Everybody talking about the batch geo, all that kind of stuff. That was some interesting stuff to use. And then I think some of the stuff you highlighted will be talking about later on stuff. That's what's got us interested in the non-clinical side because now we're more into the side of trying to maximize what we've got. Yeah, absolutely. And I think Amanda, you brought up a really good point too. You know, I mean, this really is, regardless of where you're at with your practice, how established you are, how new, I think there's pieces of it that are applicable. We're all kind of learning and still evolving. And as your practice changes, your operations have to change with it. I will say the scheduling, like a technology like that though, has really been a lifesaver in most cases that I've seen. Because also, especially if you have fewer people, if you are a smaller program, it saves so much time. Like I was amazed with how much actual time scheduling, calling for appointment confirmations, you know, all of that really, really takes. So I think even just from the time perspective that it saves your staff, you know, having a tool like that is really, really helpful. Okay. Amanda, are you with me? Oh, I'm with you. Okay, all right. Let's go ahead and get started. We have a little bit more kind of talking about some of these practice conundrums before we get into more of structuring your team. All right. You want to start Amanda or you want me to? Sorry, you start, I'll jump in. Okay. So these next couple of slides, I try to think what are the burning questions that I get just all the time, right? And starting with productivity standards, what the right, you know, patient visits per day is, is definitely one that just time and time again, practices keep coming back to and rightfully so. And the caveat to this is it can't, I don't think it can be the same between across all practices. We're going to give you some references of what we've seen on a national level from the home-based practices that we've worked with. But first I think you really need to do, think about your cost and your revenue and your payment structure. You know, what outcomes, you know, geography, again, you know, Chris, thinking about your practice in Alabama, if you have to travel, you know, that many more miles per day, you're not going to be, you know, to your point that a nurse practitioner that's more densely located in the city is able to accomplish more days because those patients are geographically located. I think we have to be flexible enough and realize that. And also the type of visits I mentioned briefly earlier, you know, talk with your providers. It should be a partnership between your administration and your business leading team and your clinicians where you need to know from a revenue standpoint, how many visits are going to keep, is going to keep you having a sustainable model without sacrificing quality, but then also listen to them. If they're saying that, you know, their new patients and their transitional care visits are taking longer, take that into account and make sure your schedulers have a scheduling guide. So they're scheduling less visits when they have more new patients or more transitional care visits. And that everyone really understands the why behind your standards of care. We don't set productivity standards to try and decrease quality or anything like that, but we do have to be able to serve the patients that we care for and have a sustainable business. And I think that plays into role clarity to what is everybody's part and how can you support people in between visits? Anything to add there, Amanda? No, I just think that role clarity piece is so important. You know, I have a big belief that as we go on, we're going to see RNs that can bill. So, you know, understanding that top of licensure component and where are you really drawing everybody to top of licensure, I think is really key. And then they kind of don't step on each other. And I think this comes back, at some point we're going to talk about some risk stratification or maybe we'll, you know, as we ask about this too, but I think this comes back to how often and who's going to see who and how often they're going to see them. And just getting that level of clarity is so, so, so important and that's how you can build your financial models, that's how you build, you know, your business plan. Yeah, totally. Yeah, just the RN question. It's always driven me crazy. Not that it pays a lot, but in the office, you know, there's that nurse visit CPT code 99211. We don't have that in the home setting and it drives me crazy. But chronic care management minutes, there's other ways to bill for your clinical staff time. So, you know, getting creative with that and to your point, using everyone to top of licensure. So this was a revenue example, you know, as you think about really looking at your people and your expense and your revenue and what you can afford that people have just shared that they found helpful. But really what makes a difference here is, you'll notice, you know, mixed in with that revenue is ACP stands for Advanced Care Planning and Prolonged Services, billing for serum removal when the ear wax, you know, with the curex is done. All of those things really make a difference. This particular provider had a caseload of about 150 patients, saw about four and a half patients per day, you know, 48 weeks a year, you know, and how that breaks down from an expense standpoint. Amanda, I don't know if you have any other thoughts or how you kind of consider this in your program. Well, I'll tell you, so if you're having a doctor do this to your point at the bottom, you get 180,000. On the revenue side and you get, you know, 153. So you start to run into how are you covering all of your costs for doing this? And again, like there are only so many levers to kind of play with, but, you know, one thing to think about is, again, how are you using your support staff, your non-billable staff, and how can they help set this up to make sure that, you know, you have docs, NPs, PAs doing top of licensure work so they can maximize these things because you can see the value of even getting to 5.5 patient visits a day. What would that look like? This goes down dramatically if you don't maximize your geography. So, yep. Yeah, I mean, and we know actually from data that nurse practitioners make more house calls than any other licensure. And I think the interdisciplinary team is just so, so important. So how are you going to work together? What makes the most sense, you know, and really making sure you hire the right people at the right