Dana, how are you the host? Dana, are you there? Dana shouldn't be the host. Look in the participants, she's identified as the host, which I'm afraid is going to be a problem. Really, Sarah, you should be the host. Yeah. I don't know how that happened because I didn't even put her in as the co host. So, when data gets on we can ask her to transfer the privileges that's fine. Okay. I'm going to text her. Here's Brianna. It worked. Oh my God. I was like, wait a second and wants me to register a free zoom account with my gmail email. Had the same issue and when I did that it's when it finally let me in. Because it's, it's because of the see the whole CME thing. We have to make sure that we, the people who are registered are the people who are coming in. That means that you have to register with the email that's associated with the LMS. I don't think that is what the problem that they're describing though that sounds like something with zoom because that was what that was what was tripping me up is that Brianna I felt so bad you kept saying like, it's saying I'm not registered and then I'm looking in the LMS and I'm like, but you are. No, it was not. What happened in the LMS. She was, she was it was the zoom link was saying that she wasn't registered because she didn't have a zoom account with that email address, it had nothing to do with the L for access in the LMS. So they had to create it was a problem outside of, of the registration little pop up that I noticed that was like register for your free zoom account now and I was like oh this is what it wants me to do. That's fine I just gave you guys a heart attack this morning for no reason. I was pretty much going to figure it out we always do. But I could tell I definitely gave Margaret and Sarah heart attack car for the course, you know, 30 minutes before workshop begins. Hey guys, Dana, I need you to do something I'm not sure why you're in is the host but can you assign Sarah to be the host. Okay, I just don't want to have problems when it comes to some of the things we need to be able to do with breakouts and so on. Now that we have breakouts today. I'm going to step away for just a minute but I'll be back. Okay, perfect. You should see it now. All right. All right, that's how it should be. And then tomorrow Brianna will have to make you a co host just that you can share your video during the share your stuff during the breakouts. Thank you. And yes, no problem. Hi. Hi, Dana. Hi. Thank you. All right. Oh, the new grandfather has arrived. Congratulations again. I told them yesterday. She is too cute to be legal, you know. So, she's just an absolutely a perfect, just such a joy. Perfect baby. Love her to death. Already. Have you gotten a meter yet or just yes, you have. Yeah. So we're waiting on Amanda. Is that it? Yes. And then Lizzie will come later. Right. Okay. Well, it is just 830, I guess. Everybody have a good Memorial Day weekend. Yes, I did. Thank you. I came down with COVID. Oh no, Margaret. I hope you're feeling better. You know what? I actually, today is the first day that I feel like somewhat of a human. So I'm grateful for that. But yeah, we had all these grand plans for Memorial Day. Ryan got sick first. And, you know, obviously, so we canceled them all. And then by Monday, I was not in great shape. But it's been mild so far. I'm glad you're feeling more of a human today. Thank you. Pre-workshop, that had to be rough. Trying to work before a workshop. Yeah, and six months pregnant. Not ideal. But I live to tell the tale. Thank you. I know Megan was telling me how much she loves the new videos, the ones you put in from the patient assessment. Since it was her first time she got to see those. Yeah, those are great. What a wonderful job. Oh, I'm so glad. I'm excited to, you know, bring them to our education program in a few different places. You know, we have a nice on-demand course that features all of those videos and more. And then to be able to use some of the pieces in this course is great. Really wonderful job. Just hit all the really nice, nice moments of the visit. Just as I would expect, Dr. Chang. We always get requests to shadow Dr. Chang, so now everybody can do that. I was ready to shadow him after that. I might go ahead and just start to share my screen just so that, because when Amanda comes on, we might, we have one question for her. Yeah, she just texted saying she's on the phone with a pediatrician. Oh, that doesn't sound good. Melissa, did you ever hear from Dr. Suchak? No. No, I didn't. I know you, you. She just changed roles. So I'll follow back up with her. She's now the geriatric education director. So once she gets her feet under her. All right. That's great. Can everybody see the slides on the screen? Yep. No, I'm trying to, this is why I'm doing this now so that I can, let's see, meeting controls, that's fine. Okay. You guys can all hear me okay, right? I just realized this is a new headset. I haven't messed with the volume at all. Say something again, Brianna, because. You can hear me okay? Yes. Okay. Okay. Thank you. Yeah, it's not quite as crisp as when you were without the headset. So that's why I'm hesitating. You think without, or I could turn it up, is that better? If I turn it up. What does everybody think? I think Brianna, you sound different from Melissa. Um, yeah, I mean, it sounds fine, but in terms of, as Melissa said, like crispness. It's like you're in a box. You sound like you're further away. Yeah. Is that better without it? I think so. Okay. While we're waiting, I'm gonna go ahead and launch a video and I would appreciate if you guys could tell me how the sound is coming across. We've had some challenges and I'm gonna play two different videos. This is Tom's opening remarks. I won't play the whole thing, but I'll mute myself and then. Sorry, I muted everyone, which also muted you. Thank you so much for joining us today. At HCCI, we talk a lot about transformation, how home-based primary care transforms the lives of the patients and family members, how this wonderful care transforms the people who provide it, and how this unique model of care has the potential to transform our healthcare system. You are a part of that transformation. You are at the forefront of a movement that will change the way we care for our most vulnerable patients, improve patient outcomes and experience, and do it in a fiscally sustainable manner. We are excited for you to begin your journey with HCCI. You are here. How did that sound? Sounded really clear on my end. There was like that tiny little gray box that popped up in front of Tom's face. I don't know if people saw that too. Yeah, it was like a very small amount of buffering within maybe the first 10 to 15 seconds, and then perfectly fine after that. Okay, so then let me try one more video. Okay, um, will someone mute everyone while I when I click this? Thank you. Well, thanks for letting me come today. Oh, thank you for coming. Oh, good morning. Ruben, how are you? Okay. Marina, is it okay I put my bag here on the sofa? Oh yes, of course. Thank you. And is it okay I put my chair here? Yeah, sure. Good morning, Mr. Osorio. I'm Dr. Chang. Nice to meet you. Hi. How are you doing? Pretty good. How did that one sound? Sound is really clear. Sounded good. All right. Um, Margaret, did you want to try? Are we still waiting for Amanda? I mean, could we, you want to, do you want to try sharing since you're going to share some of these? Sure. Okay. Okay. Melissa, can you hear me? I'm using a different microphone. Yeah, I can hear you and you sound good. Okay, thanks. Okay, can you guys see my screen? Yeah. Okay. I'm gonna also test the video. Transformation. Primary care transforms the lives of the patients and family members, how this wonderful care transforms the people who provide it, and how this unique model of care has the potential to transform our healthcare system. You are a part of that transformation. Okay. How'd that go? Good. Okay. So, I don't know, it sounded a little buffery and not to me, but what did others hear? Not as clear as Tom's first video, but I thought it was okay. Okay. Let me try. Well, thanks for letting me come today. Oh, thank you for coming. Oh, good morning. Ruben, how are you? Okay. Marina, is it okay I put my bag here on the sofa? Oh, yes, of course. Thank you. And is it okay I put my chair here? Yeah, sure. Good morning, Mr. Osorio. I'm Dr. Chang. Nice to meet you. Hi. Any better? It was a little better than the one with Tom. If you started it over from the beginning, would you find it run smoother because it just needed to load into your, this morning to your? Yeah, maybe. Oh, yeah, that's a good idea. I mean, you know. Well, thanks for letting me come today. Oh, thank you for coming. Oh, good morning. Ruben, how are you? Okay. Marina, is it okay I put my bag here on the sofa? Oh, yes, of course. Thank you. And is it okay I put my chair here? Yeah, sure. Good morning, Mr. Osorio. I'm Dr. Chang. Nice to meet you. Hi. How are you doing? Pretty good. Good. I've had a chance to review your records. Yeah, that was much better. Okay. But, you know, Margaret, I don't know. I mean, if it's simpler, I could just share my, I could be the one sharing the screen and the video through the patient assessment session and switch. Sure. Yeah. There's the bulk of the video. And I'm afraid if we're going back and forth, I don't know. It might just be simpler, you know, for me. Yeah. I mean, it's not new that I have some connectivity issues with my internet. So I think that's probably the same as that. And I'm keeping my fingers crossed that I'm going to be okay here today. But if it seems like it's working out, why don't we just not mess with it while we're playing the videos? And we'll get through the first session. All right. Then. Hi, Amanda. Hi. Hope all is well with you. We did want to share one thing. Actually, let me go back to sharing my screen so I can show something to Amanda. Okay. Okay. Bear with me because I don't want to mess up my screens right now. So I have to do this. I don't know how to get to them. Okay. This is tedious. Oh, shoot. Okay. Let's go back to that slide. 591. Thank you. Let's close over. So if you remember, Amanda, this is the quality counts, the role of care transitions. And, you know, you spent, you know, you have your other slides all the way through. And then we do a quick transition slide before we talk about key metrics and MIPS. Just very high level connection to quality. This was our straw man that we put forward about a transition slide. And I'm wondering if there's anything you want to change here. No, Margaret sent it to me yesterday. It looks good. All right. Thumbs up. Cool. Can we, can we go back just to, so last time we talked, Paul and I were transitioning on slide 79, but I think some slides moved around. So when is my, when does Paul end and I start on transitions? Okay. So is Paul starting? Yeah, I think I'm starting. I think I'm going to hand it over to you on the Naylor slide, Amanda. I think that's how we've done it before. So it's 77 now. Amanda begins presenting. I think that's, is that okay? Oh yeah. Yeah. Yeah. No, could just could not remember. Amanda, I added the billing slides too. So I can chime in just for the TCM billing slides in this session, if you're still okay with that. I think it's after. Oh yes. I'm very okay with not doing those. 81. I'll cover the couple of billing slides and then I'll pass it to you. Yeah. Is it just, you do, you go through the templates and that was part of billing too? Yeah. Just the, where it's, it starts with 81 when it introduces the concept and then I'll go through the templates, reimbursement and implementation, and then pass it back to you after 86. Yeah. Okay. So I pick up on 87. Yep. I know that was new this time. Oh yeah. No problem. Very nice slides. All right. Anybody have any other questions about today? Oh, I'm so sorry. My question is just, Melissa, then is the plan to, after the patient assessment session that I'm going to take over screen-sharing or when do you want to transition that? Yeah, let's review. Yeah. There is a, there is a break right after that prior to the quality counts. Yeah. Let's do that during the, after the break we'll switch. Perfect. That's a good plan. Thank you. Melissa and Margaret, I did want, I was going to let you guys know later, but when we go to lunch, it'll be a perfect timing. I'm going to pop on a meeting. I kind of need to be on for 30 minutes and then I'll join back at 1.30. So I'll miss Betty, but I'll join like right before we start acute and urgent care. So if we're off timing, then I can adjust, but worst case, if like Paul, like fly through Betty's case, somebody just text me and I'll jump on earlier. Otherwise I'll plan to log back on at 1.30. That's great. Thank you. All right. I sent a note to Margaret. It's, it's on me, but I need to be done by five. Okay. You, I mean, you know, I'm kind of closing. I'll just keep my remarks short to be done, but I can always help out Amanda if you need, if you need. Yeah. If they're just all these questions and people really want to spend time, I just need to, my wife had carpal tunnel and cubital tunnel surgery. I told you she just can't lift any of the children. And so I, I'm like, have to do pickup for six weeks. No worries. Well, Yikes. Hope she's, hope she's doing well. Yeah. Well, you know, I mean, it's good to get it done in your early forties. There's nothing that makes you feel younger than having carpal tunnel surgery on one hand, and then you need the next one in August. So she's feeling, she's feeling awesome, but this is why she married a younger woman. I mean, she said it all along. Like she wanted, she wanted aid in there. That's where I went wrong. Yeah. Yeah. You have to think through all these things. Building your muscles while lifting all your children at once. Right. Amanda, this is going to be your workout when you go home. Yes. Correct. The, the, the youngest two are almost as, I mean, they're both like 25 pounds. And so when I go into daycare, I, you know, I carry them both out like this. So people have to hold doors for me. I mean, it's a very dramatic scene. So thanks. No problem. No problem. Thanks for letting us know. Anybody else have any scheduling concerns for today? I had one other just because Monday was a holiday. I didn't have a lot of time with my team. So I'm going to take the 30 minutes of lunch and maybe another like 15 to have a meeting in my office. So I'm going to miss the introduction of Betty, but I know I'm kind of like be hidden on camera, but don't, don't throw the ball, the ball to me. Um, the first 15 minutes of Betty. Sounds good. Um, and, um, Megan, you're doing no Paul's doing Betty. I'm just reviewing. Yeah. So Megan, you're doing Ralph and Paul's doing Betty and we're doing it. Remember we're doing that in a little bit of a different way, you know, so we're not going to go into breakouts, but you know, you can kind of, you know, present the high level case and then, and then debrief it as the large group, you know, but, um, as much as possible, um, you know, and I'm going to cover this in my welcome to, um, let people know they're going to be times. And that's one of them where we want people to turn their videos on to, um, raise their hand so that they can talk. Of course, the chat is always going to be open for them to, um, share, um, ideas and questions, but, um, we really want to try to have this not be two days of them just sitting at a computer and not, um, talking at all. Hey, Melissa, do we have, um, Betty's, I just have one slide on Betty, you know, um, is there a more descriptive, um, um, in the, in the workbook, we have the full case. So they have it. Um, how do I access that? Do you know? You can access that in the LMS or in the guest book, uh, guest and SharePoint. I'll email it to you right now. Yeah. And, um, and Sarah is going to be, um, as much as possible trying to, um, put the workbook, the workbook page numbers in the chat when we refer to it. So, um, you know, when we get to Betty, for example, um, and I'm just double checking where we have her. Um, so she's on page 27 of the workbook. That's when her case starts. Do they have a, are they just using an electronic version of the workbook themself? Okay. I'm just going to grab a notepad in case I need it really quick, I'm right here though. And you know, I may, in my welcome, pull the workbook up to show them and make sure that they know that they will want to review, have that open today too. And just a reminder, again, I know we talked about this in the planning meeting as well. When you can refer to the learning plan, that's vital information. And also when they respond to the things that we're going to be adding in the word cloud, I'm going to be monitoring the chat for all of that information so that we can put it in the word cloud for tomorrow. So whoever's starting is going to be able to refer to it. Okay. Thank you. So in the icebreaker, it would be really helpful if, you know, between Margaret, Sarah, Dina, and myself, if we can take some notes of what people say about the, you know, if they say verbally versus in the chat, what the two things are that they want to get out of the workshop and then send those to Sarah, because she's creating that word cloud. So you may have to pull together, Sarah, anything that was put into the chat with any notes that were shared based on verbal remarks. I would appreciate any help. So if you guys notice anything, or if you can take notes, I will receive it and I will make that word cloud for you. Thank you. Margaret, in the last four or five minutes here, is there anything that you want to say about our learner profile? I know we, and let me tee this up. I know we have mostly participants in the Illinois House Call Project, but Margaret and Sarah, it looked like we also had a couple of folks from Carolina Caring. Is that right? Correct. Most of the registrants are Illinois House Call Project. I think there was, and Sarah, you can correct me, maybe a handful outside of that, a couple from which were from Carolina Caring, but the demographics are pretty diverse. I mean, as the Illinois House Call Project is made up of, I mean, we have practitioners, MDs, nurse practitioners, people, you know, director of operations, CMOs, medical directors, and care navigators. So it's a pretty diverse group. One thing that stuck out to me is it seems like we have a bit more like interdisciplinary clinical staff, which is cool. And I think the pieces that you guys added around the social workers and mental health will really speak to them. So I think that's a good opportunity for them for this workshop. And in fact, someone who I was troubleshooting and helping to register for the event actually let me know, hey, is there anything on mental health? I would love to be able to learn about that. And we'd let them, you know, I let them know, hey, we've revamped this quite a bit because they've taken it before. And I was like, yeah, we've added social worker, you know, and they'll be discussing some things. So they're really excited. This group seems very excited. I'll be very honest. How many attendees? As of right now in the LMS, we have registered 47. Now, I don't guarantee that everyone will be coming on, but I'm still getting emails of people, hey, I want to register. So, yeah, we'll be up there. And 10 of those are faculty and staff. Yeah. Oh, you sent us 27 names. Yeah, they've been trickling in. So we're going to send an updated list, but 37 of those 47 should be attendees. The rest are faculty and staff. Is there any way we could get that new list? Yeah, absolutely. Sarah, would you be able to send that? Or I can if you're busy. So what I'm going to do, I'm going to wait for everyone to get in since I'm just still monitoring the email. As soon as it kind of dies down a little bit, as soon as we start session one, I can send it to everyone. That way you can have a new and updated. You can have everyone's, you know, company name and all that stuff. OK, sorry, I'm just double checking. So can you guys see my screen with the full slides? Yeah. OK, I will be starting out the session, but I am going to wait and watch to make sure that everybody gets in from the waiting room. It takes some time, so it may feel like there's a long period of silence. But just know that I'm just watching to make sure that we've got everybody in. All right, are we ready to admit everyone then? Well, that's nine o'clock. Yep. Any last questions from anybody? All right, let's go Sarah. Hi, good morning, everybody, welcome. On behalf of the Home Centered Care Institute, I am delighted to welcome you to our two-day virtual workshop. My name is Melissa Singleton, I'm the Chief Learning Officer at Home Centered Care Institute, and we're so glad you're here. We are looking forward to sharing- I'm on download now, right, John, from your browser. Yeah. Can we just make sure that we've got everybody muted, as we, okay, if you would, thank you very much. So we're so glad you're here, we're looking forward to sharing with you timely information and guidance relevant to your practice, some of which I'm pretty sure you'll be able to implement even as early as next week. That's what we kind of hope, that you come away from this with some pearls that are really very accessible and easy for you to initiate. So in a few minutes, I'll be introducing to you our esteemed faculty, but I want to cover a few housekeeping items first. Of greatest importance, we want you to take advantage of the next two days with our experts, and to the extent possible, fully immerse yourself in what we hope will be a highly interactive experience. We know that virtual events often can come with a lot of distractions on your end, and very real distractions, but we encourage you to stay engaged. And while there will be times, for example, if we're sharing a video, or there's a lecture being presented, you know, we'll ask participants to remain muted, but there will be many other times when we will encourage you to turn your video on and raise your hand and unmute and participate in the discussion in a live way. Alternatively, our chat will remain open and monitored by our faculty throughout the two days. So if you have a question or idea to share in that forum, please go ahead and do so. We will be recording this workshop, it's recording now, and if you must miss any part of it, please know that you'll be able to access that recording in the HCCI Learning Hub, typically one week following the workshop, if not sooner. Let's go to my next slide. So just a few more housekeeping items. We do have, we share the fact that none of our faculty or staff that have been involved in planning this workshop have any disclosures with companies who are ineligible by the ACCME. You will earn CME or CE credit for this activity, and some information about that is shared here in the slides, and then at the end of the two days, we'll provide instructions for how you will be able to claim that credit. Home Centered Care Institute remains extremely grateful to our funder, the Johnny Hartford Foundation. Their support has made all the difference for the last four years in us to be able to present workshops like these to our learners. So we've established several learning objectives for this workshop, all of which are designed to enhance the learner's competence and performance in some specific areas in home-based primary care. And we cover the breadth of clinical and operations when it comes to running a house call program and seeing these patients. So first and foremost, we kind of established some foundational principles of home-based primary care. So if you're relatively new to this, I think you're going to find that kind of session very helpful. But we also really spend a lot of time talking around the four M's in the care of older adults and how that's a framework for working in home-based primary care. So we'll talk through some recommended approaches to how you care for homebound patients, including medication management, mental health concerns, prognostication, and acute and urgent care. And then you'll have an opportunity tomorrow to participate in a house call simulation and demonstrate how you would provide care to three different patients, including how you would code and document those visits. And then we also spend some time talking about, you know, it's, you're caring, when you go into the home, of course, you're caring for the patient, but there's also often a caregiver there, a family caregiver or someone else who has, you know, on whom the patient is reliant. And so your role in recognizing caregiver burnout and providing coping strategies for that individual is essential. So we spend some time talking about that. We talk about business models and some of the economic drivers for this model of care. And then also talk about some staffing models and opportunities to improve workflows and efficiency. So it's really going to be a dynamic couple of days. All right, we want to make sure that you have all of the information that you need to be able to be successful over the next couple of days. And so here are some instructions for how you would access your material in the HCCI Learning Hub. And I'm going to try to share with you, you know, first of all, let me back up. All of the slides that you see here today will be posted in the HCCI Learning Hub at the end of today. Same thing for tomorrow. The day two slides will get posted in the Hub at the end of tomorrow. But the piece that you're going to want to have open today is your workbook. And that is available in the HCCI Learning Hub. I'm going to try and pull it up here. Everybody, you should be able to see this. This is what you're looking for. You can use the bookmarks on the left-hand side to navigate. But this is going to be important for you as we're going through. And where we are making reference to materials in the workbook, we will share the page number in the chat. But just know, like, for example, we're going to be using a lot of patient cases. So we may tell you, you know, please, you know, go to page 18, and we're going to talk about Ralph there. So then here we go. We'll let me close that out. And if you have any questions about these materials or getting into the HCCI Learning Hub, please email education at hccinstitute.org. Your other go-to is here on this Zoom. And it's Sarah Brichoux, who is my colleague. And she will be able to also help you if you wanted to chat with her in Zoom. So you can email her at education at hccinstitute.org. Or you can use the chat function and look for Sarah Brichoux. All right. So let me go ahead. I'm going to share a quick opening welcome video from our founder and executive chairman, Dr. Tom Cornwell. And so I invite you to watch for a couple minutes. Thank you so much for joining us today. At HCCI, we talk a lot about transformation, how home-based primary care transforms the lives of the patients and family members, how this wonderful care transforms the people who provide it, and how this unique model of care has the potential to transform our health care system. You are a part of that transformation. You are at the forefront of a movement that will change the way we care for our most vulnerable patients, improve patient outcomes and experience, and do it in a fiscally sustainable manner. We are excited for you to begin your journey with HCCI. You are here with a few of our incredible partners, faculty from HCCI's Centers of Excellence, which have been established at leading institutions across the US. Your two days here are an important component in your home-based primary care learning experience. After this workshop, you will have numerous opportunities to continue your learning through HCCI's online courses, covering both clinical and practice management topics, as well as our next workshop in the series, Advanced Applications of Home-Based Primary Care. You will also have the opportunity to register for the HCCI House Call Practicum and travel to one of the nation's leading house call programs to participate in a unique field experience. There you will shadow expert preceptors as they perform both clinical and practice management functions at their program, allowing you to observe up close how HCCI's Practice Excellence partner puts into practice the very concepts you will be learning at this workshop. Before you get started, I'd like to ask a favor of you. Please take a moment right now to write down two things you want to get out of the next two days. Maybe it's insight on staffing. Maybe you find end-of-life discussions challenging. Maybe you struggle to increase the number of visits you make each day. Write down those two critical takeaways and share them with the group. We will keep an eye on them over the next couple of days and make sure you walk out with answers. Thanks again for joining us. Enjoy the workshop. It's going to be amazing. Now let's get transforming. All right. So thank you, Dr. Cornwell. I love hearing him welcome and get our workshop started. And that question about what are two things that you hope to get out of this workshop is something we take seriously. And in many ways, that helps to guide kind of how the next couple of days are going. So we're going to, in a minute, kind of open it up and I'll stop sharing so that we can all share our videos and talk. But we want to hear, we want to have each of you introduce yourself, what practice or health system or organization you're from, what's your level of experience in home-based primary care, and then what are the two things that you're hoping to get out of this workshop. And we have about 30 minutes available for this part, just under 30 minutes. So let's go around. I mean, that's roughly one minute per person, but I really, we really want to be able to hear from you and know those two things. We will strive then as our faculty to make sure that we're addressing those things over the next couple of days. So let me go ahead and I'm going to stop sharing and invite all of you to please open up your videos and we'll go around. And I'm going to ask my colleagues to kind of help me out here, but why don't we, does anybody want to start? I always ask for volunteers first before being voluntold, right? All right, well, then I'm going to kind of go around the room here. So I see in-home physicians and that's my, and I, would you please introduce yourself and then name the two things that you'd like to get out of this workshop over the next couple of days. Sure. My name is Richard Ansfield and I'm the administrator for in-home physicians. We've been doing it for a long time, doesn't necessarily mean we've been doing it all right and perfect. So I'm really glad to be part of this. Our biggest challenge for us lately seems to be is finding good providers willing to go out and make host calls. That's our challenge right now and it seems to be, and that's something that I would like to see what we can do to get more NPs, PAs or physicians willing to make house calls. That's number one. Number two, I like the idea of utilizing all your resources as well as the benchmarks, if you will, so we can see where we fit in and how we can reduce our travel time scheduling. It's another windshield time, non-compensated. It's kind of hard to do it on the routes just because some people are on dialysis three times a week. Your daughter needs to be there in the afternoon and