but you will find CCM details in that advanced coding handout, and for sure we cover it in depth detail, especially because it's just my favorite in the advanced course. Look at that, Amanda, we're right on time. You and I, 3.15. That's pretty impressive. We're a thousand percent on time because we made our own decision not to do the last section. Isn't it fun? But again, not that we're not planning on covering that content, so tomorrow you have an economic session with Amanda and I. Amanda does a phenomenal job earlier in the day. We're going to talk on marketing and branding during that session, but if we don't, or if we, you know, if you want to go in more in depth, then session 11 will offer this non-clinical breakout, and that's when we'll talk about that, and then just open it up for kind of group discussion and questions. I need to figure out, I don't know if I hit leave room. We all have a 10-minute break right now, so I, you know, go ahead and take your break, and then just make sure you're back by 3.25 Central, and I will figure out how to get us all in the main room.

care management codes

billing case coordination

care management services

Chronic Care Management (CCM)

Transitional Care Management (TCM)

Remote Patient Monitoring (RPM)

care plans

documentation requirements

coding activities

comprehensive care plans

eligibility criteria

quality metrics

home-based primary care

fee-for-service billing