this. I don't recommend provider self-scheduling unless you have to, because there's just so much administrative burden that comes with it. If you're a solo provider starting on your own, yes, of course, you may be doing everything by yourself, but use your team. You can always review and make changes, and we'll talk about more specific tools tomorrow. Next slide. The other thing to think about is who's answering the phone and what happens with that urgent call. So, for example, in a previous office I worked in, we would have kind of even like a stoplight, you know, sheet for the administrative staff that was answering the phone of buzzwords that were always a direct transfer to the nurse so we could make sure the appropriate person is assessing that patient. You know, what does that process even look like in your office? You know, to make sure that you're not just scheduling and inconveniencing a provider if that really didn't need to happen. So, again, and then setting expectations with your patients as well. You know, there's other providers, even people like, you know, acute mobile urgent carers that may be able to get there urgently to see your patients if you are not. And then also thinking about if they have home health. This is why this is important to document it in the EMR if they have home health. Maybe if you can't get there, if the patient's active with home health, the home health nurse is probably more readily available to go out there, get eyes on the patients, and then call you with an assessment. So, again, thinking about your community resources and what the patient's full care team is and really deciding, you know, how you can get eyes on the patient and how you can help that. Next slide. We can also be proactive. Megan talked a little bit about this too, but how do we try and avoid those urgent scenarios before they happen? There's lots of different risk stratification tools out there. I know the AAFP has one. I know practices that have incorporated into their EMR or maybe it's just something that's done on the initial assessment where you're actually in your EMR documenting if the patient's a high, medium, or low acuity or low risk. And that's driving intervention. So, a higher acuity patient is going to have more frequent visits, more frequent touches by the clinical staff, maybe some telehealth visits mixed in, and then so on and so forth. And that is a decision by the provider that's made on the initial assessment and any time there's a change in their clinical condition. So, really being proactive too about the resources you're giving their patients. Everyone's getting the same care, but the patients that, you know, are in that TCM period or who are super vulnerable should be getting more of your time and resources. And, you know, you really should be personalizing those care plans. So, there's also very tactical operational strategies and clinical strategies that we can take to try and avoid those urgent needs. And again, that comes down to patient and caregiver education as well. How are we talking to the patient and family about what to do when they have an urgent need? And facilities as well can always be challenging to try and work with those assisted livings and others to call you rather than just sending the patient out. Next slide. So, Megan, any closing thoughts about the anticipate, educate, and encourage? Absolutely. You know, the biggest thing you can do to help yourself is to anticipate, you know, review your charts in advance, consider what equipment and supplies to bring. Please, this doesn't mean that you have to bring everything. It's not realistic. The more you're bringing, going back to safety, if you look like you're hauling, you know, the whole office with you, that does kind of make you look like an obvious target. So, sometimes, you know, just really the minimum. But on the same token, if you know that this is kind of an unstable patient or it's not a common, make sure you have what you need. Assess their potential decline. Conduct early discussions. I can't say that enough is to make sure you really are on the same page with the caregiver, the family, and that way, you've got a plan before a crisis occurs. The family has had a time to come to terms with what are they going to do. Are they going to be comfortable calling an ambulance if you need an ambulance? Or are they going to be comfortable saying, you know what, we've all talked about this, and we recognize that mom or dad wants to be at home comfortable. We're going to kind of go this route. And that's okay. If you don't have the conversation when you're doing it, when everybody's emotional, it doesn't go as well. Make sure you educate patients and caregivers. You know, communicate worrisome symptoms. That way, it gives them time to prepare. Again, you know, open communication, talking about things ahead of time makes so much more of a difference in how it's going to go than letting it be a surprise. The surprise never goes well. Encourage patients and their caregivers to practice these contingency plans. For example, if the oxygen's not working, do they know how to set up their backup tanks? These tanks are heavy. And you know, if the spouse is the one that's got the COPD, I'm pretty sure, you know, the husband will say, I'm pretty sure the wife is not really comfortable lugging out the 20-pound tank and disconnecting and reconnecting everything. So keep that in mind. You want to see them do it just like you would want to see them use an inhaler. Watch them switch out these tanks. Next slide. And you know, keep track of these calls. You know, how often are you getting calls where they're in crisis mode? Also, how often were you able to avoid them going back to the emergency department or having to be admitted? Even if it's just because you had a conversation and said, look, let's talk about a plan where maybe you don't necessarily go to the hospital. We know eventually what's going to happen. Do you want to stay home? Do you want to be comfortable? You can really save the family so much time at home. Don't be shy about these conversations. And if the family doesn't want to have the conversation or want to talk about it, that's reasonable. But most of them would appreciate that you take the time to sit down and say, look, let's talk about the realities of things. And then make sure to go over with your team. How did it go? I might think it went great, but maybe Lizzie's like, that was terrible. We did not get what we needed out of this. They didn't have success. So it's always important to kind of get that feedback. What do you think, Lizzie? What do you think, Brianna? Did it work out the way we expected? Because sometimes you can have two totally different viewpoints on how that situation went. And I may have been through it 15 times, but what if it's her first time? We need to talk about, this is maybe a normal thing. We could probably do better, but let's go over what are some of the ways we could improve it so we're all on the same page and we can all go home and sleep at night knowing we did the best thing possible for this person. So really, communication is one of the most important things. Please don't, what is that saying? It's better to ask for forgiveness. Go ahead and do it and ask for forgiveness later. I'm not really a fan of that. I find that usually if you kind of tell people what you're going to do, then they just say, okay. So please just communicate with them. All right. Next slide. And of course, this is the reimbursement portion. Get paid for what you're doing or you won't be doing it very long. So Brianna, I'll talk about that. Yeah. So just again, for many of us that are still in fee-for-service, you have to be paid when you spend extra time with the patients. You can't see as many patients as you can in the office setting. So don't forget there is prolonged services face-to-face as well as the non-face-to-face codes. This is when you're exceeding that E&M threshold by 30 minutes. Again, your documentation templates, you do need to understand from a compliance perspective, you must have start and stop times in addition to total time. And the medical record needs to describe why that was the extra effort and time spent with the patient, but get paid for it because established patient visit for 90 minutes, how often does that come up? Not all of your patients, but you definitely should be billing 99350 in addition to 99354, excuse me, if you're spending 90 minutes with an established patient. That's how I remind my providers. It's just the highest level service when you spend extra time and then describe it. And then the next slide, there is also the option of prolonged services non-face-to-face. Again, we've given you an coding resource that describes this in much more detail, but it has to be directly related to an E&M visit. This non-face-to-face time could have occurred before the visit, after the visit, or even on the same data service. Maybe you reviewed extensive medical records. Maybe it was a patient and family conference or extended time with the POA who wasn't present after the visit. Again, get paid for the work you're doing. Know about all the coding tools in your toolbox so that you can appropriately be paid for the care that you're providing and the time that you're actually spending with these patients and their families. Moving on. So some key takeaways that I'll just kind of summarize for the group. Again, nothing ever goes as planned, right? You have to prepare for these urgent scenarios. How can you use your team to proactively put strategies and operations in place to be successful? And then again, always taking that opportunity for shared learning and thinking about how you can try something different for the next time. All right. Thanks so much, Brianna. We're going to just go ahead and transition. I want to remind you, if you have questions or items you want to share, please use the chat. But let's dive into medication management and aligning that treatment with the specific needs of frail older adults. Dr. Chang. Thank you. We're going to do speed rounds here. We're going to try to make up a little time. I want to give Lizzie some extra time to, or as much time as possible to do her presentation. We're going to talk about, and I already briefly touched upon the four process that I go through in my mind as I teach the residents here. Reconcile, justify, optimize, and demonstrate. We're going to talk briefly about strategies for overcoming challenges in medication management in homebound patients and talk about some tools to help us with that. Just a slide. This is all nothing new or shocking to you. Our patients take a lot of pills. They have trouble with literacy, and a lot of them don't understand all the printed information that's given to them. Next slide, please. Just quickly here, you know, this is a real patient. We think sometimes, you know, the pill box is like the end-all cure-all, but as you can see here, it is not. There's some that are missing here. There's some that the pills are in between the boxes here. So this patient had terrible rheumatoid arthritis. She had vision problems. So the pill box is a tool, but it is not a perfect solution to some