it's not one size fits all. Some patients are stable, they don't need to be seen every month, whereas some patients are just out of the hospital and they need to be seen. So that seems to be our challenge, scheduling and finding more providers to join us. Thank you very much, Richard. We appreciate that. All right. I'm going to go around my screen here, Gosha Kozol, did I say your name right? And you have to unmute. Okay. Got it. So I'm Gosha. I'm with In Home Physicians for, I would say, about 12 years. I'm the office manager, but I pretty much did everything for the company from helping Dr. Kaplan with orders, scheduling, billing, and now I'm doing more accounting and I'm the office manager as well. I do agree with Richard, finding good providers. It's pretty challenging, I'm pretty sure for everyone. And scheduling, yes. So maybe get more patients to get the scheduling easier for the group. All right. Great. Well, thank you so much. Thank you for having us. Yes, Sarah Brubacher. Hi, I'm Sarah. I'm just in the process of starting a home-based primary care practice. I've been doing some home-based care under the umbrella of a family practice for a number of years and just starting out on my own. So I'm looking forward to getting some help with the practice management piece. The clinical is more familiar, but practice management is new for me. Yeah, for starting up a new program. Yeah, we are going to cover a lot of that. So great. Sarah, where are you, Sarah? I'm located in the Barrington Crystal Lake area. Is that which state? I'm sorry. Oh, it's Illinois. So northwest of Chicago. All right. All right. Thank you. And I'm in Crystal Lake area. So I'm thrilled that because when we've had family and friends that have asked about what we do, there wasn't anybody I could refer them to. So I'm so thrilled that you'll be out here. All right. Teresa, excuse me. Or no, it's Therese. I'm sorry. No, it's Therese. I'm sorry. I was trying to deal with some things right before we started because my sister is trying to seek guardianship of my aunt and I had to answer a phone call from a lawyer I've been trying to get a hold of. And I'm really sorry I flashed all of you. My lady. Good. I'm trying so hard not to be terribly embarrassed. So anyways, I am pulling myself together. I am a doctor. I'm a physician that owns a very tiny practice out in the middle of nowhere. I used to come from Chicago. I went to school at Northwestern. I did my residency at Ravenswood, which then merged with Illinois Masonic. I guess my life has always been interesting. And I've been in practice now for 20 years out in the Belvedere area. But I serve Ogle County, Boone County, Winnebago County. I go into the projects. I go to the poor. I no longer carry a gun because I went to Taekwondo. So I'm good with house calls now. I still make house calls, but because I'm a solo practitioner, it's a challenge, particularly with being able to keep the revenues up. Because when I do show up for a house call, people want to turn it into a visit. And I struggle with maintaining a good relationship with them and still maintaining that familial tendency, but also make sure that it's professional. That is probably one of my biggest challenges, so that I can get out of the house in a half an hour and move on to the next one. You can't do anything about distance. But I try to organize them so that I'm not driving 30 miles in between. That on my way to the one that's 30 miles away, I make four other stops. Okay. All right. Great. Thank you very much. Yeah, that graceful exit. I know we talked about that too, so thank you. All right. I'm seeing Dorothy Jones. That's the name on the. All right, we'll come back. Tony Perry. Oh, what? I was on mute. Sorry. Oh, there you are. Okay. Sorry about that. Good morning, Melissa and everybody. My name is Tony Perry. I'm a physician. Geriatric medicine is my practice. Been practicing here in Chicago for about 30 years. Almost all of that spent at Rush University Medical Center, working in our geriatric and palliative care team and doing a variety of different things there. Have recently over the last, I guess, seven months now, joined a company called Dual Health, which you won't have heard of, because we're not live with patient care yet. But we are a population that's built to provide full risk value-based care for a population defined as having chronic kidney disease. So CKD, 3b, 4, 5, and ESKD is what we call it. CKD, 3b, 4, 5, and ESKD is our target population. And we're building a medical group that will be focused on full risk value-based care for that population, providing care in homes, tracking people to facilities, et cetera, as they go through the health system. So we're here. Tori Nelson is here with me. And we are here to eagerly learn because we are not up and running yet. I've done personally house calls at times, but it's only been sort of as a sort of a side thing and never a core component of what I did. So over the next two days, the two things I wrote down, one is I put down identifying the right people to do home-based services to avoid just a ton of turnover as you launch and as a topic. And then I just wrote safety of team members entering homes as a second topic. They were just top of mind when you said that, Melissa. Great. Thank you so much. My pleasure. All right, Mark Yoder. I'm Mark Yoder from Phoenix, Arizona area. I'm actually in day two and becoming the practice manager for geriatric solutions, which is under the umbrella of Hospice of the Valley. We've got about 20 providers right now that go out on a regular basis. And I'm just here to learn. All right. So but so you're here to learn. Is there was there anything in particular? I know you're on day two. You don't know. Patient pay or provider safety is certain certainly something that comes to mind. But then also just how to support the providers and give them what they need. Great. Yeah. And that's important because, you know, this is this is a team sport. Right. And so, you know, the fact that that we have kind of a multidisciplinary audience at this workshop is very important because we all need to be able to work together to support. So all right. I'm going back around here. Robert Kaplan. Two things that you'd like to get out of the workshop. I just managed to unmute my. OK. I'm Dr. Kaplan. I've been doing house calls since 1990, maybe even 89 within home physicians. And so I'm somewhat of a veteran. But at the same time, there's a lot of things that we don't do as well as we could, I would think. We've started working on cognitive assessments, for instance. But one of the one of the things that we run into is that almost all the cognitive assessments require some sort of either pencil and paper or one very difficult to do virtually because these people do not have iPads or touchscreen computers for the most part. And in person, a lot of the patients may have a stroke or something else, which keeps them from doing these things physically. But they may be cognitively intact and how to distinguish the disability versus the actual cognitive problem. OK, great. Well, thank you. Yeah. A second a second issue is a back office staffing. And we've talked about needing more providers, but we also need really high quality back office staff who will stay with it even when it doesn't always seem so easy. Yes. All right. Awesome. Thank you very much. All right. Thomas Maliti, how are you? Oh, good. How's everyone? Good. So I'm Dr. Thomas Maliti. I'm with the Advent House Call Physicians, formerly the Ameda Health House Call Physicians. And I've been pushing to change the name to the Advent Health House Call Clinicians as we have three excellent nurse practitioners and three physicians as a part of our team out in the field. So it's total of six providers in total. So I've been doing home-based primary care for about seven years now. And I've really found great reward in going out to patients' homes and just doing medicine the old-fashioned way. And I think people are really appreciative of just somebody coming out to their home and helping out as much as they can. So I think the few things that get out of this, I mean, obviously over seven years, we've learned a lot, but there's still much to learn. And so I'm just hoping to increase my knowledge base, connect with the providers, especially in the Chicagoland area, and hopefully to make strong connections so we're able to provide better care for our patients. And then the other thing I'm just looking to do is to advance our practice. We can always use better efficiencies in our back office staff as we look at more advanced models like rehab at home, hospital at home. I'm hoping to learn how to integrate these models into our home-based care. Thank you very much. Audrey? Hello, hi. So my name is Audrey Regan and I work for Mendota Health. And we are a very niche service because we're providing advanced wound care. And so we're collaborating with a lot of home-based primary care. So my whole goal, I think, for this is to learn how to optimize that partnership and how to best support any home health, any home physicians, because since our service is so niche, really trying to collaborate in the best way possible because we're just kind of an elevated level of care. If there's any advanced wounds you're dealing with, we will bring tissue-based therapies. We can do debridement in the home. So I think it's a very good partnership so far, but it could always get better. Well, and a big part of that collaboration opportunity is understanding the issues and concerns and day-to-day of a home-based primary care provider. So I think you're gonna get a good insight into that over the next couple of days. Thank you. Awesome. David Meltzer. Hi, I'm David Meltzer. I'm a general internist by training and a PhD in economics. I'm on the faculty at the University of Chicago where I run the section of hospital medicine, so the hospitalists. We've developed programs over the years that kind of go back to the future in a way by reintegrating inpatients and outpatient care, either under a single provider who will care for patients in both setting or by a dedicated partnership between an ambulatory provider and a particular hospitalist who will care for patients sort of every day in the hospital and if they're readmitted. And as part of that, we have a small home care program really with one main provider, Keona Brown-Goodson, who's our APN, but also our physician lead, Grace Berry-LaSure, who supervises her. And Keona works to some extent with all the doctors. So I'm really interested in learning how to sort of find and train more providers in this space so that we aren't so small. And then with that, of course, to build volume in the program. And the last thing I'll just say is we've studied our programs. We've done randomized trials. So we've done one 2,000 person randomized trial and now we're doing another 3,000 person, not of home care per se, but home care being part of it. So that's us. That's great. Thank you, Dr. Meltzer. Roseanne? Hello. Hi, so I'm Anne. I'm a family nurse practitioner and I am working with Dr. Maliti with Advent Health. I've been practicing for about five years now as an NP, did mostly private practice, and I joined the group about last year. So I'm pretty new to health calls. I've been loving it though. So our group has been doing great about 15 years or more. And so, yeah, I think for me, it's really looking to learn more about the procedures, looking to benchmark, and of course, learn everyone else from here. I'd like to be able to be more comfortable with managing more complex patients with the limited resources that we have in the home. And then of course, improve our processes with our practice. I'd like to make the visits more efficient, learn more procedures. I understand there are procedures like knee injections and all those stuff that we can do at home safely. I'd also like to be able to establish connections or network with the other practices here so that we can expand our services and provide a more comprehensive care for all our patients. Okay, great. And just to clarify, we do teach several procedures that can commonly be done in the home. And we're gonna be doing that at our advanced workshop in July, which I know you're invited to. So, just stay tuned for that. We won't get into it in the next two days, but it is coming. Okay, that's exciting. Thank you. All right, thanks. So, then I'm going around here. Jennifer Sgro, S-G-R-O. Yeah, it's Sgro. I'm Jennifer Sgro. I'm a nurse practitioner with the Rush at Home program at Rush University in Chicago. I started in February. So, this is all kind of very new to me. There's a lot of things. I mean, I think so far, even the training modules that I did on start were probably some of the better training modules that I've ever done for continuing education. So, I'm looking forward to it. Several things. I think the mental health concerns in the geriatric population are something that I found more challenging, and especially how it intersects a lot of times with chronic pain management. You max out on duloxetine, and then they're depressed, and then you don't know if you want to add medicine. So, some of that clinical stuff, but just mental health in general, dealing with loneliness and their body failing, then is something that I found that's challenging to me. Some of the office workflows, noticing things like labs were ordered, but then I go back for the return visit, and something happened, and the results aren't there. So, some of those workflows that might help us. And as Brianna, I hope she doesn't laugh at me, but the charting, how to chart as efficiently as possible to maximize revenues, that I found the charting to be burdensome, but all charting is burdensome. I think everybody would agree with that, so. Yeah. Here's something, because we're going to try and get through everybody, but we may not get through everybody. I'd love for everybody to put in their chat right now what EHR you're using, and that may help our faculty as well. So, this is an opportunity for you to participate if you haven't talked yet, share the EHR you're using. Thank you very much, Jennifer. Let's go around to Torian Nelson. It's Torian Nelson. Sorry. But good pronunciation, it's okay. I work as a care navigator for Duo Health, and just like Tony was saying earlier, we haven't launched live yet, and basically I'm here to just, like Tony was saying, get some safety tips and just kind of just soak up as much as we can about a lot of home-based techniques, because we haven't launched it, that's all. All right, yes. The whole getting started. Yeah. Good thing, right? So, thank you. Carrie Mitchell. Hey, I'm Carrie Mitchell. I work with Carolina Caring. We are a newer program in North Carolina under a bigger hospice umbrella. I am a new hire nurse practitioner. So, our program's about a year old, but we're definitely growing quick. We have a lot of barriers. I think some of our biggest concerns are getting appropriate referrals in the end, as far as location and travel. Maybe how do we use telehealth visits to be more efficient? I think somebody mentioned how much productivity you lose, windshield time. That would be great time to be doing the documentation. So, really just workflows and how other bigger groups are able to manage that. Great. Thank you, Carrie. Melissa Bieber. Hey, I am Melissa Bieber. I'm a nurse practitioner with Carrie. So, I tend to agree with her. And I think the other thing that I'm interested in is learning about chronic care management, the remote patient monitoring, and then probably ways to optimize billing. Okay. Awesome. Thank you. Julianne. Good morning. My name is Julianne. I'm from Geriatric Solutions in Phoenix, Arizona. And I am the office manager here. And hopefully what I'm gonna be getting out of today is just general process improvement, some improvement in efficiencies in our organization. We have similar issues. I know Jennifer mentioned lab issues, getting those labs back from the lab and keeping track of all that. Our EMR, we have not found an easy way to make that happen, the lab tracking. So, that would be helpful. And just general tips and tricks that you all can share with us. I'm excited to learn. All right. Thank you. How about Samantha? Good morning, everyone. Oops, I'm sorry. I'm pretty much new to this process as well. And I'm hoping to learn how to do the project. I'm so sorry. I'm disorganized this morning. No, it's all right. Practice management. And I'm a nurse practitioner and I have my own practice. And I do home base as well as office. And I wanna advance my knowledge in home-based care and the workflow between the two entities so that I could be more effective and it could be cost-effective. And practice management is very important right now. Samantha, where are you? Where are you located? I'm located in Flossmoor, Illinois. Okay, thanks. Mm-hmm. All right. Thank you, Samantha. Alina? Hi, everyone. My name's Alina. I'm with Anytown PCP. We're in Wheeling, Illinois. My background is I was MA or I am MA for more than 10 years for primary care providers. And then I kind of switched in the middle of it a couple of years ago and did clinical quality improvement, workflow improvements for 500-plus physicians for advocate care. And we did implementation. I was the lead implementation specialist for NCQA standards to get all the physicians to level three of patient-centered medical home, which for all the 500 physicians, we used the clinical works as the EMR that we implemented. So that's kind of my background. My current position is a director of operation and business development. So this is kind of a new venture, Anytown PCP. We have a nurse practitioner. We're looking for more to do the home visits and telemedicine. So we're starting to get patients and picking them up. A lot of physicians that I work as an MA now kind of do it as needed. They have a full patient panel. So a lot of their patients that we're getting are, they don't do home visits. They have 5,000 patients on their panel. They have a full schedule. So we get referrals from those physicians that need that care at their home. So what I'm trying to get out of this is kind of how to maybe manage the workflows better and how can I set up my nurse practitioners to have more efficient workflows and the care model that I'm trying to implement is having more MAs than providers per se, having MA go out on site and do EKG, do any immunizations, do the assessments, all the histories, and then maybe have utilizing nurse practitioners more of for telemedicine because then they can do more visits that day and having MA on site. So that's kind of the care model I'm thinking. So I'm more in office MA, so I've never had any home visiting experience. So trying to get tips and tricks and workflows and how to be more efficient and recognizing those patient needs at home and assessments that need to be done because they're very different, I think, than patients coming to the office. Yeah, absolutely. So thank you. This is all really helpful for our faculty. I'm looking around it, like Brianna and Megan, I mean, it's so helpful for them to hear kind of what you're thinking and so we can kind of tailor the next couple of days to some of these concerns. We are kind of coming up on our time because I wanna be able to spend a little bit of time introducing you to the faculty and then move on. I want, if you did not have a chance to speak this round, please go ahead and put into the chat now what those two things are that you're hoping to get out of the workshop. So, you know, Dorothy and Anna and Lisa, Sarah, Alex, Joy, Shalane, Brandy. And the other thing to look at is if you're logged into Zoom and it's got a phone number or your organization name, it would be real helpful if you could at least give us, you know, your first and last name on there too. So you can change your name in Zoom screen so we know who we're talking to. But let me go ahead. I'm gonna go back to sharing my screen. Give me one second. All right. So let's move on as I wanna introduce you to some of these great faculty. So Dr. Paul Chang is our Senior Medical and Practice Advisor at Home Center Care Institute. But in addition to his role at HCCI, Dr. Chang serves as Medical Director for Home Care Physicians, which is a suburban Chicago practice focused on delivering care to medically complex patients in their homes. And it's part of Northwestern Medicine. Home Care Physicians has made more than 123,000 house calls to home limited patients since it was founded in 1997. And Dr. Chang has personally made over 36,000 house calls. I'm just gonna let that set in for a minute. More than 36,000 house calls to more than 3,300 patients during your career. He's also a proud new grandpa, which I'm sure he'll share some information about. But anyway, in October, 2019, he received the House Call Doctor of the Year Award from the American Academy of Home Care Medicine. And we are just so glad to have Dr. Paul Chang as part of our faculty. In addition, Brianna Plintzner, who is currently Implementation Manager at Medically Home. Brianna, as many of you know, was at HCCI for several years, and we rely on her deeply. And I'm so glad that she's stayed on as faculty. Brianna has deep knowledge and experience in house call practice management, having focused her career in primary care and home care medicine. Brianna is a certified coder since 2014 and a certified professional medical auditor as of 2018. And she holds a diploma in medical insurance billing and coding. So I know you're gonna learn a ton from her. And Amanda Tufano is also part of our core faculty. She's Chief Executive Officer at Genevieve, which is in the Minneapolis-St. Paul area. She holds a Master of Healthcare Administration degree from the University of Minnesota and is a Fellow of the American College of Healthcare Executives. And a Certified Medical Practice Executive. Amanda holds additional certifications in Lean, Six Sigma, and Project Management. She is a wealth of knowledge, and I know you are all gonna enjoy learning from her over the next couple of days. And then Megan Verdoni, we're thrilled to have her on. Something happened, sorry, I've gotta go. So, sorry, Megan, I'm gonna go back for a minute to my other slide because that's where my notes are. Sorry. So Megan is a Physician Assistant, and she's currently a Senior Associate Clinical Education Director at Florida State University College of Medicine in the School of Physician Assistant Practice. And Megan has a Master's degree in PA Studies from the University of Florida, and she has many years of experience in emergency medicine as well as in internal medicine. She has been on our faculty before, and we just have really enjoyed being able to bring her experience to our learners as well. And then for the first time, we are welcoming to our faculty a team of social workers from our partner Rush University Medical Center here in Chicago. So today we're gonna hear from Lizzie Cummings a little bit later. Lizzie is Manager of Clinical Excellence and Training at Rush. And then tomorrow, we have two other members of the Rush Social Work team. Sujin Imer, who's a Community Practice Social Worker at Rush in partnership with Age Options. And then Allie Vernasco, who's an Ambulatory Social Worker with the Caregiver Initiative at Rush. So I know you'll be interacting a lot with our faculty over the next couple of days. So before I turn it over to Dr. Chang for our first presentation, this is just a quick overview of our agenda for today. We'll be getting started promptly at 9.45 with our first session on foundational principles and the four Ms. And then we cover a session on patient assessment in the home. We will have a brief break at 11.15, a few more sessions, some quick mini lectures, so to speak. And then we'll take our lunch between 12.50 and 1.20. And then we finish out the day. We have an afternoon break, but then the day will end at 5.15 this evening. All right, so let's go ahead. And at this time, I'm gonna go ahead and turn it over to Dr. Chang. Well, great. You know, as I was listening, well, first of all, welcome, everybody. And I was listening to everybody introduce themselves. I am really pumped for this group. We have people from various backgrounds, experiences, some are new, some are experienced in house calls and all the questions and concerns that were raised earlier. Like, yes, you know, we want to be able to help you with some of your questions and your concerns. And we are gonna try to cover as many points as possible. Obviously, we can't cover everything. And as Melissa said, we do have an advanced application class later on this year to talk about even more in depth some of the questions you may have about mental health, about dementia, on management of complex illnesses. And there are also resources that are available at ACCI. So make use of them and try to get as much learning from today and moving forward as possible. We are here to help you. We want you to succeed. As Dr. Cormel said, you know, we love what we do. It's so exciting to see people in this space. And I'm proud to call all of you my fellow workers, right? And the other comment I want to make before I get into the presentation is this. We can give you information in a lecture, right? But you get wisdom in a community, and that's what we're hoping to build here. Not only in the next two days, but going forward, having a collective wisdom, collective experience to support and share with one another so that we can all do this job better. Our patient can get better care. We can avoid burnout and be financially sustainable. So I want this to be, I hope the next two days will be very interactive. I know it's kind of difficult sometimes with the Zoom and so forth, but feel free to raise your hand and ask questions, and we'll try to get to them as quickly as possible. All right, next slide, please. I want to open up our session for the next two days by giving you kind of an overview of home-based medical care. Some of the foundational concepts, discuss some of the competencies that I think are important in caring for patients at home. And as we teach the residents here, they're rotating with us here from Northwestern. We're teaching them the 4Ms, and I'll go into more in detail what the 4Ms are in caring for the older adults. And then we'll talk about the HCCI learning plan. Again, we want this to be something you can use and reflect on today, tomorrow, and moving forward. Next slide, please. First, remember, I want to open up by getting your mind to think about some things. What do you think, what comes to mind when we talk about home-based primary care? Looking back in your experience, when you either think about your job or when you tell somebody, you know, I make house calls. Yeah. What are some of the ideas that bubbles up in your mind or hear people say? And people can put that in the chat, right? Or they can raise their hand. Oh, please. Oh, absolutely. Put it in the chat, raise your hand, and my staff will help me with some of the questions and comments. Yeah. Yes. Yeah. I see some of the comments, keep them coming. Even though, you know, Melissa said that, you know, I've been doing this for a long time with Northwestern, when I talk to some of my colleagues, they're surprised. Like, what do you do? You go where? For how long? So even my colleagues within a large health system are surprised sometimes. You get much more round of view of the patients. Yes. And some of the videos we're going to show today will highlight some of that opportunity. Is it free? Well, yeah. Like I tell my kids, nothing is free. You know, somebody's got to pay. Caring for patients in their home. Absolutely. All these comments are great. And yes, we can get some idea over the phone, right? You know, we've been going through the pandemic, doing some tele-visits, and they're, I mean, it's okay, but being in the homes, you really get a fuller picture of what the struggles are, right? A shift in power dynamic. Yeah, you are on their turf. Right? There's no smoking signs everywhere in this country, except when you go to the patient's house, right? They're smoking. And they're still on oxygen, right? Right. You need to engage with the patients on their terms. All right. What about some of the greatest joys and opportunities? What comes to mind? Give them, yeah, give them the resources, the whole person care. Wonderful. Grasping a better understanding of their daily lives. Yeah. Home visit generated a great deal of appreciation, holistically. Yeah, in the video, I'm not sure if it shows that, but what I typically do in a house call towards the middle or the end is something they do in real estate. I ask them, hey, take me through the life of dad. Where does dad sleep? Bathroom, kitchen, eat? What are the struggles in transporting dad from here to there and so on? Helping patients and their caregivers. Absolutely. Yes. Remember, when we do house call, it's what I call a dyad. It's always a pair. It's always a patient and their caregiver. Right? N95s are for more than pandemic. Yeah. Comfortable for, absolutely. It's difficult for many of our patients to travel. I mean, today's a very nice day here in Chicago, but you can imagine if it's cold, wet, snowy, to get mom and dad from the parking lot to the doctor's office for a 15-minute visit. You know, family members often have to take half a day off of work to do that, right? What about some of the challenges or barriers? Yeah. Setting up expectations. That's, yep, absolutely. Time. We all, safety. We heard that bubble up a couple of times. Clutter, unsafe environments. Yes. Compliance. Great comments. Yes, there could be some barriers, some confusion regarding, you know, a house call versus a concierge type of medicine. Oh boy, staffing. Staffing is a huge issue, whether you're in assisted living that I'm looking at across the street. I was just at the hospital with my mother this morning, who's really rather ill, and they're having staffing issues at Central DuPage. And even in my practice here, we're struggling with staffing. Absolutely. Yes. The disagreeing family members, right? That's always a challenge. So those are great comments. All right. Next slide, please. Let's move on. So what is home-based primary care? So what is home-based primary care? It's a model of care that brings providers and modern technology to patients. You guys already talked about this, in the comfort of their homes. Whether you're talking about primary care, palliative care, hospital at home kind of idea, it's the concept of delivering medical care using technology and keeping patients in their, say, in their living room and being treated and discharged to their living room. How cool is that? We want to improve the quality of medically complex patients. And don't forget, they're caregivers. If we don't address the concerns of the caregivers, guess what? If they panic, what are they going to do? They're going to call 911, all right? And all your hard work of trying to avoid hospitalization, ER visits, may have just suffered a blow there if you don't address the caregiver, okay? Again, we talked about keeping the patients out of hospitals, nursing homes, with the goals of not only providing great care in the comforts of their homes. And we know, we know by doing this well, we can reduce health care costs. And as we march into value-based