times. So- And has there ever been any CMS discussion? This is one of those questions I don't know the answer to. Has there ever been a CMS discussion of paying APPs or reimbursing at a higher percentage than a 15% haircut? Yeah, right, I know. It's interesting. So I'm starting to hear rumors, although I don't know any like fact base that they're going to pull Incident 2 to go away altogether. So right now, Incident 2 really only exists in the office setting, meaning what that is from a billing perspective, it's a billing and compliance term, which I am not a fan of. And it's the biggest audit risk and compliance nightmare that you could ever deal with. But in the office setting, technically, if your nurse practitioners or physician assistants are seeing an established patient for an established problem that the physician has already personally seen that patient for and developed a care plan, and the supervising physician is physically in the office suite, then it can still be billed under the MD's NPI number. Now in the home, you're not having the physician being readily available in the same suite or in the same home or assisted living facility generally. So that makes that concept more challenging. But the way around it, if it's a new patient or a new problem or anything that the advanced practice provider is personally treating the patients for, which they're absolutely capable for, you just need to make sure it's billed under their NPI number. I do think I've heard enough from CMS that they will change something. I don't know how significantly they will change the revenue structure from the 85%, but I think it will be interesting to see what happens because I'm starting to hear, and depending on what state you're in too, some Medicaid won't even honor incident two period. So you really have to know who your payers are and what their policies are. But I've started to hear rumors that that whole concept is just gonna go away completely someday. So I think they have to do something if they pull that. Thanks. Millicent asked too about who's on the team from an interprofessional and how do you maximize their licensure? I'm specifically talking about anybody that you bring under your company. So not people you're partnering with, anybody that you're responsible on an expense side, you wanna maximize whatever they can do from a licensure standpoint to make everybody at the absolute highest level. This is why some people will hire, we never did this, but this is why some people will hire scribe or hire people to even drive providers around so providers can document because it's in between visits or something or a scribe to do some of that work. Just as we think about what are lower expense structure individuals that can still gather data, do protocol driven things, whatever it might be, triage patients as necessary, and how are you gonna pay for some of those components? And so a lot of this is intermingling with how do you diversify your revenue? And there are lots of different ways to do that. When I started a couple of years ago with this group, we didn't talk as much as we do now because we just continually see Medicare and payers pushing to diversify how you're getting paid. So diversification of revenue, I think even if you're all fee for service today, it should be on your business plan in the next five years of how you're gonna think through diversifying your revenue component. And as you start doing those things, then you can start getting paid and using people in different ways. So as you look at this case example, we really fall under this on a provider standpoint, we fall in example one where around 200 patients or so per provider, but then we have a nurse that can support probably 50 to 60 patients in that and does a lot of our acute visits, but it's all under managed care where we have full financial risk. And so we can really drive up direct. So then you kind of combine this patients per medical coordinator or care manager, or even kind of back in LPN support or data gather, we put all that in one human being and they have a lower caseload. So we kind of got rid of a couple of, and consolidated a couple of different roles just to have a nurse and a provider do our home visit program. Yeah, and I mean, just to build on that, there's no like right person necessarily, whether it's a medical assistant, an LPN, community health worker, depending on where you're at with your program, your resources are gonna be different, more advanced, larger health systems. I'm seeing pharmacists a lot more on the team. But so these terms, we'll get into more specifics, but patient medical coordinator, that was a non-clinical staff member, the care manager refers to generally a nurse or a clinical staff member. And you can see the practice too, they really rely on MAs instead of RNs. And then they have a care manager that's actually non-clinical. And that's kind of how they structure their support team. And we're gonna give you some specific staffing model examples, but I would just think about, how are you gonna support your providers to make their lives easier so they can focus on patients? And I always like to think how many touches per day for messages, right? Like how much is being done so that when it gets to the provider, it really needs a clinical decision or a clinical skill to advise what needs to happen next. And then how can your team work together to just be more efficient? But thinking about caseload examples, again, when do you need to hire another provider? So having an idea of what your standard of care is gonna be, again, these are rough averages just to give you, well, these are very two specific examples, but what we've seen more consistently done throughout the field. The second practice example, they started off having larger case sizes, excuse me, closer to 200 or even 250. And then because they financially grew and could sustain and had larger patients, they actually found that it was more beneficial to cut that back. So their providers had a little bit more time on a slightly smaller caseload. So again, the national, the favorite visits per day, Amanda mentioned earlier, traveling with an assistant. So there's kind of two different models that we see. Maybe your providers travel with someone, maybe a family, a medical assistant, maybe a scribe. That person, the benefit can, you saw that in the house call simulation video earlier, can drive so that the provider can actually be documenting in between visits, which saves them a lot of time in answering messages and doing some callbacks and things like that. That medical assistant or whoever you have traveling with