of the challenges that we face. Next slide, please. Just real quickly here, management, reconcile. Again, just go in believing that your list is probably not correct. I think that's probably a good place to start. Reconcile what's in the brown bag, in the pantry, in the bathroom, everything. What your list, try to get as accurate of a list as possible. So that's the first step. The second is justification. Is there a reason for this patient to be on this medication? All right, justify the need for the use of this particular medication. All right, if there's not a reason for the use, maybe you should discontinue it. Third is optimize. Again, I'm thinking mainly of liver and kidney. Different medications are dosed differently. I'm thinking mainly of kidney functions. Some are based on grant and clearance levels. The other is based on EGFR. Again, get comfortable using the apps that you have on your phone to calculate grant and clearance and also what medications. For example, metformin is a dose by GFR and not grant and clearance. And some antibiotics are dose based on grant and clearance and not EGFR. So learn about your medication, about the tools that you have. And the last is demonstration. Again, this is just a huge opportunity for you as a house call doc going into the patient's house. Show me, show me this, show me that. I gave you, I ordered a chamber for your spacer. Where is it? I see your chamber for your inhaler. I see the inhaler. Where's your spacer device? Show me the insulin. Show me how you give yourself insulin. Just real quick, I have a patient, I had a patient whose sugar was just wildly uncontrolled. So we went through all the steps of reconcile, justify, optimize and demonstrate what she was doing. What the daughter was doing wrong was she was giving the long acting insulin at using, she was giving the once a day, long acting insulin, but she was using the short acting. She was giving that at night and then the long acting insulin with the meals. So that's where the demonstration part is so important. Show me how you use your inhaler. Your COPD patients may not need another inhaler, but they just simply need to be shown how to properly use their inhaled medication. Next slide, please. Review the medications at home. Again, it gives you a huge advantage and insight into medication adherence, any barriers to use and a completeness of your list. Do resist the tendency. Megan talked about we have all these medical conditions, but reduce the tendency to write another prescription. You're short of breath or something. Try to not to do that. Do deprescribing as much as you can. Again, review the medication. Are they appropriate? Are they beneficial? Align the medication with the patient's goals of care. If the patient has advanced dementia, they're going on to hospice. Maybe the donepezil can be weaned off and maybe the statin can be discontinued. Next slide, please. This is just a case you can read. It's kind of a funny case. So when you have time, I encourage you to read about that. It has a kind of a cute ending at the end. Next slide, please. There are just some tools here. The bearish criteria regarding potentially harmful medications. There is the start and stop tool that people have used to either appropriately use, that's the start, and then what's necessary to discontinue an inappropriate or potentially harmful medication. That's the stop side. All right? I don't memorize that equation anymore. It's on my smartphone, right? Thank goodness for electronics that can help me so I don't have to take out my pencil and do division. I don't think I can do that anymore. Next slide, please. This is just a workflow for medication management. Again, read through that. You may want to modify it for your team and with the staffing that you have within your office to make sure that the medications are refilled at appropriate time and that the phone calls are kept to a minimum. Next slide, please. Brianna, did you want to quickly talk about the meat of documentation and how it relates, maybe not so much to fee-for-service, but under a value-based and ACC score? Yeah. So, I mean, quality documentation is important regardless of the payment model. And so, when we think about your assessment and plan, trying to avoid being too brief. Trying to avoid being too brief. If you're coding an ICD-10 diagnosis code, it needs to be documented and supported that you consider that diagnosis or you meaningfully assessed it. So, the acronym that is used in ACC is called MEAT. So, it stands for Monitor, Evaluate, Assess, and Address, and Treat. So, again, not just saying hypertension, continue all medications or continue current plan, CPM. Those are things that would come up in audit findings. Again, what medication, what dose? Can I tell by looking at your documentation if that problem was stable or exacerbated? And what are you telling them to do in the meantime? How are they proactively managing it? All of those types of details and specifics should make it into your documentation. Next slide. Paul, do you want to summarize? Yep, I'm muted. Here we go. Just keep in mind, be cognizant. BactrimDS may not be the right dose for your patients. Our patients' age, the physiology change, consider the appropriate dosing and the risk related to polypharmacy. Again, try to deprescribe if at all possible. Do a thorough medication reconciliation and determine if there's any indication for the use of this medication or can we try stopping it and so forth. And use tools. Again, it's great to have electronics. You can show the family member, hey, you know, I know you love your Unisom and your Tylenol PM for your sleep, but can we just talk about this? This is not Dr. Chang dreaming or wanting to get into an argument with you, but look at, you know, it's on the bears list. Let's talk about that. Does it work for you? Can we try something else? Having some data to back up your comments can be helpful as you engage in sometimes could be difficult conversation because our patients are, they're kind of very attached to the medication sometimes. Next slide, please. All right. Lizzie, turn it over to you. Thank you so much. All right, everyone. Quick stretch. We're going to keep going. I'm really wanting to focus on managing mental health conditions in our populations. It's so important and hopefully what you'll hear today and what I'm talking about is recognizing the impact of mental health in our communities and their needs, developing understanding of the key elements of trauma-informed care. I'm pretty sure what I'm going to say today is not going to be things that are necessarily new to you, but a good reminder of things that you need to be able to take from here and continue to implement in your work. And then of course, providing tangible ways of being with patients to support their mental health needs in those moments. With mentation in this next slide of the importance of focusing on this aspect of the age-friendly health systems, knowing that our goal is to prevent, identify, treat, and manage dementia, depression, and delirium across settings of care. And my focus will be around the mental health aspect of mentation or mind, as we often refer to this particular M, if we want to say that. And my colleague, Erin Emery Tabersio, she's a geropsychologist at Rush. She shared with me some of these slides, so I want to acknowledge her incredible work that she's been doing, but really pulls out how we incorporate our forums into the primary care setting. And I'm going to focus on the last row in each of these next, this slide and the next, but we talk about from the mentation slide or mentation slide, the mentation aspect that we want to be able to do screeners to identify where someone is and how they're coming into the space. Possibly doing this right at the beginning of your work with them to establish a baseline and see if there are things that have changed over time. But you see, of course, PHQ-9, doing the MINICOG, the MMSC, the MOCA or Montreal Cognitive Assessment. Those are some things that we can screeners and tools that we can utilize to get an understanding of how someone is presenting from a mentation standpoint. We know that in order to, after receiving the results of those particular assessments and tools that we can either do a behavioral health referral out in our communities, we could refer to social work if you have that social worker as part of your group, and then really thinking about when you don't have them, who is in your community to be able to help and connect to the appropriate resources and supports, and how can you incorporate the caregiver in all of that too. In the next slide, you'll see just from the behavioral healthcare perspective, digging a little bit deeper around, assessing around depression, dementia, suicide risk, I know I talked about that in the last module, anxiety, really wanting to explore alcohol and drug use, and if that's increased, decreased, if that's shifting for folks as they age, despite not changing the frequency or amount they're drinking or using, social determinants of health, caregiver needs, all of those things are appropriately assessed, and I would say that those are also done very much so from the primary care perspective, but in behavioral health settings, we of course do those evidence-based treatment plans, doing digging and doing those cognitive assessments in more detail and referring from the community perspective. Just wanting to throw that out there as tangible pieces that we need to consider as we're grounded in our work in the homes of those we're working with, of what we can do to really establish an understanding of where they might be in that moment from a mental health and mentation perspective. So who are your allies? In this next slide, I understand that having a social worker in your court may not always be a possibility, and we know that if you do have a social worker, they are able to provide homebound patients with resources for video visits with, say, a therapist or psychiatrist. I understand there can be a massive wait list, but trying to figure out who is in our corner in these respective areas in your communities. Social workers provide support through regular phone calls and outreach, even if they're not doing it just with every appointment that the patient might have, but they can provide brief bedside, short-term therapy with individuals, really working through feelings of isolation, working with feelings of despair that someone might be experiencing, as often being very much homebound and not able to get out and access more support and connection with others. A social worker can also work with patients over the phone or during home visits on coping strategies, being able to figure out how best to manage their symptoms, being able to work through any sort of adjustments that they've had in their life, depression, anxiety. As you all know, we understand that our patients come to us due to medical issues as a primary concern, but I would say a really good number of individuals that we work with do have anxiety adjustment issues and depression connected to their medical issues. They feel like their bodies are failing them, they're dealing with grief