care, transition into value-based care, that's going to become more and more important for many of the practices. Next slide, please. Now, what does home-based primary care offer? I think we offer something that really fits the quadruple aim. Better outcome. We talked about that. Improved patient experience. Definitely. Treating patients in the home rather than, you know, waiting four or five hours in the emergency room. Lower the cost of care. I just changed the G-tube on a patient at home rather than, you know, heading off to the emergency room. Can you imagine the cost and the weight of going to the ER for a procedure that literally took, I don't know, less than a minute to do? And greater job satisfaction. And for me and for the staff, it's great that we hear stories, we get calls and cards from our patient family members just thanking us for what we do. And I say this not to be any way grandiose or narcissistic, but our patients are so appreciative. This last week, I went to a patient's home. And she greeted me with a hug. And she started to cry. And she says, you know, without you guys, I don't know what else I would do. And you share that story with your staff. And it brings fulfillment and meaning, especially during a time when staffing is so difficult. So keep that in mind as you engage with your staff. Refocus on, you know, why we're doing this for the good of our patients. Next slide, please. So when I first started this, I thought, you know, all house calls are the same format. And obviously that is not true. We got academic medical centers. We got hospital systems. We got community hospitals. As you looked at or listened to your colleagues here introducing themselves, they're independent groups. They're veteran-based services. We are seeing more and more hospice and palliative care organization wanting to get into the primary care space. And also, as I said before, value-based arrangement. So a lot of companies, they see the value and the benefits of house calls, and they want to come into this arena as well. So it's not one size fits all. Next slide, please. And there are also different clinical models in home-based primary care. Some are involved in transitional care, short-term, post-acute care of chronically ill, complex patients who are at high risk of readmission, whether they're different risk scores that different health systems use. Dooley Health or one of the other large organizations use a particular health scoring system. Northwestern here is developing our own readmission risk tools. So that's something to keep in mind as you are thinking about. I think there was a question about targeting the right kind of patients, whether you're talking about ACC scoring, plus a frailty, plus looking back at how many ER admissions or hospitalizations. So some practices are involved in transitional care. Others are involved in longitudinal care. What we do, long-term medical oversight, including palliative and hospice care at the end. And most of our patients are older, as you can imagine, and they are high utilizers of the emergency room with or without an ongoing relationship with a primary care physician because they can't get to the physician's office, right? And that relationship can be strained. And that one huge benefit of what we can do is to become their PCP and going into their homes and taking care of them. Next slide, please. Again, just structure-wise and administration, a household practice can be part of an academic department. It can be part of a hospital-affiliated medical group. You can be independent practice. The support can be from the medical group, from the health system, from academic department. You got staff. Yes, I hear the staffing issue is a challenge. You can be employed. They can be contracted or outsourced, although it might cost more in this, in our current culture, or it can be a combination of all of the above, right? Like Northwestern, we have some staff that are directly employed, and then there's some other contracted staff members as well. Next slide, please. So as I look, as I reflect back on the many years that I've been doing this, you know, what makes a household practice successful? I think I want to start with good clinical leadership and providing great medical care. We need to be very knowledgeable about what we do in taking care of complex patients, and Megan's going to talk about that later on, I believe today, about probably the top four complex or chronic illnesses that we deal with in our patients, like COPD and CHF and diabetes and CKD and so on. You know, we need to be knowledgeable in what we do because our patients depend on us to give them the best care. We need to be efficient with our scheduling. We'll talk about that later today. How do you triage calls and messages? We do get a lot of calls here. I actually did a study here in our practice. We have a relatively small practice of about, oh, 800 patients compared to a PCP in a community down the road here where they have about 2,500 patients, and yet, yeah, we get the same amount of messages from 800 patients versus 2,000 patients, and majority of those messages are not email messages. And you know what they are. They're phone calls. How do you triage them? How do you best utilize the staffing that you have in your office to take care of patients' need in a timely way so that they don't end up in the emergency room? Care coordination is very important. Amanda and I are going to talk about that during our transition care talk. Social services coordination, as you know, social determinants of health, so important for our patients. I think somebody said it's, what, 85% of our patients' outcome is affected by social determinants of health, and yet we focus on, you know, like the 15% of it, which is too bad. Follow-up orders, office management, good revenue cycles. You need to get paid for what you're doing, right? Patient, family, caregiver education and supporting them. I can't emphasize that enough. And as we get into value-based care more, you know, data management and reporting of metrics that you're following and demonstrating your value, they're very important in a house call practice. Next slide, please. So what kind of patients do we take care of, and how should you kind of look at your marketing and your efforts in recruiting more patients? You can look at, you know, do I want to focus more on transitional care, seniors with high likelihood of readmission, or those patients who are, who may have difficulty adhering to their medications or their appointments, or maybe high-risk patients of any age. Or maybe you want to focus on what we're doing, kind of like ongoing primary care for elderly or chronic illnesses, or younger people with either physical or emotional disability, or market your practice to help offload some of those complex patients that really demand a lot of time and effort from a PCP practice in the office. Maybe you need to have that discussion with a PCP downstairs and say, hey, let me help you with some of the more complex patients. So think about what you'd like to do, and then perhaps fine-tune your patient population, and then go and try to connect with some of the people that may be able to help you grow your practice. Next slide, please. It's awesome to have, I think, their office managers, practice managers, on this call with us today. It's important to keep track of your revenue expenses, right? You got money coming in, Medicare, majority of our practice, commercial, and we're getting more and more Medicare Advantage or other kind of contract payers coming in. Maybe there's philanthropic dollars that's available to you that support your work as there are people donating to our practice through Northwestern that's supporting our work currently. So that might be another area of potential dollars. And then keeping track of expenses, direct expense, provider expenses, and then the indirect costs of running the practice. Are there ways that you can maybe streamline and cut down on some of the costs here related on the expense side? Next slide, please. There are many different models of financial compensation for the providers. It could be a base salary with bonus, such as quality, or per visit, or base salary tied to an RVU, or base salary tied to dollars collected, or some hybrid of one of these models. So think about your particular model and how many visits you can make and come up with a compensation that's fair, that's competitive, and reasonable for the practice so the practice remains sustainable, right? Next slide, please. No, that's fine. I'll stick with this one. Dr. Cornwall wrote an article, he wrote it several years ago, but it remains very timely. Why are there increasing interest in house call medicine? He highlighted four major shifts in this culture in our society. That's the aging population and chronic illnesses. There's the blossoming, if you will, of technology that can be used at home to monitor patient technology, whether it is used on a professional side or a consumer side to help manage patients at home. Payment reform, I briefly talked about that and we'll talk more later on and also in advance application going away from the fee for service and into value-based care. And then the value of house calls. And I think the pandemic has really, not that it's been nice in any way, but it really highlighted the awesomeness of what house call medicine can do for our patients and the fact that they simply prefer to be cared for at home rather than going to the hospital or the emergency room. Next slide, please. This is something I came up with as I, again, thinking about, you know, what are some of the characteristics that I think a provider should have to make this individual successful in delivering care at home? And these are my eight Cs. The first two are competent with complexity. I think that's self-explanatory, right? Our patients are complex and we need to be competent. I already said that before. Do you really know how to assess JVD in our patients? When you don't have a point-of-care ultrasound, okay? So many of our patients have volume problems with CHF. Is that a JVD or is that an arterial pulse? How good are you in being competent in diagnosing that? That new facial droop on the face, is that a Bell's palsy or is that a stroke? How do you clinically differentiate the two? So you have to be competent with complexity. You have to be able to communicate comprehensively, be able to talk with the patient and family members, also extended providers such as a home health nurse or hospice nurse, and then also the family member, I guess family members, I didn't say that already, and perhaps specialists to be included in this comprehensive conversation as you're trying to develop goals of care for your patients. Character and composure, you know, we're going into the patient's homes. We need to be the people of the upright morals and, I mean, we're guests in their homes. And I don't ever want to take that position lightly. Composure, as we'll talk about in Betty's case, some of the homes, and people have written it in the chat, some of the homes that we go into really challenge your senses, right? And you know what I'm talking about. And you need to compose yourself and being able to still carry out your work even though the environment might be very distracting, all right? And the last, I actually prefer, you know, charm and charisma. Charm, not in a way that's sly or inviting distrust, but charm in a way that's winsome because you are going, we're often, we're often going into the home during a time of crisis, right, during time of transition. You need that winsomeness to help the patient and help them navigate through some of the challenges that they face. And charisma, charisma is leading, leading the patient in practice through difficult times, difficult decision making. And Megan's going to talk about that, about prognostication later on. And also charisma to lead your practice. Remember I said, you know, about having that vision, letting your practice, remind your practice, you know, why they're doing what you're, what they're doing and the benefits that the patients are getting. So those are some of the, the eight C's that I've thought about in terms of the markers of a successful provider. I would love to hear comments in later on or in the chat box about this. Next slide please. Now we are mission oriented people. I think many of, I can almost guarantee all of you guys on the call today, you guys, you guys are not doing it for fame and glory. We are, we are mission driven people. We're called to take care of the vulnerable, those with serious illnesses, with chronic illnesses, and you know, without our, this type of care, they're going to get fragmented care in the emergency room and through the hospital. And you all know as great as they are, it is just the wrong application for the wrong condition, right? The ER is just not meant for this. We're here to take care of complex conditions, complex patients, extensive medication list. We did a study from our practice, I think from our publication, I think the average number is 18, 18 pills. You know, just imagine that. That's just, I still have a hard time grasping that. Multiple labs and diagnostic testing, you know, we have to think about what testing, what blood tests and interpretation of the, of these blood tests and test results. Somebody already mentioned their psychosocial complications, right? A lot of the patients that we take care of at home have social needs on top of the extensive medication, medical conditions, right? And then somebody mentioned also about challenging family dynamics. Some are very supportive. Others are like, oh dear, you know, we need some counseling here or something, some group healing because there's just so much heat that's here during the visit. So these are some of the, I think, ideas for all of us to think about as we go into a patient's home. Next slide, please. Again, some of the key competencies for the providers, clinical skills, assessment, diagnosis, various procedures like any injections, G-tube and trach and so on, commitment to integrity, to provide safe and quality care for our patients at home, being able to work independently, but also you gotta have, you can't be an island. You have to have relationships, building that relationship with patients, family members and other care providers and specialists and so forth. Keen attention to time management. You know, there's only 24 hours in a day and 18 medications, right? And I have six more patients to go. What management in terms of travel, in terms of EHR, what can I do with macros, smart phrases to help you with your time management and organizing not only externally as I call it in the EHR, but also internally up here. As you're trying to tackle 15 different medical problems, you need internal organization up in your mind to give the best advice and prioritize what treatment ought to be delivered here and now. And of course, excellent verbal and written communication skills. Somebody has once said, you know, surgeons have scalpels, but we as primary care providers, words are our instrument. You know, we need to be very careful with our words. And now we're coming up on time real quickly. The four M's in adult care, in the care of older adults, the four M's I'll quickly, I'll just, one is what matters most. Next slide. It talks about goals and preferences, about decision-making, about prognostication, risk benefit, and making sure that we document the risk and also that we do our best to honor the wishes of our patients and making sure that everybody involved in the care of the patient is well aware of patient's goals. Next slide, please. Mentation. It's about mental health. I know we're going to have a session later on today and also tomorrow about addressing social isolation, other stressor, depression, anxiety, making sure that we are taking care of that part of patient's care as well. Minimizing medication that can cause confusion, optimizing medication that can maybe help with their dementia, supporting the caregiver, and minimizing the risk of suffering from delirium. And again, being very good at treating and evaluating for mood disorder, anxiety, depression are the common ones that we encounter. Next slide, please. Next slide, please. Mobility. That's where the walk-through is so important when we make house calls, right? You know, take me through the life of dad. Oh, dear, you know, you got steps to get to the bathroom. Oh, you don't have grab bars here. What about nightlight? And helping the patients maintain their mobility by having therapists perhaps coming in and walking, working with the patients' families, and also minimizing fall risks, whether you do a tug assessment or some of the stuff that I talked about already, just walking through and giving advice in terms of how to support the patient's mobility and maintain their independence. And then having that, working with an interdisciplinary team member to help with patient's environment, again, to keep them safe and keep them out of the hospital. Next slide, please. And medication, and I'll talk about that later on on a slide deck that's dedicated specifically to medication management. Again, it's going to be about reducing polypharmacy, dosing the medication according to their individual needs, mainly their kidney, liver function, any drug-drug interaction, and take every opportunity to deprescribe, deprescribe, all right? Make sure your medications are appropriately dosed. And, you know, being at the home, you get the chance to do something that docs in a hospital emergency room, they can't. You get the chance to take, you know, show me your inhaler. Where is it? Show me your insulin. Show me this. So they can demonstrate to you not only they know where it is, or maybe they know how to use it. So that's a huge benefit of being at the home. Next slide, please. And then multi-complexity. Again, that's where I think experience, wisdom, where you take all of the other 4Ms and you process it in your head, and you sort them out according to their condition, age, urgency of needs, and so on. You address their social concerns and so forth, and you optimize, you create a care plan that is optimized for them, for their condition at the moment, and with a plan to follow up to address some of the other complexity. Making sure that you involve caregivers in the management of your patients, and finding their goals of care, and making sure that you do your best to support them. Next slide, please. And it's a continuous, it's not a, you know, one visit, I'm done. It's a continuous plan. I do, I check, I adjust, and then I do the whole thing all over again. So it's an ongoing refinement process to care for our complex patients. Next slide, please. So the perception of house call, home-based primary care can vary widely, right? It's not a one-size-fits-all program. The decision you make will impact ability for you to achieve that, you know, the clinical outcome and the operational outcome that you desire. Keep in mind, it's really challenging taking care of our patients. Keep in mind, the 4Ms, keep in mind the 4M framework, okay? And patients can have very, very different experiences as a result of very seemingly, you know, minor care decisions. Like I said, I used that example of the facial droop, right? They may end up in the emergency room waiting for hours for a CAT scan or whatnot, or you might have just educated them that, you know, this is Bell's palsy and that you don't need to go to the emergency room for this, and this is my management plan for you. So next slide, please. I know I'm a little bit over on time. I'll be happy to take questions through the chat box or maybe later on today. Next slide, please. Yeah, and you actually have a few minutes, Paul. Oh, okay. Oh, wait, let me see. Oh, we are a little over, sorry. Okay, thanks. Well, thank you, everybody. Thank you for your time. We're here to support you. Again, this is just the beginning of what we hope of a lifelong journey together, walking together, supporting each other in this wonderful and yet difficult work that we're doing. So we offer this Essential Elements, and then there's the Advanced Applications. There's the huge online courses in our library. There's the House Call Practicum, and then we do have some webinars and virtual office hours that feel free to join and get additional learnings and, again, learn from not only the clinician and the experts, but also from each other. And then there are a lot of resources on the tools and tip sheet. So important for all of you, at least just to take a look at some of the topics that are available to help you in your work. Next slide, please. Yeah, just a word about the learning plan. This is in your HCCI Learning Hub, and it is something that we're going to use over the next two days. We encourage you to have this open, fill it out as questions come to mind, as you think about, wow, that's a resource I really want to dig into a little more after the workshop. But if you fill this out, we're going to ask you to share a copy with us. And then that helps us partner with you over the coming months and help you connect with those resources that you identify where you want to learn a little more. So please do use this learning plan and share that with us after the workshop. All right. So at this point, I know we're going to turn it over to Megan. And Megan is going to kind of start us out with patient assessment in the home. Yes. Hi, everybody. So I really enjoy house calls. It really was a moment for me when I started doing them, where I recognized how I wasn't seeing the big picture in medicine. And again, my background is emergency medicine. So to say that I didn't see the big picture until I started going into homes and seeing patients in their environments, I think that says a lot. And I'm sure all of you've had those moments where you've walked into a home and said, oh my goodness, where do I start? All right. So we're going to start off with patient assessment in the home, the opportunities, challenges, and mobility screenings. Our objectives, we're going to review those essential elements of doing that assessment and care plan for a home-based primary care practice. We're going to view and discuss various aspects of the house call, including the history and walk through how it's particularly important to understand the patient's environment and nutrition. Again, I think that's a big thing that office-based practices really miss. They think they have an understanding of what the home is like for that patient. The patient tells them the story that they think that the provider wants to hear. But then as you walk into their home, you realize I've had a gross misunderstanding sometimes. And then it all makes sense really in the end. We're going to also recommend approaches to various aspects of how the clinical assessment for homebound patients and the physical exam and the mobility screening are really important. So you understand the limitations that the patients face and how you can try to fix that so you can avoid the trips and the falls and those things that actually send them to the emergency department unnecessarily because they could have been prevented. Next slide. So a key thing, we talk about the how. We've got to prepare for a visit. And you know, it is interesting how this kind of transcends across all aspects of medicine. You want to review your patient before you go out to see them. You want to take a look at their past medical history. Pre-populate your chart. There's many things that you can kind of get done ahead of time as you're reviewing it. Use that time to your advantage. Multitask. Make sure that you put the past medical history, you update it. Look for any labs that are new or different. Anything that you can kind of get done ahead of time to save you that time later on. But on the same token, please be very careful about how much you start clicking unnecessarily. I think back to when I first started 20 years ago with dictation in the emergency department. And my first dictation was 26 minutes. I remember the timer as it clicked on the phone and I thought, this is awful. I've got to fix this. So I started timing myself and eventually I would have it down to where I would dictate a chart in three minutes or under. Not cutting corners, but learning how to be efficient so that way I could make sure that I saw the patient and gave him the most of my time. And that's where I'm going with, you really want to try to make sure you're not getting sucked into just clicking things unnecessarily in the chart that really don't pertain to the visit. I see providers do this all the time. It's just like, it seems like they should click things. So they get kind of caught in that moment. So always try to look at what, what am I clicking on necessarily? What am I dictating or saying over and over again? That's unnecessary. There are small changes you can make, but really help from an efficiency standpoint. You don't need to say every time, you know, the patient states X, Y, and Z. You can kind of start to trim out those extra little phrases. It keeps the pertinence. If the patient, you know, it's really important to say who the historian is, but you don't have to keep saying it over and over again that the patient states. We want to assess the area, the neighborhood you're going into. Go back. Every, every area and neighborhood is a little different. Make sure you're aware of your surroundings. Sometimes it's important to know when's the best time to go in that neighborhood. It might be in the morning. It might be fine, you know, in the late afternoon, but keep that in mind as you're kind of planning your route too. Evaluate the home's exterior for fall risk and kind of mobility barriers. Some of the homes down here in Florida, they're mobile homes or manufactured homes. They're on stilts. There's many of times where I've walked up to a home and I thought, I'll bet this person hasn't been out of this house in two months. You know, those are things to look at and right off the bat, recognize what's the barrier to this person getting out of the home and doing some different activities with their family that might really bring up their quality of life. And then look for opportunities to establish that rapport, build a relationship with that person. What hobbies, you know, what's their, do they have military service? What's on the walls that tells you a whole story about that person? That's what they love. That's what they enjoy. That's really how you make that connection and show that you're there to help them. Next slide. So, and this is where you really want to take that assessment and plan. You've pre-populated it with, you know, the information you need, their insurance, their past medical history, surgical history, social history, emergency contacts. Get as much as you can of that, like I said, before you go out to the call, the visit. Once you're there, you're going to want to verify it. And then once you're at the visit, that's when you can get into the meat and potatoes of it, the chief complaint. What's the actual history? What happened? And then re-verify your past medical, social, and surgical history. And then of course, your review of systems. A sample of this assessment and plan is on page 14 in your workbook if you want to look at it and see if that's something that you'd like to kind of use in your own practice or modify. And before we move on here, Megan, just a couple of comments. So, these two sample forms were really set up, the HPPC sample assessment form to help you think about your progress note templates. And so, I would also encourage you to think about different visit types. So, that first visit, like Megan is saying, you don't want to be clicking in a follow-up visit. Probably everything that you're going to need in that initial assessment of the patient. And then on intake, you know, what's unique about home-based primary care is making sure that you're capturing things like communication preferences. You know, do they have a daughter that's a nurse that lives out of state that you call for care plan updates, but the son is the primary in-home caregiver that you call for visits? Where are you going to put that in your EMR? How are you going to document and capture that information? If you're starting a new practice, HCCI also has some sample other forms on our website. You know, and I know many programs, yes, you know, we deal with a mostly geriatric population, but a lot of times they do have caregivers that if you make your intake forms electronically available, you know, where that can actually be completed online and gotten ahead of time, that's a really helpful efficiency tip. Or some of this could be, you know, an electronic questionnaire that you build into your EMR and you have some staff helping, you know, fill that out. But look at these two forms. The assessment form is really supposed to help you set up your progress note, but think about what you need for an initial versus a follow-up visit. And then think about those unique things on intake like POAs, how you're going to communicate, address logistics, and where you're going to put that in your EMR so that can be referenced to make you efficient when you're going to see that patient in the home. Absolutely. Another kind of point is if you are going to a new patient visit, and this is something from a home health company that you got a referral from, or you know that they already have a home health company in the house, call that home health company, ask them to send over their demographic sheet. It's a real nice, efficient way to get all that information up front and cross-check what you've got to make sure it matches up. So, all right, next slide. All right, we're going to go through a sample of how Dr. Chang does it. Well, thanks for letting me come today. Oh, thank you for coming. Oh, good morning. Ruben, how are you? Okay. Marina, is it okay I put my bag here on the sofa? Oh, yes, of course. Thank you. And is it okay I put my chair here? Yeah, sure. Good morning, Mr. Osorio. I'm Dr. Chang. Nice to meet you. Hi. How are you doing? Pretty good. Good. I've had a chance to review your records related to your most recent hospital stay, but before I ask you more questions, Marina, can you remind me what happened to Dad? What prompted you to call 911? Oh he had a really high fever that wouldn't quit and then um he's just really disoriented and he wasn't eating right and he had like blood in his pee and when he went to the bathroom I saw that and I've never seen that before. So he has not had an episode like this previously? No never never and and I didn't I didn't know what that meant so that's why I called Good good. Mr. Osorio, how are you feeling now that you're home? I'm feeling good. You're feeling okay? All right. Any fevers? No. No? Okay. Any trouble with your breathing? No. No? Okay. How about your heart? Have you experienced any difficulty with chest pain or racing heartbeats? I need more rub. Okay all right that's good that's good all right. How about your appetite? I don't know I don't I don't remember. You don't remember? He's lost a little weight. He's always been a really good eater and and around that time he wasn't eating quite the same. Okay. And since he came back he also hasn't been eating the same. Okay. Do you feel nauseous? I don't