them, if they are an MA, could also help with taking vitals, doing blood work, going over, starting to write down the care plan if you're using that after visit summary paper form, doing all of those things. Generally, financially, if you have about two more visits per day, if they have an assistant, that makes financial sense. I also have some programs that they rotate. Not every provider has an MA every single day, but how can you kind of give people a break every now and then or give them support on certain days? And then also the scribes, I know a lot of virtual scribes now, like the dictation or providers, putting a little earpiece in so the scribe isn't physically with them, but is still actually doing their documentation. And that saves them a lot of time. When you get in more rural geography, I've seen averages closer to five to seven per days. I'm a pretty big stickler that I think you need to aim for at least five. If you're under fee for service, I think you really have to be doing five visits per day to make that sustainable business model. But you can also consider goals per week. I know a lot of practices that have like a somewhat administrative day where maybe providers will just add a few patients on and kind of a half day session and then give them that extra day to document, do callbacks, have that extra time. Again, there's no one right solution, but here's kind of the standards that we've seen from HCCI, working with practices nationally. So you can kind of compare and make your own best decisions. Can I ask a quick question about the logistics around lab? Sure. We definitely wanna offer a lab and we're working on amending our organization's agreement with our lab vendor to add home-based primary care. So just maybe how folks are handling the logistics of that, drawing it, getting it to a lab drop-off area or somewhere and the time it takes to do that and the staffing that it takes to do that while still trying to meet the target, the visit target. I'm just curious to see how folks are handling that whole process and the logistics around it or who have been successful with it. Yeah. Does anyone else wanna share specific examples of what you guys are doing? While you're thinking, I'll check the chat. In a previous practice that I worked in, we did draw our own labs and actually had centrifuges in the car that plugged into the cigarette lighter. The trick was the blood had to be spun down within two hours, and that was how they worked around that. But I know others that contacts found, whether it's Quest or LabCorp or whatever lab was centrally located in their area and would do it that way or would only schedule patient drug blood draws, PM closer when they're going to be back to the office and things like that. That's logistically, but I think even though the practice I worked in drew blood, we had a mobile lab partner because it's not realistic that we're going to be able to do all the labs that the providers need. The mobile labs, interesting enough, not that it's ton, but if you're a CLIA certified and you're just a lab entity, there actually is a travel fee they can charge, which we can't do as providers in home-based primary care unless it's like a self-pay situation. But interesting enough, I think that's why we see a lot of mobile, some options. Again, it's very region-specific, but mobile phlebotomy and mobile diagnostic companies, I think are generally somewhat more available because they have a little bit of option for reimbursement for that. Brianna Millicent asked whose car they're using when providers are traveling with assistance? Yeah, that's a really good question because we ran into a compliance issue. The practice that I worked in, and again, there's no one right standard, but there were two company vehicles that were insured. Everyone's driver's license was verified. Those assistants were put on the cars. All of that worked, how that worked. It got a little hairier when it was, is your assistant going to drive your provider's personal car? Is that going to be a liability from an insurance standpoint of somebody else driving the vehicle? Generally, the assistants would drive if it was the company vehicle, and then otherwise the providers would travel alone if they were driving their own car. I can't remember if there was a little loophole we found around, but there was some uncomfort if it was a personal car and not a company car, so that definitely is a consideration. Amanda, I don't know from a liability standpoint, if you have any thoughts there. No, I can tell you we have looked into company cars, and it's just never been something that we really wanted to take any liability with. So we've never done the traveling with an assistant part. So yeah, it's more of a, that's a 10-foot pole for me. Yeah, it comes with challenges. I mean, we had a company car that had a deer one day, and I never thought I'd have to deal with the accident forgiveness in a role, in a practice. But I mean, it definitely does come with challenges. There's things that are going to happen that you have to think about if you're going to go that route from a compliance and just liability perspective. This is not related to that, but there's nowhere in the two days where I can tell this story. So you guys are the perfect group. But we had a nurse taking someone's trash out. They just put it by the door, and they said, oh, I have you take it out, lifts it up, and a squirrel jumped out and slashed her neck. No, no lie. And she called me because she had, and I was like, I don't know how to deal with a squirrel slashed on your neck. And she was just like, you know nurses. She was like, oh, don't worry. I put some basset tracing on it. It's fine. But I was like, OK, but then we had to fill out an incident report. But there's no place in at all for me to tell that story in this course or the advanced course. We've got to build that in. I love that story. I mean, thank goodness she was OK. But I mean, yeah, there are things that happen. You have to be prepared for scenarios that would never happen in any other setting of care. But Millicent, to your point, too, you could have scribe assistants that's not physically with you. And again, if you use some sort of dictation service, or I do know a practice in Indiana where their scribes literally just listen in on an earpiece or another practice that sends audio recordings of their notes to their scribes. So if you didn't want to go the route of someone traveling with you, or you could call your insurance and ask about even adding the assistant to your policy as a driver or something like that, there's option for virtual. I think