in so many different ways, managing family conflict. I can only imagine the family dynamics you all walk through and see in person in the homes of others, and loneliness and isolation and fear are all huge pieces of things that we acknowledge. So we as social workers do talk regularly about those symptoms that are related to these and exploring different coping strategies. We want you to make sure that you do have a really good understanding of who your partners are. I have an image in my mind, if you all are familiar with eco maps of being able to understand you in the center, your particular, and I'll speak from Rush. Rush at home, and we have this organization, and it's so important for us to identify who our really good partners are out there and speaking of mental health related partners, these are our go-to organizations and clinics that we refer to from a psychiatry standpoint, dedicating time to understanding your relationship, whether it's a great one, not so great one, an opportunity for growth, to really create more relationship and understand how can we whittle down that wait list? Who else can we access? And having a good understanding of who in our communities can be resources for our patients. Wanting to really acknowledge that. So I encourage you all to, if you haven't already, to really jot down an eco map with you at the center and your program at the center and who your wonderful partners are that you can rely on and create that whole person care for that individual and your patients at large. So I'm gonna jump into the next few slides and go over fairly quickly as I'd like to get to some of the trauma-informed care pieces of things. But we understand, we routine routinely assess all of these particular areas, right? It's so important to get a good understanding of how people engage day-to-day, how people are feeling day-to-day and if their basic needs are met and what they might be missing and where they might need support. So all of these things are things that you acknowledge each and every day, but speak to limitation in mind as we think about age-friendly health systems. From the depression standpoint, we understand that there's a unique presentation later in life for older adults. We do know that oftentimes they don't talk about their symptoms related to depression. It's often anhedonia or inability to feel pleasure. They have difficulty sleeping, fatigue, slowing down, feeling a sense of hopelessness. They have physical pain, aches and memory problems that come up as it relates to depression. We also unfortunately understand that, and you'll see in the next slide, I think we can just move on to that, but suicide among older adults is very lethal. Often happens from white males over the age of 85 and that 85 to 90% of older adults who die by suicide did have a major mental illness. And I think it's just really jarring and important for us to always be able to assess and acknowledge when that might be present for your patient. It's an incredible stark difference between older adults and younger adults in completion of suicide, and between one and four and one in 25 for each respective population. And we need to be wary of risk factors, right? Has there been a massive change in their health status or a big change that really does affect the individual and the family members? Are they experiencing grief? Did someone in their life pass away? Did a huge status change where they're grieving the loss of an ability to do something? They lack purpose. Are you feeling, are they sharing with you those feelings of feeling a lack of purpose or meaning? Increasing cognitive impairment or dementia, isolation, all of those things contribute to higher numbers of attempting suicide and ultimately completing. Substance use is really important for us we wanna make sure that you're never assuming anything about older adult substance use. There's going eventually, as we eventually turn to the next page, but there's gonna be a video that we won't watch, but I encourage you to watch on your own time, but I'll do my best to summarize what those things are. We know that physiological changes with normal aging, that really affects, and I said it earlier, but everybody has their two glasses of wine every day, then they become an older adult, and that affects them and their metabolism different. I'm a social worker, I'm not a medical provider, so I don't know what I'm talking about in that regard. I know you all do, but it just, we need to be aware of, they may not think that anything has changed, but it really is affecting their body differently and affecting them completely that we need to be attuned to. We need to be mindful of the interactions of medications, from Dr. Chang's perspective of what he just went over. How is that impacting their medication regimen? And then how are they using or misusing medications, whether that's intentional or not? I know that comes up quite frequently. To just say a little bit more before we go to the next page, we know that typically it's alcohol, it's prescription and non-prescription drugs, and nicotine as abused substances that we're seeing with our older adults, and that we have these exacerbations that come up that I don't think are a surprise to anyone, but it's really important to be mindful of when you are noticing that these potential concerns are arising in your family or your family, with your patients, excuse me. Next slide, please. So I mentioned earlier in that table, but you're noticing or you're aware of cognitive impairment, we want you to make sure that you are identifying where they may be in a particular screen, but we know that's not diagnostic. We want you to be able to refer for neuropsychology, getting a sense of further cognitive evaluation of what might be going on, referring to specialty care, et cetera. Identify a caregiver or a potential for a caregiver. You're starting to notice that you're coming into the home and the oven has been left on and you don't know for how long, and we need to make sure to bolster the additional support for that individual, whether it's family support, friend support, structured support from the community or other resources that are available. We know our colleagues are gonna talk about that tomorrow too. And always being able to keep in mind if a caregiver is involved, that we are being attuned to their needs and referring out as appropriate to whatever might be available in that community and something else you can put on your eco map of good referral sources for your caregivers. So considerations, we wanna think about one's cognition and their overall health status as we think about things from a mental health perspective. We also really need to be mindful of race, ethnicity, religion, cultural, sexual orientation as it pertains to mental health. Do we have our level of cultural humility that we all want to embody and ensure that we are providing open, genuine, unconditional, positive regard, support to the individual and getting an understanding of how this plays out in their day-to-day life and how we can support them and all while keeping in mind their culture, their religion, how they present themselves. Very, very important to consider. Next slide, please. You'll see just very briefly screening tools validated with older adults. I'm sure you all are very much familiar with this and I'll just speak to some of the last column that you see is just a few more acronyms and I wanna make sure people understand what they are, but the audit or the Audit C, those are assessing frequency and quantity of alcohol use. You understand that the CUDIT are Cannabis Use Disorder Test is what that one is. And then SAMI is the Senior Alcohol Misuse Indicator if that's helpful. We also understand the MAST or the SMAST is the Michigan Alcohol Screening Test and it's a shorter version for SMAST, but options if you aren't already familiar with these to be able to utilize to really get a sense of what might be going on for you to identify what to do next. All right, so I would love to really normalize the fact that, and I do wanna be clear, I am talking quite a bit about older adults. I understand that that's not just your population. You work often with individuals who aren't technically older adults, but many of our patients are. And it's so important for us all to really recognize the fact that depression, other mental health symptoms are not just a normal part of aging. It's so important to be mindful of the whole picture of what, as we think about age-friendly health systems too, what matters to the individuals? What's most important to them? Are we working toward goals to get them to where they'd like to be if they're able to do that based on the complexity they have? And it's so important for us to be mindful and not be myopic in thinking of the fact that many people, so many people just think, oh, as you get older, you just typically become depressed, et cetera. We wanna make sure that we are acting on those things to address and improve the lives of those we're serving. We also know that mental health and emotional health are very important for older adults, and it's really important to consider it from the perspective of discrimination with individuals. Are we ensuring that their needs are being met, that there are no concerns around discrimination in their lives and how they're engaging with others, that they're participating in meaningful activities, that they're creating that connection and support and relationship with others, that their physical health is to the best of their ability and they have the aids that they might need in order to get from one place to the other or independently if possible, and that we're also addressing poverty too. And are we able to get additional supports in place to step out of poverty if at all possible? Just in general, this has been shared widely, I think, but the spectrum of mental health care, and we understand from one side to the next that you get a sense of somebody who is functioning from a healthy perspective. It's their normal baseline, and then they get to a reactionary period, right? That you might come into a space and they're different. Something is up, increase in worrying, increase in procrastination or forgetfulness, they're impatient. That's where we wanna make sure that we're talking around what they might be doing to create a sense of support, connecting with others, providing, checking in with themselves from self-care perspective, and then making sure that we're connecting folks to professional care, behavioral health supports, et cetera, if they're moving into the injured and then ill areas, which you can see much more detail around symptoms when it gets to that point. So just a nice visual of where we might find someone on the spectrum and where we can seek support and what we need to support someone with in those moments. So stress, we know that we all experience stress. Stress can be healthy too, right? It allows us to make decisions in a split second to know what we need to do in order to protect ourselves and that we all experience this in our daily life. And we do also know that stress can have a long-term impact on our health. So we wanna make sure that we're