remember. You don't remember? Feeling sick to your stomach? Wanting to to throw up? Yes. Sometimes. Sometimes. Gotcha. Are you giving him any medication to fight the nausea? I don't recall there being medicine for nausea. He takes a lot of medicine. Okay. I see the medicine box over there and part of my visit and a very important part of the visit is that we're going to go over every single one of his medications to make sure that he's getting appropriate medication and that you understand what each one of those medications is being used for. So that's going to be an important part of our of our visit. Okay. Any trouble with your bowels? No. No? Okay. What about the urination? Are you having difficulty urinating? Why do I have to answer this question? He just needs to know he's a doctor. Dr. Chang needs to know how you... Who are you? I'm Dr. Chang. Oh. I'm visiting with you at home after your recent stay at the hospital. Just a couple more questions if you could bear with me just just a little bit more. Any falls since he's been home? No. No? Thank goodness. But he's not steady anymore. Okay. So he never had a problem walking and then when he came back from the hospital I ended up going down to the basement to get my mom's old walker because he's just not as steady and I was helping him before. Okay. And he's better now with the walker but he hasn't fallen. Good. Good. We're going to talk about the walker and ways to prevent his falls later on in our visit today. I noticed that you have some area rugs here in your home. That could be a... These rugs may be a trip hazard for dad especially now if he's weaker and unsteady and he's using his walker. So you may want to think about removing them to keep... Yes. And I literally have one in the hallway right in the entrance of the bathroom. It looks lovely but I'm thinking about dad. I'm not an interior decorator so pardon me if I'm upsetting your plans. No, no, no. Okay. Any rashes or any bed sores? Have you noticed any? No. No? Okay. What about dad's mood? How's his mood been since he's been home? Any difference? He's doing okay right now. He sometimes gets really agitated. May I ask, do you feel depressed? Yes. A little nervous. A little nervous. Okay. May I ask what you're nervous about? Uncertainty about things. Uncertainty about things. May I ask, what about? I'm not happy. You're not happy. Anything that's bringing you down? My health. Your health. Anything particular about your health that troubles you? Everything. Everything. Okay. Well, that's a little difficult for Dr. Chang. Can you maybe narrow down to maybe one or two things? Getting old. Getting old. Okay. Do you think you have a memory problem? Sometimes. Sometimes. Okay. Marina, have you noticed any memory issues? He sometimes forgets things. He repeats himself a lot. Okay. But he hasn't forgotten who I am. He's not forgetting who I am. He's not forgetting who I am. But he hasn't forgotten who I am or anything. Okay. But he forgets things and repeats himself a lot. Gotcha. Oh, yeah. He forgets to eat. I have to remind him to eat. Oh, he thinks he already ate, and then I have to remind him, no, puppy, keep finishing. You have to remind him. Okay. Is this a So that's the initial part of the visit, right? A lot of key points there to kind of pick up on. What were some of the things that Dr. Chang said or did that might be a little different than what's done in a traditional office visit? Is there anything that struck you all right off the bat? To me, yeah, he was able to directly observe the home environment. Absolutely. He asked permission. That's another thing, too. It's very easy to forget that when we're in an office environment, we see it as our territory, our turf. And so often even staff might be like, well, that person was late. It's their own fault. They're 10 minutes late. They're going to have to sit and wait. But when you're going into their home, that's their territory. That's their personal things in their life. So he asked permission. What else? Any other kind of things that you found immediately is different? We talked about the rug. One of the things I notice right off the bat when I walk into a home, I notice there's the guitars on the wall. I'm picking up that all the pictures were of boating. So those are things I'm always putting in the back of my mind. So I'm ready to ask if I need to redirect in a pleasant way. And was there anything that's really that surprised you or you thought you would have done different? Did everybody? Yes. I was just going to say he brought his own chair and cover. Yes. Yeah. You know, I think that if you get into a habit where you do that in every home, then you won't feel uncomfortable about maybe the homes that you have to do that in, because that is the cleanest home out of all the homes I think I've ever been in. I can't speak for everybody here, but that is a very clean home that he was just in. And sometimes it's just not that way. And that's okay. But if you are used to bringing out your own cover to put your bags on, and the other thing is, is your the bottom of your bag might have gotten dirty somewhere. You don't want to dirty their furniture. And then as for the chair, same thing. Often there are not chairs or anywhere to sit. So if you're just in a habit of putting out your chair and putting it down, then it's a natural thing to segue into. All right. Next slide. So he really went into the history, started with the chief complaint, you know, talked about the recent hospital visit, kind of tried to get some review of systems from the patient, although with the memory issues, not as easy, but he included the patient's daughter in this. And he really made sure to do it in a non-confrontational way. Do you think you have any memory problems? Sometimes by asking questions, it's a way to kind of get them to elicit a little bit more information about the situation and what's happening to them versus if you come out and say, you know, it seems like everybody's noticed you don't remember anything. That can really kind of get some patients to be agitated. So always, always want to come in with that kind of positive direction, remembering you're a guest in their home. Distraction, de-escalation techniques can be really helpful in these cases. All right. And next slide. Now we're going to move into the physical exam and the mobility screening portion. So, I'm going to take a look at you now. I'm going to check your ears, check your eyes, listen to your heart and lungs. Later on, I'm going to have you lie down so I can check your belly as well. Would that be okay? All right. First, I'm going to check your temperature. Okay. With this, it's not going to hurt or anything. You need to come a little bit closer. Perfect. 97.4. No fever. Next, I'm going to check your heart rate and the oxygen level in your body. Can I have a finger? No, it doesn't hurt. It's not going to hurt. See, watch. Watch. See, no pain. Doesn't hurt. So, can I have your finger? There we go. Perfect. Next, what we're going to do is we're going to do a walking test. Okay. So, Marina, if you could help dad, I'm going to reposition the chair over here. If you can help dad get up and get him sitting down in this chair, that'll be great. Now, when I tell you, okay, when I tell you to start, I want you to get up, walk at your normal speed to the edge of that carpet there. I'm going to stand there. When you get to me, I want you to turn around and then sit back down. And I'm going to time how long it takes for you to do that. Okay? Any questions? Okay. Here we go. All right. Remember, don't rush. Don't hurry. It's not a race. Perfect. Well done. Thank you very much. That was great. Good job. Great. So, there's the example on the physical exam. He did the time to get up and go test. Again, you've got to be about 10 feet away. Use a stopwatch. You're really kind of getting an idea of their mobility. How many times do they have to push themselves up and out of that chair or how long does it take? Always take your vital signs on a physical exam. You've got to make sure you document those. I know some of us are used to having staff do it for us, but it's really important. Don't start off with that right off the bat and you won't forget. I've heard other providers talk about how sometimes they get involved in talking and it's easy to get distracted. Have a system, stick with your system, so that way you don't ever have to worry about, oh gosh, I walked out of the house and I didn't get vitals and I really meant to do that. I know it was a simple visit, but make sure you get those key parts of information. That's a really important part of your chart. And then always systematically go through your physical exam. That way, it's just a routine. That's the important part. Next slide. Now, what did you notice about the exam that's different from a typical office visit? One thing is, especially when you're dealing with patients who have memory issues, sometimes it's kind of like working with children. You almost have to say, okay, I'm going to put this on your finger. It's going to hug your finger. That way it's a little bit more understanding. With children, one of the techniques I found for looking in their ears, and dementia patients are very similar, is I'll take my otoscope and I will push it into my hand, the end of it, so they can see that if it's not hurting my hand as I push the tip of it in there, then they are much more comfortable with me looking on the outside of their ear. It's the same with our older clientele. Anything that you guys noticed that maybe you haven't been doing or that you would incorporate differently, but it's the same components that you would have to do in the office, it's just that you're utilizing it at home. Let's advance. There's the next part of the slide. There we go. Use your home side manners, which is the same thing as using bedside manners. Some people bring in an assistant, and that is great. I know that there are also sometimes for some people that they're just not in their new practice financially able to, so it's just a combination of what works for your practice, admittedly. Always have good visibility to the patient. Make good eye contact. Make sure you talk with them, even if they have memory issues, because otherwise they can get very upset if you're just talking with family. Always tell them what you're doing during exam. That's another key point, because I will verbalize when I look in their ear. When I look in your ear, the TM is shiny and gray, good light reflex. They may not really understand those terms, but they know that I'm actually looking and I'm documenting what I'm doing. When I look in your throat, your tonsils, they look gorgeous. They're two plus, they're normal, or you don't have any tonsils. Your throat's not red. As I palpate their neck, no, I don't feel any lymph nodes. I verbalize it so they especially know what's going on and that I'm doing the exam, because often if you're talking and having a conversation and that sounds great, you're making good small talk, but sometimes they feel like they don't realize that you were doing your exam as you talked, and they might come back and say, you didn't do anything. But I did. So make sure to think about that, verbalize it. Again, check vitals. Make that number one first thing you do, so that way you don't ever forget it. Pay special attention to lungs and the skin. They often get sores, aren't checked. Check the common areas, back of the heels, bottom of the feet. Ask them if they have anything on their bottom. They may be shy. One of the things in this video, if you noticed, the patient was very uncomfortable discussing urinary symptoms. Not uncommon. If it's a sensitive matter, just try to, you know, put it forth in a positive, forward-moving tone, and, you know, try to help with the, get the family to help out in those cases. And make sure, try to do those mobility tests. That really gives you a lot of information when you see if they're struggling to get in and out of that chair where they could benefit from whether it's physical therapy or activity. Next slide. And here we'll talk about how he evaluates the environment and some of the nutrition. There's a bed here in the dining room. Yeah, we don't have an extra bedroom, so I just had to kind of move the dining room table over. This is now your workstation also? Yeah, it's a home office and a guest bedroom. Wow. Marina, part of my visit now is what in real estate is called a walkthrough. I really want to get a sense of a day in the life of you and dad as you go about your day, right? For example, can you show me, where does he eat breakfast? Or his meals, I should say. Well, I prepared all his meals in the kitchen, but then I put his spot here on the end of the dining room table, so he can easily access it with his walker. Okay. And if he needs to get to the bathroom? Then he, you know, makes his way this way. When he first came from the hospital, I was helping him every time. Things have gotten a little better, but. Can I, can I take a look? Yes, of course, please. Well, it's very cute, but not a lot of space. No, I know. Right. And, and the tub is beautiful, but it's not a very dad-friendly tub, right? Yeah. Again, we don't want him to fall. I want to do whatever I can to help you take care of dad, right? For example, you may want to consider a, over the toilet commode with the bars. I don't know if you've seen those. It might make it easier for him to get on and off the toilet. Okay. Now the tub situation is a bit more difficult. It's beautiful, right? But it certainly makes it challenging for dad to get in and out of the shower. Of course we can talk about remodeling, but that's kind of expensive, right? To take off that's beautiful tub and then put it, put in a shower. Right. We may want to think about the possibility of maybe a shower bench. So dad may be able to slide from the bench and into the tub. Although, although it might be challenging for him to bring his legs up because the tub is so high. What I will, what I will do is I'm going to have a therapist to come and work with dad at home. A couple of reasons to get him stronger, to build his endurance, to reduce his risk of falls, and also to talk with you about some of the challenges that you're facing here. What other creative solution and hopefully not too costly solution can we come up with to help you take care of dad better? Right. Thank you. And the other thing is I think early on you mentioned that dad gets up at night to use the bathroom several times, right? So I think it will be great to have a nightlight here to light the way so that again, to minimize his risk of falling. And we had talked about the area rug again, you know, removing that we want dad to have a clear pathway as he goes about his business, right? Luckily that's easy. I can easily remove those. Most of the time I end up getting woken up and needing to help him anyway. So that'll help. Thank you. Good. Is it okay we take a look in the kitchen? Yes, absolutely. Please. This is our humble kitchen. Great. So what do you, what are typical meals that you serve dad? Oh, um, for breakfast he's like a eggs and sausage or bacon. Okay. He used to have like, you know, two eggs. Now I'm trying to get him to eat one. Um, or, um, what about lunch? Uh, you know, we eat a lot of rice and beans. Okay. And usually I'll have a piece of bread made or a piece of chicken with that. Um, I don't always get the salad together, but some, you know, definitely for dinner we have salad, but sometimes I try to cut up a little, at least tomatoes and cucumbers. Gotcha. And dinner, what, what's a typical dinner like? Um, I would say we eat a lot of rice and beans, but we also do things like pasta, you know, I do, I do like noodles or, or spaghetti and meatballs, you know, um, I've done like lasagna. Okay. So I try to, I don't know. I mean, we're a meat family, but I definitely have put like spinach into the lasagna. Great. That's good. Yeah. Make it a little bit healthier. Right. My dad's not a bad eater. Speaking of healthy foods, I see some foods here that may not be so healthy for his heart and so forth. Um, does he eat much of this? Yeah. Some of these things he likes. He does, um, he does like, he definitely eats bananas regularly. He's not much of a chipped guy, but he does like some pretzels from now on again. He, these are kind of his favorite with my sons. Well, enjoy in moderation, right? Okay. Yes. And if you need any information on a heart healthy diet, we'll be happy to provide that for you. Uh, we can, uh, print a copy and mail it to you if you, uh, find that helpful. Absolutely. When I'm in a real pinch, I do, I do do hot dogs. I try to do the all beef kind, but we do. Now, is it a regular hot dog or do you make it Chicago style? Oh, we got a big, you know, a thick one, not just the skinny ones. And then he doesn't, you know, he doesn't do the mustard on his, he doesn't know the ketchup on his, on his hot dog. He doesn't, he's, he's a Chicago in that way. Great. Is it okay that I, that I take a look in your fridge? Of course. Of course. Yes. Sorry. Great. Well, thank you. Great. Yeah. Breyers ice cream, my favorite. Mine too. Okay, so the walkthrough, thank you Tony. You really do have to walk through some of these apartments and living situations to really appreciate them for what they are. And it is, it's a refrigerator biopsy. One of the tricks that I'd have heard in the past that providers use is, you know, in case the, sometimes a patient might not feel comfortable about you being in their home. They're embarrassed about whether it's clean enough or how they live. So the provider, they got into a house where they'd say, you know, I need to wash my hands. Is that okay if I use your sink or your bathroom? And the goal was really to go in and see if the toilet needed a elevated seat. It was to see kind of, you know, what was going on. Did they have the necessities, you know, toilet paper, soap, you know, those kinds of things. So sometimes it's another way around to kind of get that evaluation in. And absolutely, they are surprised when you look in a refrigerator. Some people get defensive, but it is really important because sometimes you open that refrigerator and there's no food. And that's the ones that you really have to look at and say, wait a minute, what's going on here? Or how are you getting your food? Do we need to get Meals on Wheels or something else to help coordinate to make sure you're getting some nutritious food of some kind out here? So make sure you ask this question, you know, where are they eating their food? How do they prepare their meals? Are they also stuck where they're just eating on the couch all the time because they just don't have the energy to really do anything in the kitchen. And so then it's just all microwave food. That's, you know, those food, those microwavable meals can be really high in sodium. And that might be why their congestive heart failure continues to be an ongoing problem and you're not making any ground on. Where did they sleep? The couch is not an uncommon place. That goes back to, again, I've been in some places where the patient was very upset and having to admit this but really felt that they needed to tell me that they had been losing control of their bowel and bladder on their couch because they couldn't get off of it. So these things do happen and you just have to have a bit of grace and compassion that they were willing to share that. But at the same time, what can I do to make the situation better for them? Evaluate the safety functionality of the space. You know, rugs, they don't realize it but as their transition points that might be reasons why they're going to fall. The nightlight, that is another great example of if you can't see, and especially as we age, we can't see. We can't see that the cup or the silverware is dirty. It's not because they're lazy. It's just, they can't really see that that needs to get cleaned better or that they need to get some help. But really take a good look around. Sometimes you'll find also, I found pills on the floor. They couldn't see, they dropped the pills on the floor. You know, those are things that you'll never know if they're coming into the office and sitting in front of you in the sterile environment of the chair next to your desk. Anybody else, anything that they've noticed when going into homes that really was effective for helping them in their practice or getting to know their patients or that they want to pass on any tips or tricks? One thing, somebody talked about how home-based visits seem to turn into concierge visits. Those patients, just as a little tip, if they're kind of taking it and taking that 30 minute visit and trying to make it an hour, I would set a timer on my phone for an alarm and at 30 minutes it would go off and I made sure it was loud. And when that timer went off, it kind of notified everybody that it was time for me to go or that I had to go because I had to go to the next one. So use things like that that kind of help to be a resource for you. All right, next slide. All right, again, we talked about the safety issues that Dr. Chang addressed with the rugs, the nightlight, looking at the diet, we need to cut back on some of the chips, the sodium, try to work on that. Sometimes it's as simple as also see if there's any way that you can get them to have a serving of vegetables even before they start their meal. Little things like that. All you can do is ask or try and reassess on your next visit. Next slide. Screenings, here's a list. You might wanna take a screenshot of this, but these are some of the screenings that are really important to kind of consider and to kind of get a sense of what's going on. So if you have a family member that's having a hard time these are some of the screenings that are really important to kind of consider that you do. Now, realistically, I'm sure for some of you right now, you're looking at this and you're saying, how do I get all of this done in one visit? You do not do all of this in one visit. You can certainly, you have to, again, the forums, right? What matters? It's not just for the patient, but it's for you too. You have to look at it and say, what matters most to me as a provider on my first visit? Okay, now I can work on what matters next on the second visit, but try to incorporate at least maybe one, two screenings so that way you continually build that chart and you're able to work with them, the patient that is. And it may be that you're gonna have to come back sooner in the beginning so you can kind of get that all taken care of and up to date. Does anybody here utilize from a screening standpoint before I start to end up, do they have any of the medical assistance? Have they tried using anything like that, doing it over the phone or virtually for some of the screenings? Have they found that successful? Hey, Megan, we've been doing this forever and we're always trying to retry different things. And as of today, we're actually trying a remote medical assistant model with our practice. So the remote MA is actually going through some of these questionnaires, whether it's a depression screening or medication and so on. And also we're talking about some best practice advisement or I forgot the term BPA best practice. But anyways, we're going through some of that. So we are trying to do something different to be more efficient, to put everybody's time to good use and also to better the care of our patients. And then making sure that all of these screenings are done and take some of the load and the pressure off the providers. Correct, because in the video, Dr. Chang did a wonderful job, but I also realized that we're all under that time constraint. Like I said, you set the timer, I got to get out of here in 30 minutes because they're expecting me at the next house. I know I'm a guest, if I'm late, then the daughter has to go. And all these things are in the back of your mind. So again, you cannot do, and especially if they've got 15 medical problems, as we all know, you have to really try to prioritize. I was just going to add too, not just the screenings. I know some practices that use virtual MAs or even your back office MAs to do some of the history, making sure the medications, importing them especially for initial visits, that medical history, past family and social history, maybe even going through the chart and noting a couple of recent episodes or pulling in labs and results for the providers. So just like in an office, they would room your patient. You usually don't have that unless you have an MA traveling with you, but those are things that your medical assistant or others could be doing in advance to help the providers with documentation efficiency as well. See if the MA can call the pharmacy, find out their two pharmacies and call the pharmacy and see what they'll tell you. Sometimes you find out all of a sudden who also has been on the case that you had no idea has been going out to the home too. That's happened to me as well. All right, next slide, please. All right, and we'll end the visit. This is our new patient packet. I'm going to leave with you today. Inside, you're going to find a lot of information about our office policy. For example, like refill, when to call for refills and so on and so forth. There's also information in here about other professional that comes to the home. Oh, a therapist? We're going to talk about that one second, such as a podiatrist or foot doctor, right? Or a dentist, if dad needs dental work, right? Those professionals can come to the home. Again, we're trying to make your life a little bit easier and less stressful, all right? So take some time to go over the information that's included in here as well, okay? And every time we come, we leave an instruction sheet with you here, okay? You can see the date of our visit. You can see his vital signs here. It's also written here that we took blood today. He was a little anemic in the hospital. His potassium was a little low. That's why I repeated the blood test to make sure they're trending the right direction. And we will call you tomorrow with the results of the blood test. Wow, tomorrow? Tomorrow. Okay. Okay, all right. And the other thing that we talked about was the physical therapist, remember? So I'm going to put an order for the therapist to come and work with you, and maybe troubleshoot some of the issues that we encountered in the bathroom. Again, keep them safe and reduce your stress. The other thing is, as we were talking and I was thinking about that, I think a hospital bed can be beneficial in terms of helping you and helping him be more mobile. And again, reducing the burden that you have to carry and getting him in and out of this. Those move up and down, right? Yes, that's right. So that it sits him up? Oh, that would be great. I'll take care of ordering that as well. That's great. Okay, these are the medication changes that we talked about, okay? And they're outlined here. And if you have any questions, please give me a call. Okay. Okay? This is my follow-up date. We'll be back in about four weeks and we'll take care of the follow-up, okay? We'll, don't worry, there's no worry on your part. We'll set the schedule and we will call you just like we did for today's visit. We'll call you two days before our visit to alert you that we're coming. Okay. This is our office number here, okay? In case you had, if you have other questions or you can't read my handwriting, feel free to give us a call. We'll be happy to go over any questions that you may have. Okay, thank you, doctor. All right, that's for you. Again, I just want to thank you for letting me come today and serve you and dad in whatever ways I can. I really appreciate you giving me the opportunity to be here, okay? Thank you for coming, doctor. All right. Do you have any other questions? No. Gosh, there were so many things covered today. It was very helpful. I really appreciate your visit and, you know, I think he'll get used to you. Okay, I hope so. Thank you. Future visits won't be as long as the initial one, so hopefully he'll like me a little bit better. And maybe not a blood test next time either, okay? All right. Thank you, doctor. I'm gonna pack my gear up and I'm gonna head out. Okay? Okay. As she advances, we're going to talk about the 4Ms, but I want to hit something really quick here. Did anybody notice that his car is unmarked? We were talking about safety earlier, and I know that was a priority when we were talking. He's carrying a certain amount of things. Obviously, he's got his chair and stool, but the car is unmarked, and something to keep in mind when we're talking about safety. Yes, you do want to advertise and say who you are, but also keep in mind, depending upon neighborhood, sometimes that may not be the best idea. All right, so how did Dr. Chang apply the 4Ms in the care of older adults? We've got what matters, medication, mentation, and mobility. Anybody want to talk about what matters? He really tried to hit a couple of things in this case, particularly the medication, asked about medications. In the history, he asked, how do you feel? He really talked about mentation and what has the patient bothered. He had a lot of patients. Absolutely, he had a lot of patients. We have to have patients in this situation. There's a reason why they're at home. They can't necessarily make it in the office that easily, so we have to have some patients and recognize that. He really went over the mobility. How are you getting around the home? He did the time get up and go test, talked about rugs, the bathroom. These are all things that matters. Thanked the patient's daughter for letting him come in the home. Again, that helps to exactly build a rapport, make them feel comfortable so that you understand this is their home, their territory, and that you respect it. That's really important. There's nothing that makes patients and family matter, whether it's emergency department and office space, but when they don't feel respected. Exactly, Amanda, future expectation. This is when we're going to call you. He also even said, I'm going to get my stuff packed up and I'm leaving. Again, saying what you're going to do so it's not a surprise as you run out the door. That really helps to make sure everybody's communicating and on the same page. Absolutely. Yep, assess the refrigerator without insult. Yes. Nobody wants to be lectured. They may not have the money to have organic produce. That's just the reality of today's food costs have gone up. When medication requests should be asked, he put that expectation out there. How do we do this? Absolutely. Megan, if I can just say two things real quick. I totally agree with you. Don't try to cover everything at one visit. You will feel completely overwhelmed. It's going to be a relationship for you in terms of gathering all the information that you will need and a relationship ongoing in terms of directing the next steps in care. I can't fit the M in this, but I think what Amanda said, and we all know this, relationship is so important. You are a total stranger to these people. You're in the living room and you are going to talk about potentially that visit or a few visits down the road about some really serious and difficult things. They need to be able to trust you. Having that relationship, building that rapport, I think it's really foundational in everything that's