especially now during COVID, I've seen more virtual practice managers, virtual scribes, a lot of virtual support going on. So we talked a little bit in the last session about kind of setting KPIs and metrics from the beginning. These were just two very basic dashboard examples, this really focusing on visits per day by the providers and then tracking the days. You could see in blue that they had scribes. They were expected to do more visits. And then on the bottom, they actually started tracking phone and telehealth encounters based on face-to-face visits so they could see that. It'd be great if we all had a practice management system and an EHR that did everything we wanted to. You can generally pull the numbers, the visits per day from the EHR, but sometimes a good old-fashioned Excel dashboard really gives you kind of that real-time picture that you need. So this is just one example. And then again, this was another one, a new program. Again, starting small, they started off just tracking really total enrollments to the program in addition to their active census, accounting for patients that were discharged, and then also new patients per month, and then their no-show rates. This was a health system practice that's RVU-based, so that's why you see those RVU goals on there, and then taking into account that. And then actually, they've morphed now, and now they've added outcome measures on the bottom of their dashboard where they're looking at admissions per month, and that's talked about in monthly IDT meetings. But just to give you some rough examples of very simple places you can start so you can at least really measure your success and see how you're doing on a monthly basis and the team as a whole. These are just, when you guys get the slide deck, these are really good things to track, both for your operations, but as you're externally telling your story, especially if you're in like a bigger system. I hear a bunch of, I hear often, you know, the bigger system doesn't understand the value I bring, or I'm trying to partner with someone they don't understand the value. You're gonna tell them it's slower medicine, it's more complex medicine, they see fewer patients than 25 visits a day, and here's how many they're actually seeing, here's the kind of quality we're getting, here's the financial performance we're getting. So you're unrolling a story for whoever you're telling this to. So these are just two, I think, really good dashboards for both internal and some of it will be external data you use. Yeah, and just a little explanation on this side too, that this particular practice, they didn't do house calls every day of the week, they didn't do them full time. And this was when they had just, just started their program. So you can kind of see that change. but for that reason, their providers had clinic sessions in addition to doing house call days, so they wanted to account for that. And I think especially if you have an integrated model, you need to be able to show so you can kind of explain those numbers if they come up. Amanda, was there anything else that you found in your practice having on dashboards or monthly reports or however you decide to look at it has been really beneficial, like outside of the standard kind of visits per day, active patient census, any thoughts? You know, I can tell you the one thing we did not do is some groups have gotten a lot of success and putting like de-identifying and putting comparisons up of providers. We actually inherited a practice that did that, and I don't think that actually went very well. That didn't have a lot of, that wasn't building a lot of goodwill to see comparisons up there. So, you know, we certainly, the only, I mean, the only other thing that I usually track, I don't think I see it up there is how quickly they close charts. I'd love a metric, but I don't know how to get it from our EHR of how quickly after a visit they open a chart. Maybe sometimes they're not completely opening them, you know, in a timely fashion, most are, but I have a couple of people that take forever to open and then take forever to close. So closing charts is a dashboard that we measure to for our success. That's just money out the door, you know? Yeah, well, and especially you'll hear me say this in my billing talk, within 72 hours, I hope you all are signing and completing notes or as close to that as you can, you know, running open encounter reports and again, trying to do that. Was there anyone, there was a pop, it's a little hard for me to see the chat when I'm sharing my screen. So Dana, Betsy, Rachel, please feel free to jump in if I miss anything. But Dave, your name popped up on my screen. Did I miss you wanting to jump in with a thought or a question? It's okay if not. No. I'm just having a little trouble with my online stuff and I'm just trying to get. Of course. Yeah, no problem. I just want to make sure we didn't miss anything. Yeah. I think you're caught up, Brianna. You're good. All right. This was another, again, talking about those conundrums of those magical questions that always come up. A question that I get a lot, especially from the coding and compliance perspective is, what is the requirement for visit frequency? How often can you see patients from a medical necessity standpoint and how do you balance that? The answer to that is it needs to be individualized and personalized for each individual patient based on their clinical status and their health status. That is totally up to the clinician's judgment. But where you're going to get into trouble is if you have a practice that wants to see every patient every four weeks. Think of a pleasantly stable dementia patient. If you're seeing them every month and I'm looking at your assessment and plan and it's very much the same as last time, pretty stable. There's not a lot of changes going on. When we think about the Medicare fee for service program and all of the fraud and abuse audits that they do, that's where you would get into trouble. You shouldn't be seeing every single patient on the same visit frequency schedule. Now, if you're in a value-based arrangement, you're going to have a little bit more flexibility. But Amanda, I know you guys use a little bit of a risk stratification process in a way. I didn't know if you wanted to talk about any experience you might have here. My understanding is there's not a common risk stratification structure that organizations can use necessarily. But we got into this bucket because we inherited an assisted living practice that had a required monthly visit. I was like, oh, that's illegal, you can't do that. They were like, but all of our