being mindful of the stressful periods that our patients are going through if we're noticing that it's chronic, if we're noticing that it's a traumatic stress where they might experience a specific event or just a compounding of traumatic experiences that are affecting their stress levels and what we can do about it. You see some examples of stress here, but I'd like to go to the next slide just to really think about from a physiological perspective. When that stress happens, whether it's a moment or something happens to the individual, what happens physiologically, you will know this. I'm assuming that most of you are aware of all of these things, but your body lights up. You've got that increased heart rate. It gives you a chance to be able to flee in those moments. It gives you a chance to get that boost and work at your maximum power in order to make those decisions. And then you realize that you're able to calm yourself. You're able to calm down and that danger is over. The relaxation takes place. But when somebody is experiencing stressful situation after stressful situation or experiencing great levels of trauma, there is no relaxation. We know that their immune system is weakened and that affects ultimately their physical health and wellbeing and brings us to what you all are doing each and every day. It's really important for us to make sure that we are addressing the stress and the sources of stress for individuals as much as we can or referring out in those moments and to be able to have someone make, don't feel as though that the danger is over, that they have the tools that they need in order to find that, to get that support is so, so important. With trauma, as we move on, we understand that it's anything that overwhelms our ability to cope. I've heard in a few different spaces, it's too much, too fast or too little for too long. That came from Women Care Institute, if anyone's familiar with that organization up in Evanston. And then I've also heard in other circles, trauma that's not transformed is transmitted. What can we do in order to transform someone's experience of trauma or how can we address those pieces? We also want to come from the perspective of not necessarily treating the trauma itself, but the effects of the trauma and knowing who to connect with when, if you don't have a social worker involved or feeling as though you needing to step out into your communities to find those sources of support. We know that complex trauma occurs when multiple traumatic experiences occur over time. They can often be developmental in nature. If we want to go into a little bit more detail with the trauma that you might be seeing in your appointments, it could be sustained abuse, abandonment from a caregiver. It can be systemic, absolutely. Institutional, I'll talk about that a little bit more today. And we know it alters our sense of time. It's really, really complex and truly affects the individual from a whole person perspective. Thinking about trauma in the context of a patient's experience is trauma-informed care. And we want to make sure that we embody that in each and every engagement that we have with the individual and it allows us to have a deeper connection to our patients ultimately. So we want to think about trauma from the three E's perspective, event, experience and effects. Is an individual trauma, and I'll just say this, results from an event, a series of events or a set of circumstances that is experienced by an individual is physically or emotionally harmful or life-threatening and that is lasting adverse effects on the individual's functioning and mental, physical, social, emotional and spiritual wellbeing. We want to make sure that we are taking into consideration the event or what has occurred, what their experience of it is and how it's affecting them day to day. We also understand the research that has come out from adverse childhood experiences and knowing that it absolutely affects the future health status of our individuals we're working with. And if it's not, and those pieces are not addressed, how it can compound and lead to bad health outcomes in later years. And so what can we do about that? So important for us to be attuned to what is coming up for the individual, have they shared that they've experienced and score positively on these different types of ACEs? What are they getting support around? Are they talking with someone about it? Are they going into detail and being able to connect around and unpack what's happened over their life and how it's impacting them to this day? Really interesting stuff, research that came out from children being born of parents who had high numbers of ACEs, that they have had, the children were preterm birth, they were premature, that they had low birth weight often and that it affected their overall health status as a child as well. So this just further emphasizes how important it is to be mindful of and experience individuals as we engage with them, knowing that everybody that we walk across and engage with could have a trauma and what are we doing to support them through that in the work that we're doing and who are we connecting them to? From the marginalization and oppression piece of trauma, we understand that equity and trauma go hand in hand. Equity targets the most vulnerable groups who have been and often continue to be marginalized and oppressed and we wanted to bring awareness to that. We know that we see so many acts of racism, sexism, ableism, all of these isms that are really important to be attuned to in our own programs and to see if we need to be connecting them to additional resources and supports or adjusting any sort of policies and protocols of what we're doing to ensure that we're not compound, we're not being a part of this. But we know that many individuals that we engage with day-to-day are often marginalized and oppressed even to this day, which is just terrible. And we need to take action around it. From the root causes standpoint of trauma, it's we understand that there's a level of community trauma, adverse community environments, minor communities are at higher risk of these adverse community events that you can see here, the poor, unaffordable housing, no access to housing, difficulty being able to make ends meet, disruption within the community itself or a lack of economic mobility, violence, we see violence so often these days and discrimination. How are we able to affect effectively support someone around these things? How are we able to do something from an organizational standpoint and turn things around or be part of that change? So manifestations of trauma, I've got a few more slides and we'll do my best to keep going, but how does trauma show up? How are we going to be seeing this? And how do you all already see these things in the patients that you're working with? We see it within their emotions, right? You see liability or change in mood, depression, they might be irritable or angry with you from the physiological standpoint, knowing that they're elevated from their baseline, that they're on edge, they're reporting difficulty sleep, memory, they might experience intense emotion without memory of an event, they might remember the event, but also feeling very numb and disconnected in those moments, that's a really good trigger that there might be some trauma they've experienced. And then cognition, their view of the world changes. They no longer feel safe in situations where they may have felt safe in the past. Those are where trauma shows up that we can see very clearly in our interventions. So what can we do? We wanna make sure that we're doing all of this in our work, grounding ourselves in the being able to understand and respond to the impact of trauma, the effects of trauma, emphasize the safety from an emotional perspective, from a psychological and physical perspective. And then always make sure that we give that individual we're working with a sense of control and empowerment in those moments. And always wanting to consider it as a lens or as a universal precaution. Everyone that we work with potentially has experienced a trauma and it could be affecting them in many different ways. And it's important for us to be attuned to that. There are four R's in trauma-informed care. This came from SAMHSA, but we as providers need to realize the widespread impact of trauma, the ability to understand and know the realization of that impact of trauma is critical. And then we need to be able to recognize the different signs and symptoms that come up that we can be attuned to and address in those moments and connect to proper supports. We wanna make sure that we respond by providing education, integrating knowledge into practice, shifting any policies that we see that might not be helping individuals from traumatic experiences. And then do our best to resist retraumatization. You guys have developed incredible relationships with your patients and that rapport is there. And we also know that oftentimes we might overstep or go too far or say something that is completely triggering or upsetting to someone where that wasn't our intention, but the impact was that it was really upsetting and it may be a retraumatization. I think it's really important for us to do our best to acknowledge, to take a step back and make sure that the person feels comfortable in talking things through of what just happened there, the potential rupture between the two of you. But to be able to do our best to resist retraumatization and support that person fully in our work. Some tangible principles that came out of SAMHSA as well, what we can do in our interventions itself is around safety, choice, empowerment, trustworthiness and collaboration. Safety, do they feel comfortable in their home and where you're working with them? Also thinking about cultural safety, that they don't ever have to feel challenged about the person who they are, that we completely accept them for who they are and are eager to learn more about what they bring to the table. Acknowledge intersectional identities and that you yourself could unknowingly cause harm. We want to make sure that the patient knows that they have choice. If they don't want you there, if they don't want to opt into that care, they can opt out of any point. I don't know if you all have specific examples of when that might not be the case, but hopefully they always do have that option of being able to step away if they feel that that's safe for them. Empowerment, valuing the client's voice, it's so important and validating their experience. They're going to be that expert in their story. We never want to challenge their truth, whether or not we know that that truth is a truth, but always validating their experiences. And then trustworthiness, we want to be transparent, we want to be consistent, we want to offer good customer service in all that we're doing and maintaining professional boundaries, because we know that many of the folks that we're working with can truly go through so much and you want to potentially step over those professional boundaries and to just check yourself in those moments of what makes the most sense for you and your organization and for the patient ultimately. We