done at home in terms of giving them the best care possible. That's why I really enjoy visiting at home and looking at whatever memorabilia they have at the house, building that bridge, building that trust. It's an ongoing process and it is going to be so important as the conversation and this clinical situation will often get more and more difficult and challenging. They need to be able to trust you. Exactly. Thank you. Keep in mind, whether it's your first or 10th, schedule a follow-up visit or at least let them know what the expectation is for that follow-up visit. Answer any questions. Remind them how and when to call because sometimes when they get in a situation, if they've got any kind of panic or things are really going downhill for them, it's easy to forget that. Some people, that's why they have magnets that they'll put on the patient's refrigerator so that number is right there all the time, easily available, but not only to the patient but to anybody else that goes in the home. Home health agencies, therapists, they will see right away. That's like your billboard. I've got a question here. Can you address consent for the visit? When and from whom? Yes. First of all, before you go out to the visit, you want to make sure that they consent for it, that they agree to have you go out there. That has to happen. And then you have to make sure that you are getting consent from the proper person. In the case of this patient here, he may have obviously memory issues, so who is the power of attorney? Who's the proper person that you should be asking? Breanna, do you have any? Yeah, I was just going to say the consent. If it's not an urgent need, a best practice would be to get those forms filled out before a provider ever goes out to the home. Again, you could make consent forms electronic to make it easier for caregivers to get that to you, especially if the POA is out of state or something like that or email it to you securely. If not, if you have an assistant with you, that form would be signed and gone over at the start of the visit when the provider first enters the home before an exam is done and at least your staff is getting verbal consent, explaining services, trying to save the provider a little bit of time if they do have to get those forms done in the home. And then the other comment I just wanted to make too is that purple folder that Dr. Chaney had in the visit, that was a simple welcome packet. It had other providers that make house calls, specialty providers, and included information about the practice and the practice guidelines, and again, how to contact them, things like that. It's really new and can be overwhelming for patients, especially if they've only ever been with an office PCP for 20 years and now here you are coming into the home and wait, do they call you or do they still call that other doctor for that medication or what was that phone number again? So spending time going over that, giving the patients resources in the home, but yeah, definitely best practice for get those consent forms ahead of time if you can or at the start of the visit. Because if you don't, what can happen is you'll get out there to the visit and they may suddenly say, well, who are you? Why are you here? I didn't want this. And then not only is that's their right clearly to say no, but then you've just put a whole lot of time and effort into going out to do something that really should never have happened to begin with. So that's an excellent question about getting consent. Next slide. All right, so the key takeaways, house call visit starts before you meet the patient. You know, as you get history information about the patient medications and consent, and it starts with reviewing those charts, the area, how you're going to fit them into your schedule, and really just trying to look at ways to establish those relationships. While you're in the home, you've got a lot of great opportunities. You can look at the risk and hazards they face, their environment, nutrition, you know, the forums, medication, mobility, their mentation, and really what matters to them. And the other thing too, is that, again, going back to consent is decision-making capacity. Do they have the ability and the capacity for decisions? Home-based primary care is about relationship with patients, their family members, and caregivers. So it's really a team approach in their natural environment. Any questions? Anything else that would be helpful? What if family is nowhere in sight? Well, the key thing is, A, are they able to give consent? And we'll talk a little bit more about this later, and we have a session coming up. But if family's nowhere in sight, usually when you've gone to make the appointment, number one, you've confirmed with somebody, because I would never recommend going out to a visit that you haven't confirmed. But you've either confirmed with the patient, so they had an understanding, they gave consent that you're coming out. And also, if it wasn't with that family member, because like in the case where Dr. Chang is, the patient himself can't really give the consent particularly, then you should have talked to the family member. And if the family member's not there when you show up for a visit like that, I would be calling to try to get them on the phone. I hope that answers that question. And he said, it's very hard to arrange patients to agree because they are so far into their disease state. That is true. Sometimes those are some of the challenges we face. Yeah, I mean, I don't think anyone has a perfect solution to that. But when whoever's calling to schedule the appointment, sometimes during first visits, we would request that a family member or someone be present. Again, that patient doesn't know you, especially if they have dementia or something like that. Just like we might remind them to ask or ask them to please have all their medications out. You know, we might also ask, you know, is there any way that we could schedule this for a day when I'll be in the area and there's also a family member or caregiver or someone present? Or, you know, maybe you make a joint visit with home health if it was a referral from home health or something. Yeah, I just saw that in the chat too. So sometimes you have to get creative and use your resources. Absolutely. Okay. Anybody else? Any questions? All right. And just a reminder, you know, if you think of anything that you have more questions on and you want to ask later, be sure to jot this down in your learning plan. Also, if you think of anything that that you do that might be helpful to others, feel free to put that down on your learning plan as well and share because I think everybody really sounds like in the end, they're all learning about some of the different tips and tricks that we can try to share. Okay. All right. Thank you. that may impact the patient's care. And the last is D, you know, what we do for our patients. From, you know, it's the four M's, you know, what we do for them. It's about mentation, medication management, mobility, and what matters most. So I think those are just some of the unique features of what we do in House Called Medicine is G-O-L-D. It is gold for them and gold for us. Next slide, please. So what are some of the reasons for readmission? These are just summary points of articles written on this topic. Lack of timely follow-up, polypharmacy, generally defined as more than five medications, multi-complexity, greater than six chronic illnesses. And we know this is no shock to any of you guys. You know, renal failure, cancer, heart failure, weight loss, those are conditions related to the risk of readmission. Low health literacy, again, not shocking to you all. Oh, what's the story like to tell? You know, when my wife, some time ago when she was discharged from the hospital, the after-hospital visit was, I think, 14 pages, nicely printed material, and so on. And, you know, my wife's a nurse, and obviously I'm a doctor. And I was just thinking, you know, people with limited literacy, and especially limited medical literacy, you know, giving them 14 pages, 15 pages of stuff to read, is that really helping them? Sometimes I wonder about that. So we can help them decipher some of the 14 pages and maybe distill it down to two or three really important points for them to understand, because I often wonder, again, you know, with all the printing and all the paperwork, are they really putting that to good use? And finally, reduced social network and other social determinants of health, all of that plays in in terms of readmission risk, right? If you live alone, if they sent you home with a prescription for medications, but you have nobody to pick it up for you, you know, that's a failure there. Social determinants of health, we talk about food insecurity, the refrigerator biopsy and all that kind of stuff, is not only the amount of food in terms of food insecurity, for example, but it's also the type of food, right? Minerva's got heart failure. And if the family's giving the patient frozen dinners, and you know the salt contents, they're easy, they're relatively, well, relatively inexpensive, and they're easy to make and so on, but they are not cardiac friendly for many of our patients. So those are some of the factors to keep in mind as you are looking at a patient with readmission risk. Next slide, please. So what are some of the barriers in transitional care? And I broke it down through two levels. One is a medical level. The other one is what I call it a system level, and then maybe a knowledge level. The medical, on the medical side, there's the clinician workload, a hospital list, a last minute change. Maybe there's an error in medication reconciliation, and maybe the discharge is not at the right time. Of the day, because you're waiting for another specialist to come, and maybe the discharge summary that should have been provided for the patient, or to the provider, to the, what am I trying to, the discharge summary that should have been provided to the PCP is not done until, say, maybe a week later. So when the patient follows up with you, there's not a good discharge summary for you to review. These are some of the medical level of complexity that could impact your transition in your care. On a system level, the whole complexity in the discharge process, all the check boxes that different work groups gotta go through, and the waiting for different providers to sign off, all the paperwork, the insurance barrier, I talked about medications, and clear directions regarding follow-up visits. Who you're supposed to see, what labs are supposed to get done, and when. Sometimes all of that can be very overwhelming for our patients and family members. And the last is what I call just some knowledge deficits. Medical knowledge regarding what's going on, what happened to me in the hospital, caregivers, what am I supposed to do with this wound now that grandma is home with me? About her tooth feeding, how should I give grandma the tooth feeding, and what should I be on the lookout for? And provider on an ongoing, like a household provider like us, we may have some knowledge deficits, especially if you don't have a good EHR integration with the hospital. You know, what was done, what labs were abnormal, what follow-up testing are needed. So there could be a knowledge deficit on several fronts that needs to be addressed. Next slide, please. So what are some strategies that we can use to help improve transition in care? And I think Amanda and also Brianna can talk about this later on as well from a logistic and also from a billing aspect. There should be an outreach phone call by us to our patients and their caregivers regarding a post-hospital phone call and a follow-up visit to make sure that they are aware that we are coming. It's important for us as providers to review all relevant medical records related to the most recent hospital stays so that when you are in the home, you are making the best use of your time possible rather than trying to flip through 70 pages of records or clicking through different screens on your computer trying to talk to the patient and trying to make sense of what happened. So get it beforehand and review as much record as you can. And typically we like to make a visit within seven days of post-discharge because there's just a lot of, often there's a lot of confusion and patient have a lot of needs and we don't want them to bounce back to the emergency room again. I already talked about review of medication records and reconciling the medication with what the patient was sent home on, what they have at home. As you all know, sometimes they are on a particular medication in the hospital because of a formulary restriction, right? For example, Pantoprazole is used in a hospital, but when they get home, they're given a prescription for Pantoprazole, but they also have Omeprazole at home. Obviously they don't need both, but reconcile any differences and optimize the medications. Again, looking out for side effects, drug-drug interactions and kidney function, creatinine clearance or EGFR, depending on what medication you're talking about. Don't forget DME needs, walkers, maybe a Hoyer lift or oxygen that could again support the wellbeing of our patients and prevent falls and reduce caregiver burnout. If the patient needs home health, please get that done. And any follow-up testing, whether you do phlebotomy at home on your own, or you use a mobile lab, please get that done. And if there's an x-ray that needs follow-up, let the patient and the family know of that as well. Oh, be non-judgmental when you talk about any barriers to compliance with like medications, diet, do you have any trouble following directions? What did I say that made or did not make any sense? And so on, and carefully talk about things, maybe some physical impairment that they may have, but they're kind of embarrassed to talk about. Even like arthritis, they might have trouble opening bottles or picking up that tiny little white tablet because of their deformities and maybe their tremor and so on. So keep all of those in mind, ask them, do you have trouble getting your pills, taking your pills? Do you have any questions about your medications and any follow-up recommendations? Next slide, please. Again, don't forget the caregiver. I've said that enough and I'll just leave that one there. Talk about goals of care and transition of care can be a time where you take a minute and review their goals of care and their advanced directives. Are your wishes still the same? Do you have any questions about advanced directives? Have you changed your mind after this most recent hospital stay and everything that was done and so on? Talk to, again, ask open-ended question. I tell my residents here, we're doctors, we're so used to giving out directions and instructions and so on. I think we need to unlearn some of that and remind ourselves to ask open-ended questions. Do you have any questions? Do you have concerns and so on rather than making statements? The reason I tell my residents that to ask questions instead of making statement, at least two, there might be more benefits. One is you can find out what they're questioning, what knowledge deficits that they may have. And number two, it might give you a better point for entry, for discussion about, for example, goals of care and so forth. Again, learn to ask open-ended question. Write down instructions about follow-up, about blood tests, about if you're ordering x-rays, any medication changes and so on. And also very important, whether it's a magnet or you can highlight it or you can circle it, say, this is how you reach my office. If you feel this, whatever that is, call me. I want you to call me because I would like to take care of you and keep you out of the hospital. You can use the teach-back method or the teach-back and read-back method just to make sure they did actually understand your plan of care. I'm telling you that you're gonna take warfarin on five milligrams on these days and two and a half on these days. Can you repeat that back to me just so that you can have an added assurance that the patient or family member actually did understand. Have an emergency plan. What I call the plan B, if this happens, you need to do this. If this happens, you need to do this. For example, like a COPD exacerbation, you have a plan, these are the medication we're gonna try, whether it's a pulse steroid or you're gonna add an antibiotic or so forth. Or if it's a heart failure patient, you're gonna increase your torsomibumetanide or whatever that might be for the next couple of days. And then you need to call me, giving them a plan B so they can feel empowered rather than just calling 911. And always coordinate with your team, whether it's home health or if you have other providers following up with your patients like an APN or physician assistant at home, make sure that you talk either electronically or by phone that this is the plan and this is what I want you to be on the lookout for at your visit. Next slide, please. What are some highlights of successful transitions? Addressing their symptoms. Obviously, if the patient's got shortness of breath or whatnot, and you kind of don't address that, not only they're not gonna be satisfied, they're just gonna get worse and end up back to the emergency room again. And talk about or ask them about any post-hospital concerns that they have regarding any confusion. Do they have all the needs and the support services that they have? And we use a particular smart brace here in the office that highlights that go through some of the bullet points. Do you have this? Do you need more support of this? And so on. So as I'm typing my note, I'm just saying forced. I'm reminded, that's a better term. I'm reminded to cover these points just to make sure that I've covered as many angles in the transitional care as possible. Manage medications. And I'll talk more about this later. For me, as I teach the residents here, it's about reconciliation, but we need to do more than that. It's about justification. It's about optimization. And finally, it's about demonstration. And again, I'll talk about that later on. Advanced care planning. If this is an appropriate time, take a minute to review goals of care with the patient and family. Again, and the final point, like I said before, it's about that relationship. It's about supporting the patient. It's about supporting the family and the caregiver, building that bridge in case things do go south in the future, that they have that trust in you. And one comment I'll make, you know, a couple of weeks ago, I was at a patient's assisted living with a patient and family. She was doing very poorly. And we went through a lot of discussions about this, you know, option A and B and so on. And the daughter said, you know, Dr. Chang, whatever you recommend, we trust you completely. Again, I say that not to brag, please, it's not about me. It's about all of us. Our patient and family depend on us to give them the best advice and the best care and that trust. And I need to remind myself, and I did remind myself, just say, Paul, don't you ever, ever take those words lightly because they have complete trust in you. Don't let them down. Next slide, please. I can't do this on my own. I'm just a doc. I tell my patients, I'm only a doctor. I can't fix everything. I need nurses, therapists, social workers, counselors. I need pharmacists, good grief, 18 pills and all the drug interactions. For example, you know, even prescribing Paxilvid for COVID outpatient, there are a gazillion drug interactions I need to go through. And I sometimes need assistant advice from a pharmacist. Community resources, you know, senior services, get whatever resources you can in your community. And don't forget, yes, there is an administrative side. There's a billing, a quality tracking side and also a marketing side in terms of what you can do for your patients and family members as they transit from point A to point B. Next slide, please. Amanda, and I think I will turn this over to you now. Yeah, that'd be great. Thank you, Dr. Cheng. Hi, y'all. So I want to talk a little bit about the Naylor Transitional Care Medicine Model. So the TCM model, it was created by Dr. Naylor, PhD RN. It's a model that provides comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical and surgical conditions. And we're going to go through kind of the flow chart of how it works. And it's also on page 14 of the learning manual. And if you were getting kind of the chat notes, they made a couple updates. So go back in and download and look at that. But the core part of the TCM model is this is following patients back into their home. It's a nurse-led multidisciplinary model, physicians, nurses, social workers, discharge planner, pharmacists, other members of kind of the care planning team to really transition a patient from the hospital back into the community and ultimately hand them off to primary care. Slide. Paul talked a little bit about some of the issues just around transitions. And so in a lot of the research over the last 20 or 30 years around transitions, it's kind of come down to these kind of six overlapping categories of problems that have negative outcomes, right? Lack of patient engagement, absent or inadequate communication, lack of collaboration among team members, limited follow-up and monitoring, poor continuity of care, and serious gaps in services as patients move between health professionals. So none of that is poor quality care. It's all the transition and changes, whether it's on the patient side or the healthcare system side to move someone through the system. And so this can help, this type of model, and jump in the chat if anybody's using this model or wants to throw out a story, but this model can really, again, help your home visit patients, is they transition out. And sometimes the, you know, what I talk a lot about in our practice, one of the biggest things that I just wanna, that I think when we think about value-driven care and the future of healthcare is where is the patient? Like actually, where are they? And people are always surprised when that's one of the first things I say, is where are they? And then the question is wherever they are, can I apply the right resource to what they need? So when they're going through an acute issue, even if it's an acute or flare-up of a chronic issue, when they're in an acute issue and they're in the hospital. And now we're trying to transition back to the community. So many things have changed in a transition that's important to kind of make sure nothing falls off that plate that you're carrying through. So I have one more slide on the savings, so slide. So there are a large amount of dollars that are saved. And so just like any value-based care type of intervention or any type of intervention that is focused or it's kind of population healthcare management, oftentimes you're spending more dollars upfront and you're putting a more expensive intervention in place. And one could even argue home-based medicine is that, a more expensive intervention in place to save dollars, future expenses, and be able to control for cost. And so they were able to see over a 24-week period, $3,000 per patient's savings and over kind of the full year, 5,000 per patient's savings on average. And getting these kind of dollars assigned, again, you're putting more expense in in the beginning during this crisis or transition period and being able to save it on the back end helps to continue to market your home visit program. So again, I didn't see if any jump in the chat, but anybody that is doing the TCM model or partnering, or maybe it's an extension of your practice, you maybe pick them up, maybe you have a nurse pick them up in the hospital and then you transition eventually to primary care. So jump in the chat and talk about your experience there too. And one other thing, this was not just sustained. So the big savings is in the reduced re-hospitalization and it was not just sustained through one month. As you can see here, there was sustained savings through the first six and year from a cost perspective. And then from a quality perspective, if they're not going back to the hospital, now we've really greatly improved quality. And we're gonna talk a little bit about why quality and transitions matter to us as a larger practice in home-based primary care. So slide. So here, and like I think it says referred to the workbook, if this is kind of too small on your screen, if you're part of a larger system or you work inside of an ACO or you work inside of a major health system in your area, really think about talking with them with some of potentially your patients. And so I'm not gonna go through the entire flow chart, but the base idea is within 24 hours of a patient being admitted and really hitting those hospital doors, they're assessed on, are they a good qualifier for the TCM model? And if yes, then the TCM nurse starts visiting immediately and then starts visiting daily until they transition out and continue to follow them into the community and can care for a patient for up to about two months, the average length of care, even longer if needed, until they successfully transition them back to their community primary care, whether that's clinic or home-based primary care. Okay, and Letitia, I think you guys are using it. Your name says Dorothy, but I'm almost positive you said Letitia in your chat. Yes, okay, great. Yeah, I mean, I do think it's worth looking into and there are on the slides, are cited information on this because again, you're not gonna be able to see information on this because again, you're doing all of this work to keep people in the community and to keep on focused on goals of care, but we know hospitalizations happen. And then, and sometimes we're like, well, I just lost them in the hospital system. And this is a way to really partner with the hospital and transition to more kind of that pop health care management to continue to follow the patient and improve outcomes. And so I'm gonna turn it over to Brianna and then I'm gonna come back, but I'm gonna turn it over to Brianna because we've started implementing a couple of how to bill for transitional care right in this section. So I know billing's a hot topic. Thanks, Amanda. We can advance, here we go. So transitional care, I mean, you have to think about it from a clinical quality perspective and what's your clinical model to manage transition successfully. And then of course, if you're billing for Medicare fee for service, there is a way you can bill for a TCM visit. So I'm gonna chime in a little bit to highlight about that. So these are Medicare's requirements. So whether you're in fee for service or value-based care, I mean, all of these principles were developed for better outcomes. So you can think about, you know, how, which one of these aspects are part of my clinical model. And if I am in fee for service, am I getting appropriately paid for it? So the patient does have to be seen within two business days of discharge. It's not calendar days, it's business days. And then you have to make that visit within seven to 14 calendar days. So it's business days for the interactive contact, which is when a nurse is calling the patient, doing a verbal check-in, we have a template for that. And then the provider in-home face-to-face visit, or right now it could be telehealth, although, you know, typically it's face-to-face, must be in home within seven to 14 calendar days of discharge. We know, you know, best practice, you're gonna get there sooner than that within 72 hours for that in-home visit, but that is the Medicare requirement. The medication reconciliation, you know, it's really important to make sure you're documenting that appropriately, not just reviewing that, you know, checkbox in the EMR, you know, what changes were made in the hospital, taking the time. And then again, all these other things you're doing this already, it's just how you're gonna be documenting it. So if we go to the next slide. Next slide, please. There we go. The patient also has to have, again, from a Medicare fee for service billing standpoint, a qualifying discharge. So inpatient and observation hospital stays qualify for TCM visits. Also, if they come to a home or community setting from a skilled nursing facility that also qualifies as a TCM visit, they could go back to a home or they could go back to an assisted living. Emergency visits do not count. So that's not a hospitalization. It's not a qualifying discharge, but SNF to home or hospital to home, all of those would be examples. That interactive contact, again, what that means is a licensed clinical staff member is just doing some sort of verbal outreach, either audio or maybe a telehealth visit. It could potentially be in person depending on your model, but that's not a requirement. And then because Medicare considers TCM a 30-day service period, it's billed when you make that face-to-face post-discharge visit, but you need to document that both the non-face-to-face services that are required as part of TCM and the post-discharge visit occurred to support billing for it. So if we go to the next slide. The most common question I get about TCM services for programs trying to implement is what do the templates look like? So these next two slides are to give you an example. So these would be examples of what goes on with the clinical staff and the patient or the clinical staff and the caregiver. Again, it could be with a caregiver if the patient's not able to answer these questions on what that might look like. You do have to do this call in order to bill. The only exception is if you've made two failed attempts to reach the patient ahead of time, but you still do the post-discharge visit, you finally got ahold of them to confirm the appointment and all the other requirements are met. You can still bill for it as long as you've had two failed attempts, but Medicare does expect that you continue to try and reach that patient. And again, if you're getting them on the phone about the appointment, just connect them with the nurse at that time to do the interactive contact. And it is what you make it. If you sell this to your team as this isn't just a billing opportunity, this is for quality, we want you to take the time actually answering these questions and not just look at it as checkboxes in EMR. It can be really meaningful to help get the provider information and really assess if the patient's safe at home before you have someone in the home face-to-face. Next slide. This might be a smart phrase or a macro that you build into your EMR within the provider's TCM progress note. Again, what we're doing here is we're just showing CMS that all of these things have been done, all of the requirements of TCM in order to bill for the visit. And again, these would need to be customized with specific clinical and patient details. It's just confirming that all those TCM requirements have been met. Next slide. So this is why. So here's the reimbursement. So rather than billing, if you're gonna be billing for TCM, you're gonna use these two CPT codes instead of your normal home visits. You can't bill both because one face-to-face visit has to be, this would be what you're billing for that post-discharge visit. If you have to come back in two weeks, that's separately billable. But you have to have one