patients are really complex. We screen them on the front end and we know how complex they are, so we see them monthly. I was like, well, turns out they change upon your entrance of your screening profile. We got to this spot of like, okay, you can't do that. They're like, well, how often can we see patients? I was like, well, how often do you get seen as a patient? You go in with an issue and they tell you when you're going to see you next. Based on that issue, whatever that might be, it might be next week, it might not be for another year for your next annual. So what we have done with some of our managed care products is created a risk stratification tool. And again, everybody has different ones, but for us, it basically says, how many times have you been hospitalized in the last month? How many times have you had like touch points or phone calls with us for whatever reason? Do you have a certain number of medications? Over 10, it puts you in a higher position than five medications. So what are the clinical qualities of your complexity of your person? And then how does that translate to how many visits? And so then, and it's still kind of loose. It says, you know, it's red, yellow, green. Our highest red is still that every other week you're getting a touch point by either a provider or a nurse. And so it gives you flexibility, like if you were like, well, the provider's going to see them every two weeks and then they can change and go up and down on that scale. So, hey, our acute flare up issue is no longer red. Now they're yellow and they only need to be seen, you know, every 45 days or whatever that might look like. So, you know, and I cleared this, Brianna was my first call when we were working on doing this. And I said, if we create an infrastructure that we equally apply to all of our patients around kind of clinical points that come in to generate touch points, how would that look and feel? And she said that it was very legal to do. And so that's where we're headed. And for a scheduling perspective, you know, now it's a check, it's a checkbox on the way out of the system of when do I want to see the patient next and who's seeing the patient next, you know, and you just kind of can schedule it. And where we haven't gotten to yet, because we're in the process of rolling it out for all of our patients, but is, then I'd love to go by profile of each provider and say, okay, how many patients are in the red, yellow, green for each provider? So I can start to get a sense of what their actual workload is. And, or maybe someone stands out like a sore thumb, which sometimes happens if everybody's red and you're like, well, you're not, maybe you have everybody's red and you have a really sick patient population, or maybe you're not applying this correctly and you're just trying to generate visits or do something else. So for us, I think, for us, it's a way to equally apply a measure. It's a way to get some data on the patient populations. And I think what we'll show is about 80% of people will have similar risk profiles. So it'll show everybody, because everybody always likes to say ours, mine's the worst. Oh, well, everybody's is the worst, right? And then we can generate our visits off of that. So. Well, I mean, I think that it's great to have a tool. And then as long as it's left up to the clinician judgment, you know, then you're not doing anything wrong. And I think also this isn't to say that you can't see your patients frequently, because we know that high touch, you know, high needs care, these patients seeing more often keeps them out of the hospital. But again, you need to make that case through your documentation and support it at the encounter level. So you very well may need to see patients, certain patients for a period of time, every two weeks or every three weeks, or even in a week follow-up, depending on what the clinical nature of their presenting issues is. So I don't want anyone to take this slide as you can't see your patients frequently. You just need to be careful and not apply, you know, the same broad concept to, without considering each patient's health status. And Chris said our, you know, our ALFs are kind of, we're saying we want monthly. And I'll tell you ours do it too. And so there was, we got, we had another group that they were, you know, they wrote down, we'll see you every other month or by medical necessity, wink, wink. And then everybody was every other month, exactly the way they did it, or every month. And I was, you know, and I'm like, look, I don't, I mean, I do look good in orange, but I don't look good in orange really. And I don't look good in stripes. Like I, you can't, you can't administratively, it's DNO, that's why you buy DNO insurance, but it's a DNO insurance claim. If you administratively put a policy in place that you're not actually willing to support, then you you've gotten yourself into trouble. Like if you do something. So I'm like, you know, what I tell ALFs is many of your patients are going to have monthly visits, but we will partner with you on figuring out how acutely that you're needed to come out. If you need us to come out sooner because the patient is having an issue, you absolutely should call us and we'll be there to support you. And usually I find that that kind of works because we're still on site. We're still seeing patients, but the reason they're pushing that is because they want the help because they don't have the staffing. You know, they want an extra pair of eyes. So I, you know, you just, again, don't be like, okay, well, we're going to put it in writing, but we're really going to see everybody monthly. That's not keeping me out of jail either. Yeah. And it's not uncommon. I mean, thanks for bringing that up, Chris, because I've heard it time and time again to assisted livings. You know, you could say, yes, we will absolutely have a provider. They're seeing patients every month. We may not see every single patient every single time, but, you know, we'll check in with the DON or, you know, maybe that patient can be seen by another interdisciplinary team member or what it can do. And maybe you make the case that most of those patients are totally appropriate to see every month, but yes, definitely not putting it in writing and kind of having those conversations that look from a Medicare fee for service compliance standpoint, visit frequency has to be personalized and I can't just see every patient every month if they're stable and it's not warranted to do so. There's a, we're going to be here to every concern. You know, we're going to communicate a lot in between when we physically see the patient