know boundaries can be really healthy and really good for our patients. And ultimately through collaboration, be aware of staff to client power differential and how that could be impacting someone who's gone through a significant trauma. All right, so I am going to keep going a little bit more. I think that it just some tangible things to do about inquiring about trauma with somebody that you're working with. We want you to practice with those before you jump in or as you're continuing to jump in to develop a level of comfort and being able to explore things with the individual and consider your own potential traumas, your own potential triggers and seeking support around those as well. And then always assure that the privacy is there, that clients know that any disclosures will remain in confidence as long as there are no concerns about harming anybody else or abuse, neglect, et cetera. So we want to be able to acknowledge in this next slide to thank the client for their disclosure. Thank you for sharing that information with me. We want to validate, empathize and show support. I can imagine this has been really difficult for you. I'm sorry this happened to you. We never want to say, let's move on. Try to move on. That's been so many years ago. Look at where you are. Try not to think about it relating to the story. I know that that could so easily slip. I've been through something like this or it's just think about your boundaries there if it's appropriate or not. And then try to match clients' feelings about disclosure. Body language, if they're closed off or their emotions are displayed, try an empathic nod, be really mindful of cultural differences and eye contact, et cetera. What makes the most sense for the individual and how you present yourself in those spaces too. In addition, we want to make sure that you're, of course, being attuned to their needs, saying you're not alone. Listen actively. We want you to make sure that you're sharing with them that we're here to provide some assistance. We want to connect you with the right resources and support and inform them of those things and think about those coping strategies and what you can hand off. And then of course, providing those resources as appropriate. We also want to be mindful of the containment and grounding aspect of trauma and what we need to do in this small amount of time that you have with patients. We don't want to open up at the last, you know, five minutes of your time with them to be able to contain that and ensure that you're not opening up the can of worms and not able to provide support after you've left, right? So you may want to pause, resume another time. We want to make sure that those grounding techniques that I talked about earlier could be a good thing to have them hold onto and utilize after you're done working with them. And then reinforce what they've already done and shared with you about coping techniques and how they can use them moving forward and what's been helpful to them in the past. We want to, of course, ask for permission. This is, you know, making sure this is coming from them, that they have control over those situations. Would you be okay if I connected with you to supports or connected you to supports? Is there someone trusted in your life? Key word, trust. We want to really emphasize that as things go on, who you can call on. I know that I'm not always able to be here. And then from the sharing perspective, we want you to just have this and embody the need to know basis. We don't need to talk about this in detail in documentation. We don't need to share all of these details necessarily in IDT meetings, et cetera. It's important for us to think about how much should be documented here, what is the impact of that documentation and what I'm sharing with others and what absolutely needs to be stated with my care team. You could say just very, very simply, there are stressful events that still impact the client today. All right. So in the last couple of slides, I'd like to end on a high note of just how resilient those that we work with and those around us are and what we can do to really, you know, emphasize resiliency in the work that we do. It's the process of adapting well in the face of adversity, trauma, threats, or significant sources of stress. It means bouncing back from difficult emotions. We know that. And it's the ability to cope and being able to deal effectively with something that's difficult. So we want to do our best to support individuals and emphasize that your resiliency cup does not, you know, it does not remain empty. It's not something someone is born with. It's something that can be nurtured and fostered and built on in the work that you're doing with folks. How can we seek resiliency? Many, many factors in resilience. And that most importantly, it's about caring and supportive relationships. How can we strive to connect our individuals to those potential relationships, whether it's family, friends, community members, somebody who's connected through a mobile device that they can access easily, and also being able to have the capacity and create that capacity to make realistic plans and take those steps to carrying them out. That really builds resiliency. What can they do to take those next steps? And what do they want to do to move forward around this particular thing that's going on? That they have a positive view of themselves, that they have the confidence, that they're able to take those next steps, that they have strengths and abilities, wanting to have those conversations about what their strengths are, to pull them out and evoke from within, having skills in communication and problem solving. Are we able to really talk about and share with them, like you did this, you were able to take these next steps, which got you to where you are at this point around this need, that's incredible work. And then the capacity to manage strong feelings and impulses that we're able to with our patients, that they feel as though they can have the appropriate coping strategies in order to manage those impulses and high energy emotions that could really set things off and where we think that resilience really comes in. So I really urge you all to really think about resiliency in your patients and examples of what those might be, because it's so important for us to strive for that so that they feel that they can climb out of those moments of darkness, that they are able to take action and take those steps needed in order to support themselves from a mental health perspective, with the help of any sort of resources and supports we can provide them in our communities or within our treatment team. The last thing I'll leave you with is work that Erin Emery Tabersio and Robin Golden have been doing a lot of really wonderful work over at Rush through Catch On. It's our geriatric workforce enhancement program, as well as the E4 Center. It's a center of excellence for behavioral health disparities and aging that I encourage you all to access if you'd like more information around these things. And I'll just leave it with takeaways. We know that they can really affect all of us, the stress, trauma, mental health. It's important that our teams are absolutely aware of that impact on patients and their connection to physical health. So remember, everyone can be resilient. They are resilient. We wanna treat everyone as though they've experienced a trauma, and we ultimately want to emphasize that you are not alone in holding something for our patients, that you have the support of those around you in order to really be able to provide a holistic care to the individual, and that you can rely on the support of your colleagues in doing so. So thank you for your time. Lizzie, thank you so much. We're gonna be going to break in just a minute, but first I have a couple of things I just wanna say. First and foremost, I wanna thank our Rush social work team, our partners here in the Chicago area. It's been wonderful to have you share your thoughts and expertise with our group today, Lizzie, and we look forward to hearing from two other members of your team tomorrow. So that's a great add-on. And I want everybody to remember, I mean, our partner Rush has the ability to have social workers as part of our team, but we're very sensitive to the fact that not every house call program can do that. And so that's why the guidance that Lizzie shared with you just now, we really hope that kind of arms you with some tips and tricks for you to be able to attend to some of those mental health conditions for your homebound patients, or at least be thinking about how you might be able to partner with a social worker so you can make sure that those needs are getting met. So thank you very much. The other thought that I had is, the concept of resilience and coping with stresses and everything, that's not limited to your patients, right? I mean, that's a big concern in your program for the people that work with you, because this is not an easy job. And so at the end of today, we're gonna be spending some time talking about that. Amanda has some great insights that she shares. So that's our last session of today. But for now, I wanna leave you, we're gonna take a 10 minute break. We are still just a tiny bit behind, but we are catching up. So we'll come back, it's about 3.12. Please plan to come back before 3.25. We'll try to get started about 3.23, something like that central time. All right, thank you very much. Thank you. All right, so we are in the homestretch for day one. I know this is a long day for everybody, but thanks for hanging in there with us. I'm pleased to now turn it over to Brianna Plentsner, who's gonna cover some important information to help you get paid for what you're doing, right? Because we know that this is mission oriented work, but you need to be paid in order to sustain your practice and be able to serve more patients. So Brianna, why don't you take it away? Thanks, Melissa, and thanks everybody. So, all right, hopefully you got your stretch in. We're going into a coding talk in late afternoon, which is always interesting. So it'll make this as entertaining as possible. So we can advance to the next slide. Just a quick disclaimer. Again, everything I'm gonna talk about, I only talk about published Medicare guidelines, your organization, especially if you're part of a larger one. There's a lot of gray area in Medicare may have more specific policies. Also important to understand when there is gray, a lot of time your local MAC, it's called, Medicare Administrative Contractor, may have more specific policies. So I don't tell you anything that's not backed up by documentation and coding policies at the federal level, but important to understand the nuances. Next slide, please. So we're gonna talk about some red risks and red flags from a coding perspective. We're gonna spend the first half of the session really talking about your E&M because that's your bread and butter. What needs to be documented from your home and your domiciliary code perspective? How are you making sure you're not undercoding? Because usually, honestly, that's the case with complex patients. And then we're also gonna talk about CCM, RPM, and some