face-to-face visit. And when you draft this code, even though we just talked about all the requirements within 30 days is when you see that patient face-to-face. Medicare has increased the reimbursement by 30% for TCM services in past years. So again, it now makes financial sense. It used to pay more to do the high-level home visit. It doesn't anymore. But two key differences with these codes. One is, again, how quickly you saw the patient, the 99496 within seven days, the 99495 within 14 days, but also the level of medical decision-making. So we'll talk more about how to understand MDM later, but you have to have high MDM if you're billing the 99496. If only moderate medical decision-making is supported by your documentation, then you're still billing the 99495. Again, this could be new or established patients. The only thing that doesn't count is ER visits. So some implementation considerations. Again, when we're thinking about workflows, how are you getting notified that your patient was in the hospital and at their home? Maybe you have access to a health information exchange or you have some sort of electronic notification, but you may not. If you're not affiliated with the hospital and health system, you have to educate the patient and caregiver. We're your primary provider. We need to know when you go into the hospital. We need to know as soon as you come home. Maybe you talk about that during a first visit. Make this easy on your provider. Again, we're talking about trying to reduce burden and increasing efficiency. That's where those templates and those smart phrases can really help. We'll talk more about scheduling later, but how are you gonna make sure that when a patient comes home from the hospital, you have room in your schedule to get them seen as soon as possible, maybe push off a more stable patient that doesn't need a sooner visit right away. Making sure that interactive contact call, again, your front office staff has to be involved too. So, okay, they schedule a TCM visit. Are they notifying the nurse to reach the patient or are they trying to connect them? And then are you maybe talking about hospitalizations within interdisciplinary team meetings? Are you debriefing? Are you talking about from a clinical quality perspective, which patients have been in the hospital and why? Was it preventable or what resources do they need? What can we do better next time? So I'll pass it back to Amanda. Okay, just a few more slides on kind of care coordination. We talked a lot about the importance of it. We talked about the different model, how to get paid for it. I think care coordination is the vaguest word of all time. When someone says, you know, or term, when someone says, oh, we have care coordination. And I'm like, you know, what does that mean? There's no title, license, role necessary for that. There is a sample job description in the book. Everybody kind of defines it differently. So I would say, start with what you're gonna, how you're gonna define it, where are your biggest issues and how is, and who's gonna help you? Is that a lay person? Is it a licensed social worker? Is it licensed RN, LPN, MA? How are they gonna work together to solve your biggest care coordination problems typically around communication and transition? And then as you think about it, kind of build out that more formal position, care coordinator, care navigator, care manager, whatever that kind of looks like, formalize that definitely in a job description. So slide. And really, as you think about kind of what someone's going to do, you know, in that NALER model discussion, a lot of issues are communication transitions between services or locations. And so how often are they gonna check in and what level or frequency do they check in and coordinate with the health plan, any waivered services, your local services, and we have some resources coming up, and make sure that everything is documented appropriately for future use, because you really wanna, make sure that part of the job description for a care coordinator or care navigator really includes documentation that's easy to find, easy to use, easy to understand. So you still, you get that same type of care that you'd get two in the morning, that you get, you know, two in the afternoon, I always like to say that, because everything's well-documented and put into place. And so then one of the ways you can do it is create a template within your EHR to make things really easy to document. Even the phone calls you have, you know, have you received all the medications? Does the patient feel safe in the home? And so kind of, as you go through these checklists, make sure that the care coordinator knows what to do with every answer, even if it's a negative answer, how do they document that and then put that plan in place and communicate that that's been done in case something changes, especially. So, you know, again, a lot of times we kind of start and there's so many variable practices. Some are very well-established, some are part of academic health centers, as we were talking earlier, and some are just getting started, haven't seen a first patient yet. But really, again, you know, and we've talked about it, luckily the providers have talked about this already all this morning, is there's so many moving pieces here to make sure that everything is appropriately documented and you know where to find your answer. And that the space in between, it's not always just the clinical care, it's likely more work doing the communication and setting up the services to get the patients to reach their goals of care. So the next slide shows just some finding resources. And if anybody else has any links in chat, throw them in there, but connecttoeffect.org, eldercare.acl.gov, auntbertha.com. These are just places that you can go to find services in your area. You might work within managed care programs that have service vendors where you can find it. I definitely worked in a state where we're having a lot of trouble because of the hiring issues. For a lot of hourly staff, we're having a lot of trouble finding waivered services that we used to find before. And so, you know, these are some additional resources to find options. And then finally, I wanted to talk a little bit of quality. So I put some thought into this concept, like, you know, we care about transitions because it improves individual quality, right? An individual can have a very negative experience in a hospitalization. They can have a very negative experience if they leave the hospital and the transition doesn't go well and they end up back in the hospital. So there's this individual quality of care piece. And here are kind of effective care transitions. Avoid these things for individuals. But when we think about the practice as a whole, there's really almost no reason to track this, except for, I guess, kind of two reasons. One is, and we'll talk about MIPS, it's required to track some of these things, but it's also gonna be really effective for your marketing, for your payer contracts, you know, to really understand how do you do a better job than others of managing the transitions? Because again, this is where a lot of the cost comes in. Nobody's saying, I think we've moved past the day where we're saying primary care is too expensive or you're seeing the patient too much. We know generally as a healthcare community that if they're a high utilizer, if they have, you know, what did Paul, you said 15, 18 medications on average, we know that you in primary care need to see them more often. But there are really expensive transitions that come with it. And so your ability to kind of track and avoid negative outcomes is really important. So if you go to the next slide, here are just some key metrics to track. And some of your EHRs will track them and some are not going to do this and you need to just kind of do it by hand. For years, we just kept track of our transitions by hand and in Excel. And so, you know, deaths at home versus SNF, versus hospital, referrals, number of deaths on hospice, referrals to hospice, hospitalization rates, yearly census, time to first visit, time to TCM visit. These are all key metrics that as you start tracking them, you can use for so many other things inside of your practice and externally to, again, prove that you are actually improving the quality of costs and then tie these things to the quality of care and tie these things to cost later. Slide. And then the first thing I mentioned is some of these things are required. So, you know, MIPS is part of the Medicare Access Chip Reauthorization Act, MACRA, back in 2015. And you really, by this point, you have to participate in MIPS for kind of this APM if you bill over $90,000 in Part B prophy services and have more than 200 Part B patients. And so, they're really kind of the four sections, quality costs, promoting interoperability, and improvement activities. And as you think about two that would be really good, and I don't know how many people are, you know, really strategically digging into MIPS, but the Home-Based Primary Care Learning Network highlights these two measures. So, they've gotten these added around cognitive assessment and plan of care for home-based primary care and functional assessment and the ADLs. And so, you know, we like to encourage these as well if you're not familiar with them, because, again, it's stuff that you're already doing. It's stuff that you get credit for. And we, as a home-based primary care community, really need to continue to use the quality measures that our partners have advocated for to continue to use them that they're still relevant. So, just a few notes on the quality and how that ties just intrinsically linked to transitions. So, as we wrap up, we'll take questions. Of course, there are a few comments in the chat. I'm not sure if there are questions yet, but every practice is capable of creating these quality transitions. Again, build that transition person however you'd like and establish those roles, establish protocols, and so everyone knows their role on the team, and empower the caregivers with knowledge. And I just love all the videos that have come before us because they really show how important the caregivers are, which you all know in the home. But when you're talking to other people, not everybody really is fully understanding the acuity of the care for the patients, and then the importance of the caregivers, unlike so many other primary care patients in the world. And then effective transitions are really tied to high quality of care, and then being able to prove that and demonstrate that to your partners is key. So thank you. I'll take a look at chat, but anybody looked at it and have any questions I should draw? Okay, thank you. Okay, so I think at this point, we're going to turn it over. Thank you very much, Amanda. That was great. And Paul and Breanna. Yeah, thanks. At this point, we're going to meet our first patient. And this is someone who we're going to continue to see tomorrow. So Megan, would you introduce us to Ralph? Yes, yeah. So Ralph is an example of a patient that is very typical in a house calls. Okay, we've all had a Ralph. But we want to give you a couple of different examples. And Ralph was our first one. So that we have in the back of your mind as to how we would approach these patients. Ralph is a 76 year old African American male with oxygen dependent chronic obstructive pulmonary disease, pulmonary hypertension and heart failure with reduced ejection fraction. You have seen him for the past few months. Before he got involved, he was frequently admitted to the hospital for shortness of breath. You Ralph, his nephew Reggie have been working on a care plan so that the hospitalizations and ED trips had stopped. But now he's had some increased shortness of breath. He called an ambulance three days ago, put an observation overnight. And he's been home for two days now. You have a routine post discharge visit with him aka a TCM. So go to you're going to want to look on page 20 of your workbook. That'll give you a lot more information about Ralph. And the key is how it goes into kind of his what the visit would look like his chief complaint, the history of present illness, his past medical family, social history, and just all the information that would carry through in a chart. But you want to look at that get familiar with Ralph. Because ultimately, what we're doing is you want to really when you walk into a situation like this, even though you've seen Ralph before, you know, Ralph, that's okay. Next slide is that you want to be able to ask yourself, okay, what matters when I walk in this door, I know the background, but I got to make sure I address what's going to matter what's important to the family? What's important to the patient? What is my short term goal? What am I going to fix today? What can I fix maybe in over the next couple weeks? And is this going to be realistic for him to stay here long term? Or do we need to start talking about what's the next step? I need to make sure his mentation is okay. You know, do I need to do mini cog MMSC? How would you address Ralph because he's got some depression going back to we talked about mental health? How are we going to address his depression? Make sure when you look over Ralph that you kind of get an idea of you need to start looking at his mobility. How does he need help? Is he a fall risk? Can you help facilitate the mobility and safety for him? These are the big questions you have to again, really put to your mind first and foremost. Medication is his plan of treatment. Is it too complex for him going back to his mentation? Can he manage it? Is there somebody to help him? Do we need to start deprescribing for him? If yes, what? And you know, looking back at his multi-complexity, why is he complex? Is the plan too complex? Is it feasible for Ralph to follow? What concerns do I have and do I need to be more realistic as a provider and talking with the family about this? Are you able to, we pull up the workbook and look at the workbook part. I just want to give kind of a, what the workbook would look like just for those of you in case you haven't had a chance to look at it yet. All right. We can't see it yet. Oh, there it is. Did it come up? All right. So I said it's around page 20. I know in the workbook that it starts and it gives that in-depth history for Ralph and just kind of goes through and talks more about his story, those considerations that when you're asking yourself, you know, what matters for Ralph, some of the different issues that come with that. There we go. It got bigger. So, and it talks about, you know, his current physical exam on the visit. You kind of take a look at it and you can see the issues and medications. Look at all his medications. It's a lot of medications, screenings that have been done that are available to you to review. And again, this is an ongoing patient you've been seeing or we've been seeing, and we would not expect you to do all of this in one visit. So that goes back to prioritizing your 4Ms, what matters, mobility, the medications, is there anything I can take away, and how's his mentation, how's his mood. And then that just kind of gives you an idea, but get familiar with Ralph because you're going to want to know kind of how, you're going to want to look at doing a sample assessment and plan on him just to kind of get in that practice mode. All right. And then Melissa, if we could go back to the next slide, back on the slide deck. And then, yep, nope, we're going to go ahead and we'll come back to Ralph, you know, in the next couple of sessions, but just that way you get familiar with him. Okay. Okay. So you all may have noticed that we're a little bit behind, but we're going to plow forward. Thanks for hanging with us. Take your breaks as you need to. But for right now, we're going to dive into what matters, prognostication and advanced care planning in home-based primary care with Dr. Chang and Brianna. All right. I agree, Melissa. Hang in there with us. We're almost to lunch, and I'll try to make this hopefully efficient and meaningful to you as we talk about prognostication, advanced care planning. There's some overlap between the two, so I will zip through those slides. We're going to talk about prognostication and the role it plays in caring for patients who are sick and complex, as well as any concerns from their family members. We're going to describe and discuss functional patterns of decline and life-limiting illnesses. We're going to talk about barriers to accurate clinical prognostication and utilize effective tools to help overcome these barriers. I still struggle with these conversations after many years of doing this. It doesn't come naturally for us. It's not fantastic news, right? But it's really important for us to do this and do this well. We're going to illustrate importance of advanced care planning for patients with serious illnesses and introduce steps for communicating with patients and family members about advanced care planning. This is very dear to my heart right now because my mom is in a hospital, and we are going to need to make some decisions soon about her care. I teach this stuff. Obviously, you can see there I practice this stuff. But when mom was in the emergency room, things were not looking so good, and the ER doc turned to me and said, what are we going to do, Paul? I froze. Mom and I have had conversations about this for years. She's ready to meet Jesus in heaven's glory, but I backed away a little bit, got very tearful. I said, I need a minute here. I can only imagine if family members really never thought about this and if there's a crisis moment and how difficult that conversation, that environment could be for our patients and their families. Yeah, I'll just leave it there. Next slide, please. So what is prognostication? It is a science of estimating the likelihood of an outcome due to a medical condition. I'll get to that. It's a singular there, and I'll get to that in a little bit. It focuses on the remaining life expectancy, and it should include outcomes that are important to patients and families. Most patients with serious illness would want the discussion, but often it doesn't happen, and we need to ask ourselves, why doesn't it happen? Is it time? Is it reimbursement? Is it lack of confidence? Or is it just a stiff arm from the family that they don't want to discuss hospice? We've all heard this. Don't you mention that H word. Don't you mention that M word. It's morphine, right? Don't you bring that up for mom. So it could be from the patient or family that resists this kind of discussion. Next slide, please. Recognizing the pattern of decline or the clinical trajectories can help inform prognostication conversations. So there are four major categories, if you will, and there'll be slides next, and they're all kind of self-explanatory. There's the sudden death. There's the cancer death. There's the organ failure, and there's the dementia, frailty, or the dwindles, if you will. So schematically, next slide, please. That's sudden death, right? You're going along, everything's fine, and then something catastrophically happens, and sometimes this could be very hard for family members because it's completely unexpected and unanticipated and unplanned for. Next slide, please. This is the cancer death. You have cancer, and then you start getting treatment, but despite treatment, the cancer progresses, and you start seeing a palliative care specialist in addition to your oncologist, and your disease continues to decline despite best efforts, and that results in possibly a rapid decline in your health, and then you passing away. Next slide, please. And this is the organ system failure trajectory, and we've all seen this, right? Heart failure, COPD, we treat them. They never quite bounce back to the level that they were before. So yes, they improve, but the overall trajectory is one to decline, and eventually, you know, we just cannot pull them out of the abyss. Next slide, please. And then this is the dwindles. There are no major upsets. There's no major curves, if you want to call it in this slide. It's just an overall gradual decline that results in the death of a loved one. Next slide, please. So what are the limitations of prognostication? You know, evidence-based guidelines, it's hard to come by, and remember I said about your prognostic tools for condition as in singular. For our patients who's got 10 different complexity or medical conditions, you know, how do you put them all in and come up with a prognosticating curve? Excuse me. It's very difficult. There's not a lot of solid guidelines out there. Acute hospitalization is very, unfortunately, very, I don't know if important is the right word, but it really is a disabling process for many of our patients. You know, we think of hospitals healing, and they have all this technology and improving the lives of our patients, but we all have seen this, whether we practice it or see it in our loved ones, when they go out, when they leave the hospital, they're just not quite the same, despite them doing everything that they can to help our patients. And the combination of prognostic tool and your clinical judgment is better than, you know, either one alone. We do need some backing. We do need some data, but at the same time, being at the bedside with a patient and putting those two together, I think it's really important for us to guide the family regarding, you know, what to do or what not to do. Next slide, please. So what are some of the barriers? We've all heard this. You know, I don't want you to talk about this with mom because it will remove hope, right? You know, and then when the hope goes and they were just, you know, mom will stop eating and she'll die. So there's that concern about us removing hope. And then our focus and our training has been emphasizing, it's been, not emphasizing, geared towards, you know, fixing, treating, again, making things better and so on. And that may not always be possible. There could be cultural issues related to talking with prognostication with patients. For example, some cultures, I cannot talk to the patient directly, but it has to go through, say, the firstborn son in a particular culture. And the son has requested that information be not shared with the patient. You know, so how do you navigate those kind of tricky situations? Obviously, we like to be right about what we do because we are, many of us, most of us are perfectionists, I think. We don't like to be wrong. And we have made calls, all of us, and I'm sure if we, you know, have people raise their hands, all of us have made mistakes when it comes to estimating survival. I still recall visiting a patient down the road here to assist their living. I said, you know, Grandpa doesn't look good. I think it's time to fly everybody in. Everybody came in, and you know what happened? Yep, Grandpa survived for another three to four weeks before Grandpa died. You know, memories like that kind of shape our experience and maybe our hesitancy when it comes to, like, you know, I don't want to be wrong again about, you know, calling everybody in. We might be overly optimistic about a new treatment protocol for this kind of cancer and so on. And then a reaction to prior, you know, poor experience that can shape our thinking. And I don't remember, and my school might be different now. I've been out of school for many years. Medical school or nursing school or PA school might be different. I didn't really get a lot of training on how to have this type of conversation about end-of-life care and so on. And so maybe that is also an additional barrier simply because I don't have the tools to do it. Next slide, please. Yeah. The management should reflect an older person's own preferences and goals in the context of his or her own combination of diseases and condition and prognosis and the feasibility of its implementation. So that's kind of, it's a very good, I think, summary of what we try to do. We don't always do it perfectly. I don't do it perfectly. But that's kind of the goal, the aim of what we're doing when it comes to prognostication or advanced care planning discussion. Next slide, please. Here's some guides. You can look through them. I have them on my phone. And you can certainly Google them on your computer. That can help guide you. Remember I said you need data and also you need some clinical judgment and putting them side by side the best that you can. There are multiple calculators. One I use, for example, is Calculate by QXMD. There are lots of calculators for many different kinds of diseases that you can find in there. Next slide, please. And then just some common prognosticators for the diseases that we encounter frequently, you know, the BOLD index or COPD, the Seattle heart failure model, predictive models to CKD and brain metastasis. Again, get used to some of the apps that you have on your phone so you can have a confident conversation with a family member backed up as much as you can on your smart device or your computer so you can feel more confident when you engage the families or the patient about a very difficult conversation. Next slide, please. There's just some other additional resources. If you're thinking about treatment or not treat, maybe go palliative hospice way versus one more try of chemotherapy and whatnot. So think about these or review these resources as well. Next slide, please. As I look at what we do at home, these are kind of the four bubbles, if you will. There's the assessment of the symptoms. There's the functional assessment. You've seen it on the video. Look at the social structure, the social environment of the patient and supporting the daughter in the video there with her caregiving burden and so forth. And then the final piece, because the nature of what we do and the kind of patients that we take care of, it is advanced care planning. So we really do need to be comfortable with this realm as well. Next slide, please. So what are some of the benefits? I already talked about it briefly. It avoids crisis decision. We can have time to better understand the patient's values and choices. We can have time to think about the risk benefit of doing A or not doing A, gives patient and family time to cope and process all of the medical information, right? A lot of times I hate to do what I call the dump truck visit where I go in and I just completely unload on them about the 20 medical conditions that they have. And you can see it in their eyes after point number three on the after visit, written summary there, they're gone. They've kind of checked out there. So having that time given, having that extended period where you can give them some time to review some of the medical information, it can help them with understanding and choices. And it can help certainly reduce stress and anxiety for the patient and family members. Next slide, please. The impacts, we can reduce unwanted medical interventions. Do we really want to put a pacemaker in a 98 year old patient, okay? We can increase palliative care and hospice care utilization. And we know these services are awesome, not only for patient, but also for family members. Gives patient time for preparation, financial, personal issues that needs closure. It increases the likelihood of the patient dying in their preferred place. We have studies telling us that majority of us, I think it's about 75% of us prefer to die at home, surrounded by our loved ones, but 75% of us die where? You know the answer, in a hospital. You know, where's the disconnect? What can we do to improve those numbers? And then also it can reduce some of the moral distress in the care providers. We've all had those feelings in our hearts. You know, am I doing the right thing? Is this ethical? And so on. So having that discussion can perhaps reduce some of the burden related to that. Next slide, please. But okay, we got all these benefits and so forth. Why don't we do it? Lack of time, lack of training. We talked about that, about taking away hope. We're not sure about what's going on on the prognosis. Cultural conflict, family conflict. Patient may not be ready to hear this. Who should take the conversation? Who should start the conversation? What would be the main person to take the role in this? Is it the PCPs at us? Is it the oncologists? Is it a cardiologist? And then there might be some, there might be, most likely there's some bias in our own hearts regarding, you know, well, maybe this is not the right time. He doesn't look so bad. Ralph has bounced back from his COPD exacerbation before. He can do it again. Maybe there's some bias within us. Next slide, please. When should we have this conversation? I think we talked about transition, post-hospital, post-rehab. If there's a change in a condition or the patient's function, post-stroke, for example, if there's a newly diagnosed serious life-limiting illness, you've just been told that you have cancer of some kind. All right? If there's consideration of stopping a medical procedure or intervention, such as, you know, tube feeding or even talking about dialysis or turning off that defibrillator and so forth, that's a good time to talk about prognostication. And obviously it's a good time if the family wants to engage with you on that. Next slide, please. So here are just some steps in terms of the kind of the checklist in my mind when I sit down with family members and carry out this conversation. I need to make sure I've read the chart and get updated information, okay? I need some time. It cannot be, you know, it shouldn't be a rushed visit because rushed visits for prognostication, often it doesn't turn out well. If possible, just turn off your electronics, your, you know, close your laptop, put away your phone and so on. Assess the patient's capacity for understanding, you know, what you're about to discuss. Also talk about, you know, who should be here? Where should the discussion take place? Remember I said about asking open-ended questions. Ask patients, ask family members, what is your understanding of your condition? What is your understanding of the CAT scan that you just had today, okay? And ask for permission to discuss the findings and a prognosis with the patient. Don't just come out there and say, well, you got cancer. That is just not very a good way to engage with a patient regarding a very serious conversation. Do your best, do your best despite failure. And I've made enough mistakes. Do, I'm gonna do my best to talk about the condition and make a recommendation and prognosis. And be comfortable with silence, pauses, or even a lot of emotions. It could be tears, it could be anger at you, not directly perhaps. They could be just venting, all right? Just be comfortable with that. Give them time for questions. Again, you can't rush through this. It's just very difficult for our patient and family and don't try to fit it in, you know, the next five or 10 minutes and then moving on to the next patient. Always take time to summarize what you talked about and plan for the next step. I am going to do this. I'm gonna make some medication changes to help you with your nausea, pain, hiccup, secretion, whatever, and or I'm gonna call in hospice to help support you all. Document the discussion and most importantly, share it with the relevant providers. Your nurse back here at the office, the facility where the patient