face-to-face and there will always be a provider here on this day or that, you know, that if a patient needs to be seen or an acute issue arises, you know, we're here to help. So kind of how Amanda said, you know, there's ways to work around that, but sometimes that's just some conversations that have to be had. So thinking about boundary setting, and I think this is really kind of a difficult one to think about because we're all, you know, human and we want to be able to kind of be at the beck and call of our patients, our caregivers, you know, our partners, you know, what we can do, but we also have limits and we need to take good care of ourselves. And Amanda's going to talk about self-care at the end of today. She always does a phenomenal job and it's a nice reminder because if we're not taking care of ourselves, we can't take the best care of our patients. But I will say one thing I found really effective is really setting expectations of care on intake. So having a new patient checklist that the front office staff or whoever is talking to patients when they're setting it up actually goes over, okay, this is how scheduling works for our practice. This is how future visits will be coordinated. This is what to do when you need us. You know, we're not, you know, after hours, you can reach someone, but we don't make house calls on the weekends or after hours, but we'll give you medical advice, you know, going over all of those things and really taking the time to have that conversation. And then certain things that providers need to go over during the first visit are using welcome packets to supplement that. And, you know, and then knowing, making sure your providers, especially if there's new providers on your team, know that you're there to support them and, you know, encouraging them not to give personal cell phone numbers that aren't business lines and helping them and doing something about it when they really do have a patient or a caregiver that's kind of maybe abusing the system. You know, who on your team can kind of figure out what the barrier is and how to support that person by just listening and making a call. Amanda, any other thoughts? Nope, thanks. So in summary of this kind of segment of ours, Dr. Cornell actually came up with this, the three Ps. I mean, home-based primary care really comes down to three things, you know, thinking about your patients, your processes, and then your payment. And so that's kind of the key takeaways that we'll leave you with from this segment. Any questions before we move on? Okay. So we're gonna talk about who to hire, some competence considerations, specifically diving in more in the weeds and front and back office roles. Here are those very specific staffing model examples in this segment that we promised you, and then some more on care ratios. Amanda, you wanna start or you want me to? Oh, you keep going. All right. So thinking about the team, I mean, obviously first, you can't have a home-based primary care practice without your clinical providers, right? And whether that be physicians, nurse practitioners, or physician assistants. I've heard some really good experience too about hiring if they have home health or hospice backgrounds, you know, thinking about things like that, or hospice and palliative care experience. This really isn't for everyone. So think about what kind of experience you want in your clinical providers. I've heard a lot of practices that have hired even newer nurse practitioners, but with a long extensive home health and hospice background has worked out okay. Or, you know, maybe you don't hire new grads, but those are things you need to think about. And especially when you are, you know, adding a staff member, thinking about people who can wear many hats. Again, there's no one right term care navigators, you know, we'll go on more specifically, but generally very broad, maybe a medical assistant, but that can also help with scheduling or some administrative things. That's not, you're not using a nurse licensure for, but they can really support your office in many different ways. And then making sure that you have that clinical support staff. If you are a newer practice, I think the pitfall that I see is, yes, you wanna start small, but it will generally save a lot of headaches if you have some sort of support without putting everything on an independent, you know, provider, practice owner without any support, even if they're part time, you know, thinking about that. And then as you grow, you know, can you have more defined roles where certain people are really just doing schedulings? You have to consider call volume here because the amount of calls per day, calls per day, excuse me, and the length of time that your staff has to spend talking with this kind of population really does make a difference. And so being responsive and understanding of what they have to go through. And then of course, you know, leadership, management, financial, are you gonna outsource? Are you gonna use consultants? And then having social services support, you know, whether that be through partnership or people that are actually employed on your practice. This is just talking about the importance of the interdisciplinary team. Some more kind of uncommon roles that I've heard about that, you know, we haven't necessarily referenced, you know, is some practices using community health workers. Social workers are a huge, huge, you know, asset. Depending on your state, if they're a licensed clinical social worker, they can bill for in-home face-to-face psycho counseling. The psychiatry codes, very, very limited code set, but I mean, there are billable revenues for social workers. And actually during the pandemic, we saw a lot of these certain kind of phone calls and e-visits where they created non-practitioner codes that people like social workers could actually have a little bit of reimbursement for. So if you are gonna look into social workers, maybe consider that licensed clinical social worker. And again, it just depends on the state, but most states, there are certain codes, psychotherapy was what I was trying to, the word I was trying to think of, that they can bill for. Some people that have dieticians and nutritionists, or can you find one, a home one? EMTs, we've been seeing a lot of telehealth models that have been using EMTs as staffing. So, and then just always remembering that the patients and caregivers are part of the care team. And just not forgetting about that, because I think communication is so important. Amanda, any other thoughts? I have one, I'm not 100% sure where it fits in, but this might be a good list. So