other ways that you can use and some other ways to optimize revenue. We can move to the next slide. So some golden rules. I actually don't like the way the first one is worded. So you've probably heard throughout your career, if it wasn't documented, it doesn't count. I would change that to, it can't be validated. I can't back it up. Again, in the event of an audit, if you didn't tell me it, I am only looking at the EMR. I'm only looking at that piece of paper. So that patient needs to look as sick in their medical record, and I need to understand everything that you actually did in order for you to compliantly get paid for it. Also really important when we're working with partners, that they understand a clear medical picture of the patient. And then like Jennifer talked about earlier, how do we balance efficiency? Where do you need that documentation? And where can we take away clicks and avoid that overpopulation of templates? More words does not equal better documentation. We can be mindful and strategic in where we spend our time. The practice of cloning is known when two, let's say two progress notes or two different visits within the medical record look exactly the same or very similar to previous encounters. A MAC can actually deny claims for cloning. It threatens the integrity of the record. So there's certain, you know, carry forward and practices that we can use for certain history elements, but each visit truly needs to be documented. I'll give you an example. You know, sometimes when I'm doing audits and the visit before the patient was having a significant wound and then it was really resolved, but the whole documentation is conflicting each other because the provider accidentally copied and pasted something from the last visit and then didn't update it and it's not relevant. So that's a record integrity concern and can cause claim denials for reimbursement. So know those practices and how to avoid them. Next slide. So what do you have to have, right? So what are the documentation guidelines? So chief complaint has to specify a medical reason for the visit. I'm gonna give you some examples, but it needs to be specific. Your history, we need three different things. We need HPI, review of systems and past family and social history. Of course, then you have your physical exam. We're gonna talk about medical decision-making and how to make it, you know, a little less nebulous from understanding how that's scored from an audit perspective, but then everything comes down to medical necessity. Regardless of the E&M factors, I'm sure you've heard this before, you know, the level coding is always supported and the overarching medical necessity is always the supporting criterion for payment. So again, that's where those words and how we use them strategically really matter. Next slide. So again, I always like to say, if it doesn't have to be in the medical record, I don't want you to have to document it. We did get some regulatory flexibility in 2019. Providers used to have to document why a house call was required in lieu of the office visit. That is no longer required, excuse me. Medicare changed that in 2019. And as long as the provider and the patient feels the home is the best setting for them to be cared for, you just don't have to explicitly document it. We're only gonna be there if the patient has a need. But again, if you still have that language in the template, that did change in 2019. Next slide. So what do I mean by that? You know, what specifically can you do? If I'm looking at your note, are you really telling me for that date of service, for that visit, what was going on with the patient? What were the recent concerns? Which of those chronic conditions, like Megan and Paul talked about, you can't do it all. Are you really prioritizing that visit? Can I tell if they're stable? Can I tell if they're really declining or maybe mildly elevated? Are you using those descriptive words? When you're doing things, a lot of the times I just see missed opportunities. If you have to talk to home health, if you have to talk to other providers, if you're talking to the sun or you're consulting with specialty providers on the patient's care, make sure you're noting that because that adds to complexity. What things did you have to consider even if a decision wasn't made at that visit? Medications. If you're prescribing or even continuing medications, but make sure that you have a clear treatment plan. Your assessment and plan should always say the condition, the status, and then what your care and treatment plan is. Any other unique considerations, non-compliance, things like that, we want to make sure we're capturing in our documentation. Next slide. You also, and this affects your revenue cycle management, want to make sure that your providers are completing and signing documentation as soon as possible after the visit occurs. If you're not signing notes right away and that claim is taking a week or more to get out the door, that's slowing down your revenue. Best practices within 72 hours. This was just an example. Medicare says it must be signed as soon as practical after the encounter. Your MAC may have even more specific guidance, so you can monitor open encounter reports. If a provider really is having trouble completing their documentation, maybe it's a barrier. What can you do to help them be efficient? Have they tried dictation or maybe it's a template issue. See what support you can provide. Next slide. We can go on one more. Thinking about common reasons for claims denials, again, we talked about the medical necessity. What you want to avoid, and I'll get into visit frequency too, is seeing all of your patients on a set schedule. It really should be personalized based to each patient's clinical needs and health status. Not every patient needs to be seen four weeks. Putting patients on a set schedule for convenience is always going to result in a denial if you can't support it by the documentation. We can absolutely build minor procedures and E&M visits on the same day, but we need to know when it's not appropriate to do both. If you just added the patient on your schedule because they're in route and they really just needed a knee injection and you didn't take the time to do a full visit, then you shouldn't be building both. If you're truly doing a full visit and then you also happen to have the supplies with you and they really needed that knee injection, you can build both with the modifier 25. We know it's really not practical just to go out for injections all the time if not, but then your documentation needs to support it. Don't tell me in the chief complaint that you're seeing the patient for a knee injection if you're trying to build both. Then again, I talked about the risks of cloning. Really make sure that appropriate documentation is being used. Avoid that copy and paste because it just really can threaten the care that's being provided. I can't really tell what you did or how the patient's even being done. If they were in the hospital and the provider pulled up a note and it's a completely different medical picture than the patient actually is, it's always unintentional, but I've seen it a lot in audits. Next slide. Again, the EMR, if you haven't reviewed your templates with your provider as a whole within the past year or two or even three years, I would say take the time to do it because a lot of the times the results of an audit, a lot of times I'm coming back with recommendations. Hey, I've seen all these extra clicks or all these things that I can tell the providers aren't using or I'm seeing it's there and it's kind of mishmash. Can we look at that? What's a follow-up visit versus an initial visit? How can we streamline that? EMRs are great, but they have also caused challenges. So really thinking about how you can optimize what you do need to document and what's available. I think to me, unchecked or not used when it's not clinically relevant for the patient. Next slide. So place of service, it matters where you see the patient. And again, this is why it's important on intake to understand, okay, is this a private home or is it an assisted living facility or group home? Both assisted living facilities and group homes have different CPT codes. So that's why it's important to get to understand that this is kind of a backend claims thing. It's okay. You can go ahead and move on to the next slide. And the other important aspect that ties into that is modifiers, right? So we talked about modifier 25. If you're doing a joint injection and an E&M or you're doing a debridement and an E&M, you're not going to get paid for both services without that modifier. Also hospice patients. So many home-based primary care practices decide to continue seeing their patients on hospice care. They are entitled to Part B services. However, you need to be designated as the attending provider for the hospice. And if you're seeing a patient, then you have to use a hospice modifier to get paid for it. So GW would be if you're seeing the patient and it's not related to their hospice diagnosis. And GV would be you're seeing the patient and is related to their hospice diagnosis. As a best practice too, you want to go ahead and note what the terminal diagnosis is and what their hospice start date is in the EMR. So your billing staff can help with that. And then again, 95 Medicare telehealth, it's a big thing right now. And we might, you know, it's ever changing. So understanding how to appropriately bill for telehealth services as well. Next slide. So again, every team member has a role in reflecting the provider. If they're calling for an acute visit, you know, it's just scheduled with an acute visit and that information is not, you know, making it in there. Again, understanding what facilities really are group homes and assisted livings because independent living, that's not a group home, doesn't provide room and board and medical services would be billed as a private home. So that's why this is really important to gain on intake. Next slide. So again, one of the most common questions I get called. So again, you can see your patients as often as clinically necessary, as long as you can support the documentation by medical necessity. Again, we know these patients, high need, high touch, more frequent visits, but you don't need to see every patient on that schedule. You want to see as many patients in that building as is necessary. But that's why if you have a lot of patients in certain buildings, rather than just scheduling them all, can you be there once a week to make sure you're seeing really appropriate patients or once every two weeks and so on and so forth. So this is why you need that scheduling process. So you under, so you're proactively scheduling when the provider's in the area, but you shouldn't be seeing every single patient on the same schedule without the provider using some clinical judgment. Next slide. So these are examples. I don't want to see just new patient or follow-up visit for that chief complaint. I need to understand what is the medical need, not just establishing care, right? Why do you need to see the patient that day? So be intentional with your chief complaint. It also starts