is at. So they're aware that you had this conversation, that the hospice is gonna be called and so on. Again, we don't want mixed messages. For example, the facility calling 911 when the patient, you know, really should be cared for by the on-call hospice people. Next slide, please. Use decision tool to help you with discussion. I talked about that. Prognosis is important for planning and perspective. Again, we reviewed that as well. Give a warning shot before sharing difficult news. None of us like to be blindsided, none of us. And then talk as best as we can in clearly layman terms, not medical jargon, treatment options and range of outcome. If we did another round of chemo, you may have my estimation, 12 weeks of life, but you may need to go back and be treated for side effects related to chemo. If we treat you with hospice, then your life expectancy may be eight weeks or whatever, but it is our hope that you experience less side effects related to chemotherapy and your distress will be perhaps better managed. Next slide, please. Advanced care planning, real quick. It's a continual process and I like that term. We often think of ACP as, you know, I did it, the pulse form, the pink form is done, I'm done, you know, that's it. But it should not be that. It should be a continuing process, checking their, you know, are their goals the same? Have their decision been different than change based on their most recent experience? You know, we want, all of us want to receive the care that's consistent with my values. I don't want, you know, if I don't want XYZ treatment, I don't think you should force it on me. It should be a proactive conversation, could be integrated into a routine visit. Also as part of the annual wellness visit as well, I think Brianna can talk about that later. Oh, there it is, that's my next point. Be part of the annual wellness visit conversation as well. Next slide, please. Overview, again, this is very similar to prognostication. We want to understand their preferences, their understanding of their disease, talk about treatment options. It may result in the completion of an advanced directive of pulse forms, often kind of the end result, if you will, but that should not be the end game, especially if the patients are hesitant and whatnot. It should not be like, oh, Chang is here again. I know what he wants. He wants me to complete that pulse form. It should not be that repetition, like that's your main motivation for seeing the patient at home. Again, similar to prognostication, disseminate the information, document, so everybody will be informed. Next slide, please. Here are just some examples, advanced care planning document, living will, proxy, the pulse with the most form. Next slide, please. The benefits are, again, pretty much the same as prognostication. We find the patient's goals, deliver care that's consistent with their goals, reduce anxiety in the provider, the family members, the surrogate, and then having that plan B, right? I'm into this plan B a lot because I want our patients to be supported, empowered, and have another option rather than calling 911. Next slide, please. This is, again, I won't read through all of this, but the steps are very similar to prognostication. Next slide, please. And again, it's about asking questions, right? Rather than making statements. Ask, tell, and then ask again. Are there more questions? Did you understand what we just discussed? Ask, do you need more time? Do you need to discuss it with your brother or your sister? So use the ask, tell, ask approach. Again, just try to unlearn the idea of making comments, but be more comfortable, more natural when it comes to engaging with patient is to ask the questions, yeah. Next slide, please. Brianna, did you wanna talk briefly about getting paid for the time that we're spending with our patients with these difficult conversations? Yeah, so I'd love to hear in the chat, those of you, I know many of you are probably already billing for advanced care planning, but we did wanna touch on it. Again, it's something that you're going to do regardless, but we want you to know about the opportunities and get paid for the work that you're doing from a Medicare fee-for-service standpoint. There are advanced care planning codes that can be billed in addition with a visit. But again, from a Medicare billing perspective, these are time-based services. So you have to spend at least 16 minutes just documented on that advanced care planning discussion in order to bill for it for Medicare purposes. That would be the 99497. CPT time rules have, you know, the code itself is the first 30 minutes. So if you've passed the midpoint, then you can bill for it. If you spent 46 minutes or more, then you would bill both of the codes. If you bill advanced care planning as part of an annual wellness visit and use modifier 33, it waives the copay for the patient. There is a small copay for advanced care planning. You do have to, you know, get consent for the voluntary nature of the discussion. But if we go to the next slide, this is my recommended template. Again, advanced care planning is, it should be personalized. Templates are great. We want you to save you time. I don't want you to have to remember what the billing requirements are, but the most important part is being specific about what actually occurred. What were the patient and family's, you know, preferences? Who do they want to make decisions for them when they're unable? All of these smart phrases and templates should always be customized to that specific patient during that encounter. And then where are you going to put that information in your EMR so that when there is a crisis or there is an important decision, other people can find it at the right time. I know some EMRs are creating new actual tabs for advanced care planning within the EHR. Maybe you put it on your problem list with the details of the most up-to-date conversation so it can be found easily. Like Dr. Chang mentioned, making sure you're sharing it with people. And again, from a Medicare perspective, they encourage you to let the patient know that they're above the cost sharing if it's done outside of an AWB. But the real important part is that you're documenting the voluntary nature. You're explaining the conversation that you want to have and they're agreeing to participate in that. Next slide. So this is the reimbursement. Again, every little bit counts at fee-for-service. Again, we want you to be sustainable. We want you to get paid for the work that you do. There should be no reason that a home-based primary care practice or even a home-based palliative care practice is not billing for advanced care planning conversations. Right now, because of the waiver, it can even be billed if it's a phone conversation, if it's done via telehealth or over the phone. This is one of the Medicare telehealth services that can be done audio only. So again, important to just get paid for the work that you do. Next slide. And I think that's our references. So I know I'm gonna let our staff chime in about the lunch break. But again, if any questions, please put it in the chat. We'd love to hear successes and challenges about doing or billing for advanced care planning. Okay. So I don't know. Did you have any other final comments, Paul, on the key takeaways for this session, or can we move on? Let me unmute myself. No, I don't. I think people are probably ready for lunch, but I'll be happy to talk more about this now or maybe later on this afternoon. Okay. All right, thanks. So we are going to go to lunch now, but hold off, don't leave yet, because there's some instructions and some additional information. This is our scheduled lunchtime, and we'll plan to return by 1.20. If you are struggling with finding the resources in our LMS, I'm gonna invite you to stay for just a few more minutes, because we're gonna demo for you exactly what you need to do to log into the HCCI Learning Hub and to see those resources. If you already have the resources and you've got this all figured out, you can go to lunch, return by 1.20. Please do not close out your access to this workshop. Just mute yourself, turn your camera off, go have your lunch, come back in 30 minutes. So at this time, I wanna introduce Sarah Breschew, who is going to demo for you how to access your resources in the HCCI Learning Hub. Sarah? Thank you so much for your patience. I'm not gonna take much of your time. I would just like to help you all kind of troubleshoot what is going on. And I have asked for permission from Tony and from Julianne Geit to kind of share their screen to walk you through, okay, how do I access these materials? I'm here, you know, if everyone can see my screen, I'm showing Anthony J. Perry. In the case of Mr. Perry, he is actually a part of our Illinois House Call Project. Now our Illinois House Call Project folks make up the majority of the people who are here with us today and who will be participating in the workshop. In order for you to access your materials, you're gonna go to your My Resources tab on the left-hand side here that you can see. It's got a little house. That's your home base. That's where anything that you've purchased will automatically go. In this case, he's only purchased the Illinois House Call Project subscription plan. What you will do, click on your Illinois House Call subscription. Is it will open up to this lovely page where you can see your workshops, your online courses and so on. I won't go through everything, but you're going to click on your essential elements of home-based primary care. This is the workshop that we're currently attending and this will be the same steps for advanced applications as well. This is where you should have joined in using your link for Zoom. When you hit course here, I'm gonna show you two different things. One is this course material button and you're gonna click access. Now, once we're done with the workshop, you're gonna have to go in and also do the post-evaluation. But for now, we're gonna go to course material, go ahead and click access. And as you can see, Mr. Perry here has access not just the learning plan, the agenda, but also the workbook. As I said, the workbook was recently updated. So please, if you downloaded it earlier this morning, re-download it so you have the newest course materials. This is how you access your materials and you don't have to pay for the course. Now, let's say you're someone who's not a part of the Illinois House Call Project, we welcome you as well. I know we've got Carolina Caring. So I've got Julianne Geit here who also was willing to let me use her account. In her case and in any case that is not a part of the Illinois House Call Project, you're going to go to your My Resources tab the same as the Illinois House Call Project folks. Only in your case, you'll see your essential elements course right on top. If not, you'll see it in your recently viewed content. In that case, you'll click on that. As you can see, we're in session. It can tell that we're live and you'll do the same thing that the Illinois House Call Project folks do. You'll click on your course, course material, you'll hit access, and then you'll be taken to the page in which you can access your learning plan, the agenda and the workbook. If you have any questions or continue to struggle trying to access your materials, you can feel free to send me an email. The majority of you have my personal email. If not, you can send an email to education at hccinstitute.org. So that's how you access your materials. At this time, you can feel free to go to lunch. And like I said, I'm available for any troubleshooting if need be. Thank you and enjoy your lunch. If you can hear the sound of my voice, this is your two-minute warning. We will be resuming with our next session on multi-complexity and the art of managing multiple health conditions in two minutes, thanks. All right. Hi, everybody, and welcome back. I hope you were able to get a little bit of sustenance for your lunch, and we're ready to dive back into the next session, which is Multicomplexity and the Art of Managing Multiple Health Conditions in Homebound Patients. So I am welcoming back Megan Berdoni. Hi. Great. I hope you guys got some lunch and got to the bathroom, all that kind of necessary things and equipment and items to do, but we'll get going on this. Now, Multicomplexity and the Art of Managing the Complex Patient. We're all pretty familiar with the challenges of these homebound patients and their multiple diseases. So I won't spend a huge amount of time. I just want to make sure I've got pointers for those of you who this might be a little bit newer for, and it's really just something that where if you want to do some screenshots, I think that would be a good idea, but to put this information in your back pocket in case you ever need it. We're going to be applying the management model for treating patients with these kind of chronic diseases, and we're going to describe treatment and some medication management approaches to the four big chronic diseases that you commonly find in a homebound patient, diabetes, CHF, COPD, and chronic kidney disease. All right. Next slide. So these are certainly challenges that we face. You know, when somebody's got these multiple chronic conditions and 10 is sometimes a low estimate, you know, what do you attack first? What do you do first without causing five more problems? And that's always going to be the difficulty. And so keep in mind, whereas we want to maximize their treatment, at the same time, we want to be careful we don't over-prescribe. And that is a tricky obstacle. They have multiple medications. So again, we're really just trying to keep it simple, but yet keeping them out of the hospital, which does mean medication sometimes. They're at risk for those admissions and overall high healthcare costs. And because these medical conditions, they really contribute to their overall functional, nutritional, and cognitive issues that they face. So that's why it's important that we address them and we still treat them. Sometimes the caregivers have to assist. They have to make sure the pills are counted and put in the pill boxes appropriately. And sometimes the caregivers are not quite able to do that as well as we'd like. So those can also be some of the challenges. Next slide. So the management model, like always, plan, do, adjust, check. We're check and adjust. We're always looking to review what we've done, see if we can't fix it, make it better. You're not always going to get it right the first time. It's unfortunate, but again, that's why medicine's an art. Sometimes you just realize, well, maybe that didn't work quite as well as we wanted it to. All right. And next slide. So when we plan, we need to prioritize their treatment. Oh, go back one, please. Consistent with their goals. Again, what matters to the patient? What are their goals of care? What do they want to see improved for them? So you have to look at their symptoms. How can we make them feel better now? How does that change their mobility, their overall safety? We don't want to do medications that make them feel lightheaded and dizzy, because then again, if we thought they might trip over that rug in the hallway before, they definitely will now. We need to look at preventive care. What can we do to try to keep them from going, you know, falling down or getting worse? And what other obstacles do they face? You know, whether again, family is helpful or unfortunately causes more obstacles or drama for them. Next slide. So we prioritized their treatment. And let's go to the next slide there. Thank you. So we determined what, there was a delay. Back one. There we go. All right. So we determined the testing that's needed. Try to be appropriate and intentional when you pick out tests. Make sure, you know, that if you're doing it, you've got a specific purpose behind it, or is it going to change your management? You really want to ask yourself that. Also assess your anxiety and their depression. You know, sometimes these are big life changes for them. It's not where they expect it to be. Make sure you talk about that. You know, don't ignore it. See if there's anything we've done to help. It might be really simple, the solution that they need to, that would make them feel a lot better and more comfortable in their situation. Look at their living conditions. Is there anything that can be done that would make it better? You know, to us, it's a really simple thing is to get an elevated toilet seat, but to them, they may not even realize that was an option. And that may be a constant source of fear or struggle to them is getting off and on the toilet and being embarrassed about having family come in to help them with their trousers. We don't sometimes recognize how people really have certain anxieties about having family help them. And what are those other contributing factors we want to look at? You know, is it family? Is it cultural? Is it just in general that they just are ashamed of maybe their living condition or how their own health has deteriorated? These things come into play sometimes with their attitude and even how they present. So we try to have a little grace with that and realize if I were in that situation, how would I be? Probably not the most happy-go-lucky. Next slide. So what do we need to do? Sometimes we need to recommend medications, other treatment plans, lifestyle modifications, you know, change in diet, foods. You know, we need to work on prescribing appropriate treatments. What kind of, when we do a medical intervention, make sure to go over what the benefit is. What are the adverse events? It's like, for example, right now, if you have a patient who has COVID, do you write for PaxLovid? Do you, you know, what are the benefits of the PaxLovid? What would be the adverse events out of it? You know, why would you not do it? So that way they have a full picture of what's happening to them. And importantly, we really are trying to prescribe some of these medications when possible. You know, ask, is there a real benefit to this medication? Or are they just taking it because we thought it might be helpful, but we never really went back and reassessed to say, maybe we can just stop this and see if you need it after all. Always consider durable medical equipment. Again, anything that might be helpful. Is it a hospital bed? Is there, do they need a new walker? Sometimes things, they eventually wear out and break down. Always feel comfortable about having home health come out, physical therapy, occupational therapy, speech therapy. I can't say enough. I don't think sometimes we really utilize some of the therapists as much as we can. You can always ask for the therapist to come out, do an evaluation, you know, order it. And if they feel like that there's nothing that they can provide or services that they can do to help, then that's fine. They'll say, everything seems to be okay here. We did an evaluation and they're at their maximum potential. But if sometimes you'd be surprised at what they can come up with, it's in their arsenal that might be helpful for that patient. Next slide. So always, you know, check and adjust, make changes. We want to evaluate progress, you know, make sure that we're moving towards that patient's goals. What do they want to see? You know, sometimes also don't forget home monitoring options. And, you know, at the same time, we're looking for adverse effects. If you do medications, make sure they're taking them. I can't tell you how many times I've counted pills and said, wait a minute, this isn't adding up. You know, I see when you got the prescription, I see how many are not missing. So you're not taking it. Or you've got to specifically look in the pill boxes. Often they can't see very well and the pills will drop into other days. And you may find that the warfarin was, you know, taken three days, three doses in one day versus spaced out appropriately. This is not uncommon at all. Often they'll come out of the hospital, they come home and they'll have a med reconciliation that's supposed to be making some significant changes to their prescriptions, but they just go right ahead and back to their home medications. So always check for duplications. Again, continue to constantly reassess. Next slide. So diabetes, this is, we're going to see more and more of it. It's just, that's the nature of where we're going with, you know, obesity rising in the country. You're going to need to discuss the frequency of how often they should be doing blood sugar testing. What are their goals? Ensure that they're taking the medication as prescribed. Modification of diet, you know, the ice cream, the Breyer's ice cream in the freezer when they did the, when Dr. Chang did the freezer biopsy. Somebody's eating all that ice cream. You know, try to talk about exercise. You know, sometimes again, going back to PT, that kind of gets them up and moving, making sure that they're able to get, you know, in and out of the manufactured home if there's steps. You know, always try to look at what can we do to make little goals, you know, to chip away at improving their health. Maybe it's just by saying, can you try to just walk to go get the mail instead of having, you know, your son or daughter do it. Make sure they follow up with specialists, eye and foot care, and also order cholesterol and microalbumin tests to see if additional medication is needed. Remember those also come into play with diabetes. Monitor their A1C. Now keep in mind, eight is considered reasonable for an elderly complex patient. We would much rather they run a little bit higher and not start having these hypoglycemic events because then guess what? They're going to fall and it just starts a spiral of problems for them. Next slide. All right. So some of the medications with diabetes, you know, as always, we start with metformin if we can, unless there's a strong history of kidney disease, which we'll get to. And, you know, take a screenshot of this when you need to have an alternative to metformin, your sulfonylureas, the DPP-4s, GLP-1s. You know, again, this kind of gives you a breakdown of you want to try, often we try our oral medications and see if we can get them under control. But in the end, sometimes we just have to go to insulin. But who's going to help with that insulin? Who's going to monitor it? Who's going to pick it up? Those are all questions we have to go through. Next slide. All right. Congestive heart failure. Big thing is to talk about salt and fluid restrictions with the patient's goals of care. Again, are they eating a lot of processed foods? Are they getting TB dinners because they're too tired or exhausted to make themselves food? Make sure when you look in that freezer, you know, if that's a big part of what you're seeing, or is there a lot of takeout? Those are things to try to talk about. There's always the story from a recent provider who they couldn't figure out why the patient kept popping back in the hospital until they found out that their favorite beverage of choice was pickle juice. There's a lot of sodium in that. So that explained all of a sudden real quick why they kept ending up in CHF. If they smoke, make sure to try to tell them to stop. Make sure you document it. Monitor their weight. What does that mean when we say monitor their weight? Well, make sure that they're looking to see if they gain more than three pounds in a day or five pounds in a week that they're calling you, letting you know, because it's time to make adjustments to medication to try to get some of that fluid off so they don't end up back in the hospital. And explain that's the reason why that's the adverse event that's going to happen. And that's what we're trying to avoid. And they don't want to go back to the hospital. So make sure they have that connection. Of course, take medications as prescribed. If they have increased weight, leg swelling, cough, shortness of breath, all of that, if they can't lay down flat at night, make sure they call you. Next slide. Just again, some of the medications with heart failure, the loop diuretics, thiazide diuretics, going on down the list. It should be noted, interestingly, the American College of Cardiology came out and they did make kind of a change to their recommendations for heart failure. They talked about how rather than doing a stepwise approach, that they're looking at doing low dose of, or at least sufficient dosing, of the four major classes. So keep that in mind, that there have been some changes. Try to make sure you stay up on recommendations as to what's recommended out there for our heart failure patients. But again, this is tough, admittedly, when we're talking about deprescribing. But in this case, if we can keep them out of heart failure, we keep them out of the hospital. So it's a necessary evil. All right. Next, thanks. COPD. We want to make sure, again, what's your goal? Do you want to be able to go outside? Is it that you want to be able to get up and go to the bathroom without getting short of breath? And try to see what to them is important. If they smoked, tell them to stop, especially if they're on oxygen. But nothing worse than the person who takes their nasal cannula, puts it on their forehead, and lights up. Always makes me a little nervous when you have to go in those homes. Instruct them on how to use an inhaler. Again, we sometimes are too quick to say, here's a prescription for an inhaler, but we don't really follow through to make sure they're using it right. So they just kind of put it in, and they don't even get a full breath in. I really try to stop and explain it in terms of, we have to open up the pipes, use albuterol, here's how you do it, give demonstrations. Then you got to sometimes turn to the spouse or family and say, is this what they look like when they use their inhaler? And often they'll say, no, they're not using it right. And the patient had no idea. They thought they were doing fine. But then they say, well, I don't know why it doesn't work. Make sure that the COPD patient has an action plan. The action plan is, you know, once they start to get short of breath, it's really tough for them to really coordinate thoughts and really help themselves. So when they start to feel bad, they need to know to act quickly so that if they continue to decompensate, the help will be on the way for them quickly. Don't wait until it's too late for them. Make sure that their oxygen equipment, do they have a backup generator, or do they have some way of continuing to have oxygen if the power goes out? Are they just on a concentrator? That should make anybody nervous. Anytime a COPD patient, you know, comes out of the hospital, really you want to call them within that 48 to 72 hours of discharge, follow up on them. That's, they are so vulnerable in that time period. A, it's TCM. You absolutely should be there in that home within seven days. So many of them, again, they make mistakes in their medication. They're struggling. They're weak. Get out there, check their med reconciliation, see what they're doing, see how they feel, and go from there. And eventually, sometimes it just comes to that point where you do have to have the, we all have to have the hospice talk. And it's better to have that conversation early. Say, look, this is how, we want it to be a comfortable experience for you. Not that we think that you're necessarily dying right off the bat, but we want a comfortable experience for you. What can we do to make sure it's as comfortable as possible? What are your goals? What matters to you? How do you see yourself transitioning? You'd be amazed. Sometimes they have a thought or a plan themselves all figured out. Next slide. All right. Going back to the medications with COPD. Again, we have our short-acting beta agonist, along with the Ipertropium. And then we have our long-acting beta agonist. We have inhaled corticosteroids. So again, stepwise therapy, right? Take a screenshot, put it in your back pocket. We've all seen these inhalers and different combinations before, but it's really stepwise. Next slide. Continue. All right. So then here's a few other options with COPD. You know, azithromycin, with our COPD patients, this is where it gets a little tricky. There has been, in our area particularly, there's about 40% resistance to azithromycin. However, there's a bit of an anti-inflammatory component, it's thought, with it. So again, talk to your patient, see what works for them. And then, you know, make sure that you're a little bit more aggressive with your antibiotics in your COPD patients, because they really need to have that upfront care. And make sure, you know, if you need to, get them on the prednisone, get them on that corticosteroid. Make sure that they've got a plan for that, because again, we want to try to reduce it early. Don't let them get into trouble. Next slide. And always reposition them. When they slump down, a lot of times that can be part of it. If you reposition them, they breathe better, they're more comfortable, make sure their oxygen's on. That can happen too. And again, as their oxygen levels drop, you know, they just, they're hypoxic. They can't think, they don't know to recognize that sometimes. Make sure you've got airflow so they stay nice and cool. When they get hot, a lot of times, that's when they get into trouble. Have something for coughs so they don't start to struggle. The anxiety, if you can't breathe, you get very anxious. Then again, that starts the whole process where then they get worked up, they can't breathe very well. So be a little bit more liberal with your benzodiazepine and your morphine in this case. Because really, we're not changing the outcome. Eventually, it is going to come to that point. Make them comfortable. Ask them what they want to do. And if they've got, if they have CHF on top of this, or if they have any volume overload, make sure that they've got something to take that fluid off. Watch for it. You can get a combination of both illnesses happen at the same time. Next slide. There we go. All right. And then chronic kidney disease. So the first three, you know, we tend to get pretty aggressive and we try to use different medications. But in the back of our mind, we always have to think about that kidney disease and how is that going to affect our dosing. So we do, to help out those kidneys, we want to make sure we optimize our glycemic control and diabetes. We need to manage the hypertension, of course, so that way the poor kidneys get a break, stop smoking, weight loss, salt restriction. Okay. Make sure that we treat the hyperlipidemia with statins. Again, then that way we're not throwing, you know, those large globules of those poor kidneys and they're not having to filter such a, you know, thick environment, you know, and putting that strain on them. Make sure we manage the hyperphosphatemia with a phosphate binder. Treat their hyperparathyroidism with vitamin D supplement. Manage acidosis with sodium bicarbonate. Again, we talked about managing hypertension, you know, with the different options, particularly if they've got heart failure, manage their diabetes, their microalbuminemia, and make sure, you know, talk about their goals when it comes time to consider initiating and or even withdrawing dialysis. So these are all the things, you know, you kind of want to keep in mind. You know, again, I would screenshot it so