when you're building your team and you're trying to find the person, the flexible person that can kind of wear many hats, et cetera, there's something called the Peter Principle. And I don't know how many people are familiar with that, where you promote someone because they were good at the last thing. And now all of a sudden they're out of their depth. I think about that a lot in healthcare. Healthcare is fantastic at doing that, where we promote someone because they were good at the last thing. And then we get totally stuck. So as you try to figure out who's the right person, what are the hats everybody's gonna wear? We have a slide on insourcing or outsourcing in-house. This is where those types of things kind of come into play. There's no great HR question list on how do you capture in an interview someone's adaptability or ability to change as the situation changes, right? Like it's not always easy to do that, but certainly, certainly as you go to do this work or you go to promote people, get a good sense of where they're going, what they're actually good at, what they're not good at. And those things are all legal to ask. You can certainly ask, where do you see yourself in five years? You can certainly ask, what are you good at? What are you not good at? People give weak answers, you can double down, so. Yeah, absolutely. And if you can employ a social worker on your team, because I think that's such a valuable member that we get a lot of questions about, I mean, home health has social workers, if the patient's active with home health, are you placing a referral if necessary? Or I've seen some pilot programs, even through the local area on aging or senior services in your community, they generally have social workers on staff. So again, if you're not in a point to hire, thinking about those partnership opportunities. And as we look at kind of the mergins for this, again, staffing and productivity, your people and how productive they are are your biggest expense for sure. And it's your biggest source of revenue. What happens if one person, your top billing provider goes down? What happens if they leave? What are you willing to give them in exchange for them leaving or anything else? There's certainly other expenses. There's all your overhead, your admin, your paper expense. I think the next growing biggest area, if it's not your biggest area today, outside of over like physical resources, depending on if you have a location is gonna just be technology. It certainly is gonna be technology if it's not your biggest one today. And thinking about how do I set a budget for that today? And what's that gonna look like in the future? And then we'll keep talking about how to think about other sources of revenue and stuff, but payer contracts are gonna have a big, big impact. They're not just getting one or two points on top of Medicare. They're gonna have a big impact for how you think about partnerships long-term. Yeah. And also, maybe not every payer is the right partner. Sometimes here are some really horror stories from practices like this particular payer is all of a sudden trying to deny services or is not covering this aspect of care or things like that. Again, thinking about which patients you're gonna serve, you can't see everyone. And especially if a payer is not home-based friendly or your team friendly, making sure you understand all of that upfront before you actually start providing care for a patient, especially if it's like a managed care situation where you might have to be a network or assigned as the PCP, you really do need to understand what insurance they have before you take them on. I don't know if any of you from a payer standpoint, if any of you actively follow like stock markets and funds and stuff like that, but I'm on my investment committee for our company. And every time an investment manager moves off a fund, it's very, very closely watched because it could have major impacts for that fund. And think about that for your payer contracts, every relationship you form, as soon as a person leaves, it could change. And so how do you kind of build in, build your tentacles in with the payer and or build an exit plan at all times too. Yeah. And I think we drove this point home, but your biggest expense is providers and thinking about, especially when you're maybe you know you're ready to hire, do you need someone full time? Is it gonna be a per diem relationship? What kind of support or structure do you need? And then also remember about probationary periods, right? Your providers, and especially if you're paying to get them credentialed for your practice is a huge expense. So how do you account for that when you're hiring and onboarding? So just so you know, like you're getting a lot of people who can help you with this part of hiring these folks. You can do a lot of your own research. So you can go to your state census data or what is it? State and they will publish positions. And so if you're hiring for example, family or internal medicine docs, they may not get to the geriatrician level, but they could tell you your census data could tell you what your Bureau of Labor Statistics can tell you how much a family docs gonna make in your area. And so you can do that. And you can certainly call up other practices and ask what people are most practices, their HR teams will tell you what a range is for a position if you call them up. Because like, even if you look at that position when $50,000 range, you don't wanna come in too low and you don't wanna come in too high for some of these providers. So, and what we do at our practice is we actually put them on guarantee the first year and then they can come off guarantee and go in a panel size model if they're successful. And if they're not successful after the first year, they get one more year of guarantee before they're pushed into the panel size model. So they really have a two year ramp if they want it. And then we have about half who come off after the first year, these are successful, about half that don't and stay on for the second year on the guarantee. So it just depends on the year that we're also rolling it out. Like a pandemic year is a little different. So thinking about some strategies, we're gonna talk about smaller programs first and then larger programs. I think we talked about kind of that jack of all trades or your staff that can assume multiple roles and responsibilities, but also understanding when that needs to be more refined and thinking about social services support. Again, the non-medical needs of your patients are gonna be just as significant and providers, you heard Dr. Chang say earlier, I