painting the picture of complexity. Next slide. So here's where we could be brief. I know many providers prefer the long narrative kind of paragraph form, which is fine if that's what you're comfortable with. But we know that our patients may not have all these acute problems. You may be seeing them more just to manage their chronic conditions. A comprehensive HPI can always be satisfied with this documenting the status of three chronic conditions. So again, try bulleted form, you know, focus. Again, I don't need their whole past medical history and their summary of everything that led up to now and all of their diseases and a follow-up visit. Focus on what you're managing that day and give me bulleted, how are they managing today? What are the changes? You know, how did the patient and caregiver feel they'd be managing? Or if you have an acute problem, the acute problem example, that's a comprehensive HPI just for one problem, right? It describes the pain. It tells me the severity. It tells me when the pain started and if they've tried anything to make it better or worse. So this is where that, you know, think about when you can use less words and still have quality documentation. And this is going to be a little bit of like a change management brain if you're used to it. So maybe just try it for a couple notes or kind of challenge yourself the bulleted form and see if it saves you any time. I liked Megan's suggestion of even putting a timer on when you're doing your documentation and trying to really challenge yourself to be efficient. Next slide. Review of system. This is another place I think providers can save a lot of time. So on the right-hand side in the RRS box, from a documentation perspective, there's a total of, you know, 14 systems, but 10 systems is considered a complete RRS. It's much more meaningful from a documentation guideline standpoint to document the positive and the abnormal. Anything that's abnormal, positive, or it's a pertinent negative should be explicitly documented. Then you can always use the phrase, all other systems were reviewed and are negative, and that will always still get you complete HPI, or excuse me, complete RRS credit without the provider having to say negative, negative, negative for those other, you know, nine systems. So just something to keep in mind, and again, trying to think about reducing the number of clicks. Next slide. So past family and social history, this is the difference between a new patient and an established patient encounter too. This is why using your medical assistance and getting those intake forms ahead of time or electronically and getting that medical record can be really helpful because it's my pet peeve when I have to technically downcode a new patient visit because there's no family history. I know the patient may not, you know, know if there's no independent historian available and you don't have family history in the medical records, then all you need to do is document the rationale on why it's unobtainable. So for example, you know, patient with dementia, you know, unable to report family history and no independent historian available. I can't count that against you then, but do try and make your best efforts, especially for new patient visits to get both the past family or all of the past family and social history. And with family history too, it's not just, it's what specific relative, what was their disease history? Are they alive or deceased and approximate age that they passed if known? So again, if you don't know it, then tell me why, but otherwise this needs to be documented for new patient encounters. Next slide. Physical exams, usually not an issue. Again, these patients are really complex. They have a lot of issues that you need to address. Just know that comprehensive exam is eight organ systems only rather than body areas and systems. So keeping in mind what your templates look like when you can. Next slide. So the next few slides, I want to, I'm going to show you how I would audit MDM because I think it's important for providers to understand. But when we think about medical decision-making from an audit and a documentation compliance perspective, I have to look at three things. The number of diagnoses or conditions that you meaningfully assess during that encounter, not the patient's problem list. What are I seeing in the assessment plan that's actually addressed? What else did you have to do? That complexity of medical records or other data and information you had to review, and then the overall level of risk. So we can go ahead and move to the next slide. So again, this point system in these graphs are not things that I want you to memorize, but these are all audit tools and you could, you can look at your map for resources for your own. But I want, what I want to highlight here is if I look at your map, I can see that you have But I want, what I want to highlight here is if I look at your assessment and plan, and I can't tell if the problem is new or chronic for the patient, and I can't tell if it's stable or if it's worsening for them, that impacts medical decision-making. So just using those couple more words and phrases to tell me, you know, if their COPD is exacerbated or if their hypertension has been mildly elevated, you know, or their arthritis is flaring up, just using a couple more words really matters for medical decision-making. The next part, and we need all three of these things. So next slide. The next part is, again, just missed opportunities. If you reviewed or ordered a graph or any diagnostics, or you had to obtain medical records or talk to someone other than the patient, so you either had to maybe talk to a home health nurse or like Paul was saying, using your specialty providers, make sure you're documenting that in the progress note because that ties into the work that you had to do to care for that patient during that encounter. It plays into MDM. So if you don't note that, then I can't give you credit for it. Next slide. And then the final part, this is just the CPT table over it. These bullets are all examples. The one bullet meets the, you know, complexity. So again, moderate complexity, two or more stable chronic conditions or prescription drug management, or one, one, you know, exacerbated problem. That's almost all of our patients. High complexity is really when that patient probably needs hospital level care, or maybe it's a DNR and a hospice discussion and your words are going to get you to that bar. And I have to move to the next slide. How this all ties together is MDM is a two out of three mentality. So again, I'm showing you from an audit perspective, how I would score your medical decision-making. And this is why all three of these things are important, right? So maybe we don't have a ton of, you know, labs or data or things ordered, but, you know, you've addressed three medical problems or, you know, and then the patient overall easily got to that moderate level of risk. Moderate complexity, 99350 for an established patient is moderate or high MDM, right? New patients with a higher bar, we need that high complexity for that high code. But this is how that plays in. And I have one more example for you. If we go to the next slide of kind of how these things all tied together. So, right, so maybe it's a patient that you're really just focusing on one problem that visit that one problem was stable. And then, you know, they had an acute new issue that was worsening, and then you ordered some labs. That's moderate MDM altogether. Another example of moderate would be, you know, one problem that's worsening. Maybe you made an acute visit just to address that. And then you had to call the son because the patient has dementia to obtain history. Maybe you had three stable problems, no data. And then you, you know, continued medications, but we're still at moderate MDM for that. How we're getting to high is maybe in the assessment and plan, you addressed four chronic medical problems. They were all stable, but you also had to review and order labs, plus a diagnostic, plus you talked about home health nurse. You know, that's where we're getting to that, you know, again, a two out of three, the possibilities with the high. Or maybe, you know, you showed up for them. It was like that route, that acute, that really urgent visit, that patient is acutely unstable. And they have problems that are requiring a lot of extra work. And that's when we're getting to that high MDM level. Next slide. So I talked about meat earlier. Again, I think the assessment and plan is really the critical part of documentation. It's where we should be spending that time and trying to, you know, minimize templates and other areas. But again, what are the signs and symptoms of their disease? What tests are you ordering or considering? Are they stable or not stable? You know, and when you're referring out, it's been a big audit finding when providers make referrals and the progress notes don't support it because it just says ordered PT or ordered home health. You know, make sure you support the clinical indication on why you're ordering treatment for patients. Next slide. So again, we talked a lot about this, but it should really, you know, paint that picture of medical complexity, as I like to say. And again, you don't have to address every problem every time. I don't want to see every problem that's on the problem list in the assessment plan every time, unless you really took the time to evaluate and meaningfully assess all of those diagnosis codes. You don't have to do everything at once. I only care about what was meaningful for that particular visit. And it does have to be supported. Also from an HCC coding perspective, you know, when you're prioritizing and focusing on different problems and, you know, make sure you're assigning their correct ICD-10 codes for each of those visits and alternating, you know, which are your primary diagnosis that they're getting reflected for patients. Next slide. So this is just an example. The AMA, many of you, if you practice in the office setting, I know a couple of you said you do both, so I'll comment on this for a second. It's incredibly frustrating because right now we have different documentation guidelines for office-based providers than we do for home-based providers, right? In the home-based primary care world, in the post-acute world, we can't just use time alone or MDM alone. We're still following the same documentation guidelines, but this is what the AMA means. So again, you know, what is your role in considering a problem? Don't just document that the patient's, you know, followed by immunology without you commenting on how you address their Parkinson's. Next slide. Again, don't forget about the instructions. What are you actually doing? How is that patient managing? What is the care plan for each of those conditions? Really important to make sure that that's getting in. Next slide. So, and maybe someone can grab this from the slide and put it in the link here and put it in the chat at some point too. I really liked this article on prescription for no float. It was actually focused on hospital-based providers, but it talked about kind of the problem of overpopulating