that way you kind of always ask yourself, am I going through and addressing these issues? Next slide. So strategies for overcoming these challenges. Knowledge base. You know, these are really like kind of the same four conditions you're going to see over and over again. So you really want to try to become very skilled at them and getting comfortable with what you're going to do to manage them. So make sure, you know, if you don't feel comfortable with diabetes, for example, or insulin management, you know, work on it. Face it. Try to get better with it. Make sure you prepare before you go out to the house. Take a look at what they've been on. Kind of think about, well, what are my goals going to be if they're in mild heart failure or if they're having a bit of COPD or if their sugars haven't been well controlled and that A1C's climbed up to 10. You know, think about what you're going to do ahead of time. That kind of helps. Talk it over with your colleagues. Sometimes just talking it out, it's amazing how much you can learn that way. Make sure you use your software, your EHS software, to kind of keep abreast of notifications or when you want to recheck labs. That can sometimes be helpful to make reminders. Use smart phrases, voice recognition, so that way it takes some of the burden off of typing out each thing individually. I mean, if it's the same four diagnoses over and over again, often it's the same four kind of commentaries or statements that you're making to the patients over and over again. And if you do that, then you have enough time to sit down and say, what do you want to see? What do you want to achieve? What can we do to make you better? Where can, what can we do for you? And having that moment of time and moment in time to sit down with that patient, that makes all the difference, where you can just sit down, look at them, put the computer aside and, and just say, what, what can I do for you? And Megan, if I can just add one comment here real quick. I think one additional bullet point for overcoming challenges is developing relationships with a specialist or with specialists, right? We got the top four, we got CKD, we got diabetes, we got COPD and, and CHF. I can't, I don't know everything about all those diseases and I'm not a specialist, but yet often we function at almost like a, well, because the patients can't get out, we function almost like near a specialist level. So it'd be good to have that relationship with a specialist. So in addition to, you know, you talked about the heart failure recommendations. Yes, that came out, I think in April from the ACC, the four pillars, you know, be comfortable, you know, ARNI, ACEs, ARB, that's one pillar. You got your beta blockers, you got your MRAs and your SGLT2Is, right? Get comfortable with the medications, with the dosages and how they should be used. COPD is the same. Get used to the goal criteria and get used to the different inhalers. We got all common, all different kinds of combinations of LABA, LAMA, SAMA, IX, and all those things. Know kind of what's covered typically, so you don't run into a lot of headaches. You know, you order something and it's denied and so forth. And then diabetes, there's some overlap. There's more and more overlap with diabetes, especially with the SGLT2Is in heart failure, right? You know, and also for example, the Pagliflozin or Farxiga that can be used not only in heart failure, but also to reduce incidence of progression CKD. All that is to say, get comfortable with these meds, take some time, read up on some of the guidelines. And because, you know, I think, well, it's very interesting. We're doctors, we're like, we're providers, I should say. You know, we need to know these things. It's fun to see how things work. But also again, you know, patient depend on your knowledge to keep them safe, keep them healthy, keep them out of the emergency room. Yeah. Thank you, Dr. Cheng. Next slide. And the next one. Okay. And this is where Brianna is going to kind of go over some of the coding issues. Thanks, Megan. So I'm not going to spend too much time, but we wanted to give you some examples of proper ICD-10 diagnosis coding for each of the chronic conditions that Megan just went over. You know, many of you are continuing on to the advanced applications virtual course in July, and we'll spend a whole session on HCC coding, but HCC or hierarchical condition category coding looks at all of your patient's ICD-10 diagnosis codes within a 12-month calendar period and projects risk and healthcare costs. And it's really important for value-based care contracts, but also just any coding in general, you know, we're no longer in the time where you can just use the unspecified diagnosis code. ICD-10 guidelines have to be more specific. We've even started to see some payers outside of value-based care start to deny claims if you're using unspecified diagnosis codes as the primary diagnosis. So important to understand that for diabetes, you know, the E11.9 is everyone's favorite code that exists for ICD-10, but you have to code the complications. A diabetic patient who is having complications is so much more severe than a type 2, you know, unspecified controlled diabetes. So you identify the type, the control. Again, there is a whole plethora of diabetes codes for every complication that you could ever imagine. Look for the specified code, add it to your favorite list or add it to that patient's problem list if it's common for them so you don't have to look for it the second time. If the patient's on long-term use of insulin, there's an ICD-10 code for the actual medication and treatment that goes along with that. And if we go to the next slide, I've given you just some common examples of what those diabetic codes look like. So again, if your patient has a chronic condition with diabetes, you should also be using the appropriate diagnosis code to reflect the appropriate level of risk and what's really going on with the patient. Next slide. Heart failure. Again, if you're using just the heart failure unspecified code and not even a category from congestive heart failure, unspecified heart failure is not even an HCC code. It doesn't even carry that risk adjustment weight that we want to. We want to tell Medicare and tell other alternative payment models and payers how sick our patients are. You have to use the congestive heart failure code and you should be specifying the type as well as the acuity. Different ICD-10 codes for all of these different things. If we go to the next slide, again, I've given you some examples, lots of combination codes, lots of things that could be going on. You want to make sure you're capturing that appropriately. Next slide. COPD. Again, we have four things to think about. The type. Again, complications. If there's an exacerbation, make sure you're using that exacerbation code during that visit. Acute and chronic respiratory failure is actually a different ICD-10 code, but it does carry an HCC value. If your patient's having acute respiratory failure or acute and chronic respiratory failure, you should be coding that separately. Again, risk factors such as tobacco use and other treatment. All of these are things that exist. These are all from the ICD-10 guidelines. Those are online at CMSs. If you have coders or practice managers that are helping you with this, spend some time talking about common diagnoses with your team. What can you do? How can you optimize it? Again, add those specified codes to your favorite list. Your providers even know the importance of them capturing their complexity through diagnosis coding. The next slide, I've just given you some specific COPD examples. Again, making sure that you're coding that exacerbation when it occurs. Next slide. Megan, I don't know if you have any key takeaways you want to highlight. Sure. Again, plan, do, check, adjust. You want to try to do the best you can. Plan for what you can get accomplished. Sometimes it's not everything. Do what you can. Check to make sure to see if you're getting the results you were looking for. If you're not getting the results you look for, you adjust. We're not always going to get success on the first try. Sometimes it takes a lot of what's going on or what's causing the issues that make the patient worse. Or sometimes it's several things that we have to put into play to make them better. But always go back, revisit what can you do to make adjustments and start it all over again. Multimorbidity increases with age. It's not uncommon in our geriatric homebound patients. It definitely is a challenge to care for these patients. And each chronic disease likely affects another disease. And there's a lot of truth in that. It's really that game of Jenga. You take one piece out and you think that you're going to be okay. And sometimes it's not quite as easy as you think. Those four chronic diseases we just talked about, diabetes, congestive heart failure, chronic obstetric pulmonary disease, and chronic kidney disease, they are pretty much the pillars of most of our geriatric patient population. And make sure to keep in mind and get effective treatment strategies for these patients. Focus on the patient, not necessarily just the disease or the numbers. Ask them where they're comfortable. I know, again, we mentioned we don't necessarily need to push that hemoglobin A1 down to six, but do what works for the patient. Reduce their symptom burden, optimize their function, and we want to make sure the caregivers are supported. If you're asking unreasonable expectations on the caregivers, it won't work. So make sure you try to just keep it all in mind from a holistic standpoint. And that's it. Next slide. Questions. Make sure, again, look at your learning plan. If there's anything you have questions on from these four major medical conditions, write them down. That way you kind of have an idea. And we'll look back at it later. Thank you. Well, thank you. Thank you, Megan, for that awesome presentation. And it's time for us to meet Betty, our second case. Next slide, please. I'm not going to take a lot of time because we are a little bit behind in terms of our scheduling. Take a look at Betty in your workbook. I'll just give you a high-level overview. She's not that – she's a younger patient. She's a little bit older. She's not that – she's a younger patient. She is overweight. We're seeing her at home. She's got a lot of medical conditions. Again, take a minute to look at her history. And we're going to talk more about Betty tomorrow. She's got medical problems. She's got anxiety, depression, mental illness. She's got mobility issues. She has not left her basement for months. She can't make it up. It was a split-level house. She can't make it up six, seven steps because of weakness and lots of pain. And she's afraid. She's not been able to get to the primary care doctor. So here we are. We're seeing Betty at home. And thank you, Sarah. Betty can be found on page 29 of your workbook. Again, it gives a more extensive history and also a context of her condition at home. Again, just some things to keep in mind. The four Ms, right, even though she's not quite geriatric, but the complexity, we can use that model to help manage her complexity. What matters to her? What matters to the patient? What are the short and long-term goals? Okay. The other Ms is mentation. The story talks about her being depressed and anxious. What tools do you need to do an assessment for depression, anxiety, cognition, and so on? Mobility. Betty can't make it up the stairs. Oh, dear. I suspect that she's also at a fall risk. What can I do to help minimize that risk? Medication. You see Betty's list. They are huge. We need to do better in terms of getting rid of medications that are not necessary and or inappropriate or inappropriately dosed, right? As you put Betty together, as you look at that list, you kind of shake your head and say, what makes her so complex and challenging? What concerns do you have and what resources do you need to take care of Betty at home? I want you to keep those ideas in mind. Next slide. Okay. So thanks so much. Yeah, we can't wait to dig into those, a little more of those patient cases tomorrow when we do our house call simulation. But for now, we want to talk about managing those acute or urgent care issues that can come up in home-based primary care. So I'll turn it over to Megan, Brianna, and Lizzie. Great. All right. Acute and urgent care. So we want to make sure that we review common urgent medical issues that arrive when you walk into the house that you weren't expecting. How do you plan for and how do you prepare for those urgent scenarios as well as what's the way to implement and evaluate strategies so you can do it better next time if it happens again? And how do we use these acute and urgent issues to our advantage for continuous quality improvement? Next slide. So a typical urgent call might be chest pain, shortness of breath, I've got a fever, or hey, they're confused, they're not acting right. It could be a fall with an injury and they can't get up. Sometimes it's a mental health or psychosocial crisis. Next slide. All right. So there's kind of really two different ones. There's the regularly scheduled visit where you arrive, you're thinking this is just like a follow-up for their kidney disease, blood pressure, no problem. And you find they've got abnormal vital signs, confused, they're unaware of their sudden illness, they have no idea. So you have to triage the severity. Do they need 911? Can family help with transport if they're really that sick? And what are we going to do? Yes, we have talked a lot in this about how we are trying to avoid unnecessary ER visits. We're trying to avoid unnecessary hospitalizations. But the the key is if they're having what looks like a stroke, are they septic or are they complaining of chest pain? Call for help. Please don't don't stop and think about it. Don't question yourself. Just go ahead. You call the ambulance. Let that get sorted out. A lot of times these are really timed protocols. You know, the longer you spend trying to decide what are we going to do? Is family on board? In this case, if you haven't already discussed it, that's brain health right there. So make sure you've already kind of gone over these possibilities so that you can act ahead of time and be ready to go when you walk into it. Next slide. Resources that you can carry. Some people like to carry EKGs and do rhythm strips. They've gotten a lot easier over the years. There's things that can plug into your phone, you know, make it easier from a handheld standpoint. Of course, we have pulse oximetry. It's easy to carry that. Labs and x-ray gets a little bit more complicated. We have mobile x-ray in our area that can get you results back pretty quickly. But again, keep in mind if you're talking about somebody might be septic, you don't want to necessarily delay by trying to do outpatient labs, x-ray and delaying the timing of that if they're really confused and out of it. If their vital signs are comfortable and they seem to be tolerating their illness well, then you've got time. You can do that. Telemedicine. Make sure to utilize your telemedicine. If they call in and they're saying that they're that sick or they've got major problems, make sure you facilitate a telemedicine visit. Try to establish that right up front. Is this something I'm going to be able to take care of by walking into the house? Or am I still going to have to call an ambulance? Because you don't want them to struggle for the next two hours when you're going to have to call an ambulance because you can't manage it. And sometimes they're just physically too big. You can't pick them up off the ground. Next slide. Other urgent scenarios. What if it's the caregiver? And this happens. I mean, we see people in the emergency room who I can't stay. I can't be admitted. I have to go home and take care of my husband. He has Alzheimer's. He gets confused. He can't go anywhere else. You really want to make sure that you've established a plan for that caregiver. So if they have a crisis, they can get the help they need. Because if they die, what are you going to do then? It really becomes a problem. Sometimes there's progressive illnesses with increasing functional debility, the stressful nursing tasks, all the psychosocial issues that go with this. And then, of course, you've got mental health. It's a big strain. And if somebody already has some mental health issues, and to put that increased strain on them can be sometimes that last piece that kicks it over the edge. Next slide. And I'm going to have Lizzie kind of talk more about when that happens. Yeah, absolutely. Thank you so much. Nice to see you all. I'm hopping on. My name, again, is Lizzie Cummings, clinical social worker and manager over at Rush University Medical Center here in Chicago. I wanted to just acknowledge, and I'll do my best to be brief, from the acute and situations where there might be crises that come up. And it's situational and around mental health crises or psychosocial crises. So that's what I'll focus on. And I think it's really important to hold and structure and ground ourselves in what we see as this six-stage model of crisis intervention. First and foremost, it's so important for us to be able to sit in what the problem is. What are we going to be able to have control over and support someone around regarding their need or issue or concern? That could be, and where I typically come in, is around mental health aspects or serious psychosocial issues that are affecting their ability to complete day-to-day activities, et cetera. So define the problem. Make sure that our rapport is there, hopefully with your incredible relationships that you're creating and already have with your home-based primary care patients, that that rapport is there and they know that you are a resource to them to be able to support them. We want to be able to assess, see what's going on, ask those open-ended questions that we've already heard about today, ensure that there's empathy there, there's genuineness, and that we have that unconditional positive regard with whatever crisis or whatever urgent concern is happening. And then we want to be very clear and not jargony in being able to summarize the work that we are working on with them, that we are on the same page after utilizing our motivational interviewing skills of really getting to the needs of the patient. After that problem is defined, it's so important for us to ensure that they're safe. Are we needing to do an assessment around suicidality or homicidality? Are we needing to identify who is, and as we think about the previous slide with Megan, do we need to be mindful of the caregiver and ensure that we have all hands on deck as appropriate? Who do we need to have as continued supports if their normal support is not in place? But we do those assessments. We think about the importance of thinking about the plan that someone may have as we think about a suicidal ideation or homicidal ideation plan, method, intention to do so, and that we're very clear on those questions and that we know what we need to do in those moments when they do say yes. And when those things do happen, what does support look like? We need to make sure that the access to any particular means is out of the home, out of their reach, not available to them, and that they have a great support system in place or that we're able to put supports in place in order to support them. We want to always accept the patient as a person of value, communicate that we are there to support and we care about them and these next steps. We are offering our empathic skills. We are possibly helping with instrumental tasks and doing something for someone if that's part of the work that we're doing. And then we're providing education and all of this from an informational standpoint, providing that support. We think it's so important to understand the lay of the land and the alternatives that could be out there for our patients. What are potential solutions? Thinking from the person in front of us, what can we do in order to address the crisis or acute need that's there? Oftentimes in those moments, that ability to problem solve is out the window, right? Problem solving can be very difficult. So who can we get to support that individual as they go through that particular experience? So are there situational supports, people who might care what happens to the client? Do we have them on board and being able to assist? Do we have an understanding of what their potential coping mechanisms are? Do they have certain actions that they take in order to find comfort and support in those moments or behaviors that they do? Or different resources out in the environment around them that they can access in those moments when things are really, really hard. And then always thinking about those positive and constructive thinking patterns for individuals and being able to reframe, like cognitively reframe difficult emotions and thoughts that are coming in. Really, really important to think about what type of plan can we put in place as we come to that next step of ensuring that they know what to do when you're not there, when their treatment team is not there and that they know who to reach out to in those moments. We need to think about what their protective factors are, who they can communicate with, because they know they're looking forward to their grandson's graduation in a few weeks. And you're seeing and hearing those things from that individual, that they're saying they're incredibly religious and they couldn't do that in the eyes of God, that they are incredibly connected and have so much support that this just happens at times, that they do have these suicidal thoughts, or as just an example, and they know who they can reach out to and when we can develop that plan of who they reach out to in those moments. That we're restricting those potential means of how they would actually carry through with harming themselves or others. And then having a sense from the protective factor perspective of identifying some problem solving skills. And whether this is part of your role or part of a social worker's role, if you have that member of the care team or we identify additional support someplace to really think through this, I think it's overall really important to think about a structured way of thinking with crises that occur often or can occur often. Specifically with making plans, we want to be very concrete. As we know, problem solving and crisis and anyone in a crisis can be absolutely overwhelmed and not be able to take those steps. So is it in writing somewhere for them to access? Is it on an application with their phone that they can easily pull up and know that's a source of support? And I can go there and I know what steps I need to take in order to obtain that assistance. We want to make sure that things are realistic for them. What barriers do you think would come up with this plan that you have? Can we anticipate any of them and ensure that we work around those and identify ways in which that we can seek other sources of support in those times of need? And always centering around patient empowerment. What are they able to do for themselves? Do we need to involve anybody else in these conversations? And always striving for self-efficacy, empowerment in the work that we're doing. The last step is around just obtaining commitment, being able to summarize the plan that we're on the same page, that they feel supported, they feel that they have tangible next steps that they can access in those critical situations, that oftentimes it can be really helpful from the standpoint of someone needing to have something written down or in an app, like I mentioned, that somebody else can also hold for them if they feel that they need that additional support, but knowing that it can be in different spaces and platforms for them to easily access. But in all of this, when we talk about commitment, we need to understand that there is a sense that it's voluntary, that it's realistic, and we want to ensure that we're on the same page with the folks of what they do want for themselves in these moments of crises. I'll move to the next slide, please. To just really hit home the importance of a safety plan with individuals when we do have this, and when you think about the previous slide with Megan, you find that the caregiver is not able to care for the individual, and we have these things written down, a plan in place, so that in those moments there's no chaos or limited chaos for the folks and those around them. You make that concrete plan. We want to make sure that the individual knows the scope of your role or the role of the entire team and their availability, because we want them to know who to reach during off hours, that they know who to reach in moments on weekends, et cetera, where you may not be available. But it's clear-cut, transparent of who they can contact, whether that's hotlines that are available, going to local living rooms, wonderful structure for folks that don't want to go to the ED necessarily for mental health crisis, but they feel that they can go to this living room setup that we often have around our city and elsewhere. We want to be able to normalize what might happen if they access different emergency resources and crisis resources in the future, know what to anticipate so that there aren't any... I know we can't control or be mindful of everything, but whatever we can do to help ease somebody into that experience, we'd like to be able to do that. We always want to be mindful of vicarious trauma, always be able to reflect on your experience, see what you can do in order to acknowledge, this is the work that I've been able to do, this is what we were able to do together, and to be able to leave your work at the end of the day as best as you can and honor that time with your patients and also be able to step away appropriately as well and to engage in that self-care and those boundaries. We always want you to feel comfortable and engaging with your peers or your supervisors around and unpack those things as we know acute and critical situations that come up can be very taxing on your work and to know that you're not alone in all of those experiences. One of the last slides that I'll share is just around the value of connection on the next slide. Research indicates that people who have experienced various crises absolutely benefit from feeling safe, connected to others, calm, hopeful. We want to be able to transfer our sense of calm when we note that there's an acute crisis that's going on with someone, regardless of what that is. How are we as a provider able to transfer our sense of calm to the moment in order to be a great source of support for that person? We want to ensure that they have access to social, physical, emotional support that leads to a benefit for that individual experience that crisis, feeling able to help themselves, that they're able to take those next steps on their own as individuals within their communities, et cetera. You can read here, I won't read it due to time, but an incredible quote from Brene Brown of how important empathy is of just being with someone in the work that we're doing is so important in those moments of crises. Tangible in the last slide is you see here is a tool, several tools that you can utilize as any type of provider and for yourself as well in the need to ground in those moments where emotions are high. Do we need to have a conversation with our patients around deep breathing? Do we want to talk about a box breathing? Breathe in for four counts, hold for four counts, breathe out for four counts, hold for four counts. Do we want to be aware of our body noticing that I'm starting to feel really numb? I'm stepping outside of my body and to be able to tap my fingers on the table in front of me or my legs in front of me that I can press my feet gently into the floor to really bring myself back into my body. That's been really helpful in moments where crises come up. And then mindfulness, being able to describe what's going on around you, thinking about your five senses. I'm probably going to not hit this on the head, but just how you think, like, I can see, can you please tell me five things that you see around you? And they say, crayons, books, a phone, water, a table. Can you tell me three, you know, four things that you can touch? And they touch four things and they tell you four, three things that they can hear, two things that they can, et cetera, like you keep going. And that really brings someone back into their body as well. So just wanting to give you some tangible experiences that you can have for yourself, for your patients in front of you, regardless of what type of crisis might be coming up and encourage you to come up with your own. There are so many out there, but just wanted to give you a few. I'll pause there. Thank you, Lizzie. And if anyone has any questions, I encourage you to use the chat box. I'm going to chime in for a little bit about some operational strategies for acute and urgent care. We can go to the next slide. So we're going to talk more tomorrow specifically about geographic scheduling, but specific to the urgent visits, right? We are going to do our best to plan a geographic schedule with patients we think we need to see. But when those patients come home from the hospital or something urgent comes up, how are you going to try and proactively plan of that? So here are some strategies. Again, we want to hear from you all and learn from each other too. Please share in the chat if you have others or things that have worked well. Some practices will keep certain providers or even just throughout the week, the whole team, a few less appointments than is considered full so that they have that availability. Don't forget about telehealth. What may feel urgent to the patient, can you really assess them and decide if someone truly needs to be in person that day? Using your clinical staff, we call it the facilitated telehealth model, or maybe it's not the provider that goes to the home, but maybe it's even a paramedic, community health worker, medical assistant, nurse, someone else that's able to help the provider virtually get eyes on the patient and really assess what's going on. Daily huddles, even just quick touch bases with your team. Communication is so important. So if you're starting every day with kind of grounding your team, okay, here's the lay of the land today, here's where the provider's going to be, here's who had maybe some cancellations and might have some availability if someone calls and needs something urgent, or how are we going to handle that? Even when you're hiring, you know, thinking about what areas you need to serve and where your providers live in proximity to the patients they're going to be serving can sometimes be helpful. Again, and your payment arrangement is going to weigh into this too, you know, but your scheduling team, whoever's making the schedules, it needs to be a partnership between clinical and administrative leadership. What is a full schedule? How do you accommodate that through the week? You know, there's so many last-minute schedule changes. Many practices have found it to be effective to have a set scheduler or, you know, person on their team that's really

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