can't do everything. I can't solve for everything by myself. So how are you gonna account for those kinds of needs on your patient population? And then also when you think about outsourcing, especially when it comes to revenue cycle management, I mean, you really need to understand if there's money on the table or are people appealing denials? When you get claim denials, you have someone that can do that. Do you have someone on your team with coding and billing experience that can really make a difference from a revenue standpoint? And maybe you don't, and that's okay, but what kind of maybe annual training or annual auditing or things like that can you look into to kind of support you? And if you are gonna outsource revenue cycle management in particular, really need to make sure you're getting real-time feedback and that you're getting good AR reports and meeting with them monthly because there's a lot of options out there. And if you're just doing your billing through your EHR, you need to understand if there's a problem with a particular service or all of a sudden you're starting to get denials with modifier 25 or something like that, because it really can make or break your practice. But you can also outsource a lot of these things, especially if you're small and you don't wanna have to take on that burden yourself. Is anybody good or bad stories with outsourcing revenue cycle? Or is everybody do it in-house? All in-house here. And what RCM system do you use? We're under an umbrella of a home health company and a physical therapy. So they have one person that handles all the companies together, but we're just part of the umbrella, but it's all in-house through them. And we have somebody that handles all of our rejections and they tell us what it was and what we need to recode it as, or anything like that. Yeah, I agree. Okay, let's see. Mary Lynn was in-house. I'll tell you, we outsourced ours for a couple of years. And we certainly got to the point where it was never perfect, but we went way past our expiration date with them and it moved it all in-house for sure. And there's just, I mean, the bigger you get, I think it makes sense to outsource when you're smaller, because it's hard to find duplicative services, to Brianna's point of like, well, if my coder goes down, what happens next? And so that's where I was a little bit scared. And so we went with this outsourcing company and it's the number one thing I think you should do is have direct eyes on your finances all the time. That's a good place to spend money, a good financial person. You have to figure out how you build and support. And I always like to think about how do you build and support, not for if they leave you, but if they get hit by a bus, like if tomorrow they're not coming in, what happens? Now, my staff don't love it when I say that, but you know what I mean. There's a very fond mentor and lifetime friend of mine too. And he was like, yeah, but if you get hit by the beer truck, what's gonna happen? And preparing your staff for that. I mean, you do have to think about when you think of kind of retention and long-term planning and things like that. And also, especially if it's billing and coding, a lot of times when I run into, and I do a lot of education with these teams of you also need to have someone that understands home-based care and understands what billing opportunities there are and understands, like for example, the office guidelines change. Well, we're, I mean, you know, we're not there yet, but we're about to do a transition coordinator just to bring down our Medicare a sniff days. Because our facilities love their Medicare a sniff days and if we could just figure, figure out how to lower that you know a couple of days would mean a lot of points in our value contracts so. Yeah, absolutely. Right. So, when you think about kind of tying this together and the optimal qualities of your IDT team they need to be patient focused and each person I mean you can't hold people accountable for results, or really get buy in unless they all understand that they're making an impact and what's their role whether regardless if it's the front office person in your triage support your provider, you know, and then really making sure when you think about the lean methodology that you're not having waste or redundancies doing kind of similar tasks that you understand what everyone's roles and responsibilities are and that when there is a breakdown that you're doing problem solving, and you're thinking towards the future, and you know, in a 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, any 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 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 1500 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 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, that, 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 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 3.09 now. At 3.15, we're going to be going back to the main session and then everybody will get a break. 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 it's, I've had such a different perspective on things since I've been very blessed to have the opportunity to work with 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 just, 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 a lot, 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 got to survive. I mean, you're providing a meaningful model of care. You know, just to note, even under value, like you need, you need to maximize fee for service. 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 hits, we had a really banner managed carrier. 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 carrier we've ever had from a cashflow perspective, because managed care money is not going to come until 18 months after you start. Um, you know, we, we were immediately in trouble because of fee for service. We just did not have the cashflow anymore. Um, and it's only 20% of our revenue. So it, it always, it always matters. And there's really no, there's nothing else that you would do. There was no, 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, your best bet might be going to get, you know, 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, 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 or 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 than session 11, we'll 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.

practice management

home-based primary care

technology tools

role clarity

visit frequency

tracking metrics

KPIs

team engagement

quality improvement initiatives

financial data monitoring