templates and kind of how we lose quality sometimes. So, you know, really, if we're thinking about tips, go back one slide, sorry. Yep. It should be up to date, should be accurate, but it should also be useful, organized, you know, that I can follow along with a train of thought and where you're going. And it can also still be succinct, you know, avoiding that phoning that's consistent and documentation's not conflicting with each other, but talk to your providers. And I'd love for our faculty and any of you to share in the chat too, like how do you stay efficient with documentation? Because right, we know this can be one of the biggest stressors or one of the biggest burdens. So we'd love to hear, you know, you guys in the chat and other faculty members encourage you to share any tips or tricks that you have for people in the chat. Next slide. So the other option that we have is again, the history exam and medical decision-making. That's when you're doing your E&M visits on what I call documentation and conformity, right? And that we're supporting that medical necessity. There are times when we may want to consider time-based billing. You can only bill on time if the visit was truly documented by counseling and coordination of care. Again, specific to the home setting, the office is different and a compliant time statement has those three things. But if it's not, if it's more of like all these mental health and really challenging psychosocial visit, then you don't need all those other documentation elements. If it was really focused on a conversation and counseling, then that's when time can be your friend. And then again, there's extended time visits. If you're there for a really long time, you can probably justify what either counseling or coordination of care complications tied into that visit. So think about when it makes sense to bill on time rather than having to have such comprehensive E&M elements. Now you can move on to the next slide. And then this is some examples of some templates you can think about for time statements. Again, if you are billing on time, you do need to be compliant about it. So I need total time, the exact language that graded that 50% of it was dominated by counseling and coordination of care. And then specifically, again, customized. Don't just have it be generic for every patient. You shouldn't be billing a hundred percent of your visits on time either. That's a huge audit red flag and risk. So you really do have to validate when you're billing on time and customize that smart phrase for time on what, you know, what, you know, that was the patient, you know, talking about depression or talking about, you know, the progression of their disease and really focusing on care planning efforts and what they want to go forward with. Just give me even a couple of sentences of what the specific nature and the context of the counseling and coordination of care that occurred was. Next slide. So I kind of jumped ahead. Sorry, we can go ahead and move on, since I was kind of already giving you tips and tricks on when to build more time. So, these next four slides, we can just kind of advance through them. I went ahead and put these on here just for your reference. You know, if you ever had provider TTs, or you're not as familiar with them, this is each level of service for the new and the established patient visits. Again, those new patients are a higher bar, 99350, comprehensive history, comprehensive scan, moderate or high medical decision-making, so don't be scared about code. We know that 99349 is the most common for this patient. Your domiciliary visits, again, if you're seeing patients in the assisted living or the group setting, your same guidelines, but different CPT codes. These are the ones for new patients, and the next slide is the ones for established patients. So, I'm really a big fan of annual professional development and documentation and coding education. You all went to school to be amazing medical professionals and not for coding, but it is important, and it does tie into our job, and ultimately, the sustainability and the resources we can offer our patient. So, if you don't invest in annual training, or it's been a while since you've had a refresh with your team, peer auditing, you know, annual internal auditing, even giving each other feedback might be time to invest in that. So, we're going to talk about a few of these specifically, and then I've given you, if you go to your workbook, the advanced coding opportunities, I talk about all of these things in more detail. All of the guidelines are in there for you. What I like to say is think about your clinical model first. What care are you providing, and then what opportunities lay into this? This is fee-for-service. If you're in value-based care, we'll talk more about that later and tomorrow in the advanced, but you're more getting paid for the whole person care, but in fee-for-service, you have to be creative. So, advanced care planning, TCM, when you're, you know, counseling the patient for four minutes on smoking cessation, making sure you're documenting that. Prolonged services, especially for new patients, is pretty common, and then you have to be thinking about how do I get paid for that non-face-to-face time as well, that CCM or CPO? I know Dr. Kaplan mentioned the cognitive assessment and care planning visit. That's a very specific visit that pays almost $300, and then again, the home health certifications are an easy one. If you are the, you know, ordering and overseeing provider for home health, nurse practitioners can really bill for these codes, too. When you sign the 485 and the first can't plan enough care is established, you bill the GL-180. Once every 60 days, if they're recertified for that same home health episode is when you can bill the GL-179, so know all of these tools and make sure that you're getting paid for the work that you're doing. Okay. So, let's talk about CCM. Can we go to the next slide? So, chronic care management, again, I'm talking from a Medicare fee for service billing perspective, again, you could, you can think about care management as just part of your clinical model, too, but the patient has to have two or more chronic conditions, place them at risk, all of our patients. You need, this does take some practice consideration, so there has to be an electronic comprehensive care plan that Medicare has specific recommendations for that's established, it's provided to the patient or caregiver, it has a schedule for review, and then all of this is time-based. But the nice thing about it, too, is you can get paid for your clinical staff time. So, often this is how our practice might fund, you know, clinical support staff because they're getting paid for their time in addition to provider time. So, if we go on to the next slide here, these are all of those requirements, too. Again, think about the workflow, meet with your team, you know, how are you going to document consent? New patients or patients that haven't been seen in the past 12 months, you must enroll them in a face-to-face visit, you have to use a certified EMR. 24-7 access does not mean you're going to drop everything and make a house call after hours, it means they can reach you, right, do you have a call service or on call, they have a designated relationship with some sort of primary clinician to help them, again, that electronic care plan, and these other things are all things we're doing, right. You know, we're managing transitions, we're connecting them with resources, and enhanced communication opportunities. It could be a patient portal, it could be secure email, it's just an electronic means of communication between you and the patient. Next slide. So, here's an example in your workbook of a comprehensive CCM care plan. Again, this does need to be in the EHR. Everything on the right-hand side is what Medicare recommends be included in that care plan, so I always, anytime CMS is recommending something, I recommend that we follow it. I will say, again, primary care, I think most, you know, providers tend to think of care plans as just, you know, their care plan within their assessment and plan. This is a separate and formal care plan document, so that takes that team. You can use your clinical staff to help you develop the care plan off of your first assessment and plan, but then it has to be signed and reviewed by the provider, and the patient and caregiver has to have a copy of it. So, thinking about how you're going to fit this into your workflow before you bill for CCM services. Next slide. So, these are the codes. We have different options. So, you can only bill one type of CCM per patient per calendar month. The first two codes are the traditional CCM, as they're called, and so this is when it's provider time and clinical staff time. The most common question I get is, how do I get paid for all the time I'm on the phone with patients, or how do I get paid for all this non-patient time? CCM is the potential solution for that, right? So, 20 minutes per calendar month are both provider and clinical staff time. You can do up to 60 minutes. There's an add-on code, 99439. Again, in full 20-minute increments, so you could be getting paid for up to 60 minutes of time. If you're a solo provider, maybe you want to consider this third code, 99491, and then there's an add-on code. This has to be a minimum of 30 minutes, and it's all qualified billing provider time. So, one billing provider is spending their full 30 minutes per calendar month, or their full 60 minutes per calendar month pays a little bit more because it's all a qualified billing practitioner's time. And then complex CCM, just understand it actually pays a few dollars more to bill 60 minutes of traditional CCM, and you don't have to meet this higher bar. So, complex CCM can be an audit focus because the patient really has to have declining diseases, need assistance with ADLs, just more assistance. So, you don't have to have that higher medical decision-making with the traditional CCM codes. Again, this is your clinical staff times, too. It might be how you grow, and it doesn't even have to be all phone call time. It's any and all medical management time, care coordination time, time with pharmacy, time with home health. Think of all these options that you could be getting paid for the work you're doing when you're not face-to-face with the patient. Next slide. There is an add-on code if you're doing the care planning during a face-to-face visit. This can only be used once for new patients when you're enrolled in for CCM during that face-to-face visit, separately billable from your visit itself. It's not time-based, but I would expect to see, you know, consent and explanation of CCM services, and then the provider themselves starting that care plan. Next slide. So, how do we tie this all together? You know, if you're going to roll out CCM, I recommend you have some clinical staff to help you with the care plan and to kind of operationalize all this. You have to think about how you're going to track your time. Most EMRs may have a CCM or time-tracking module. If you ask the right buzzwords, there's also a lot of technology vendors that will help you do this, or maybe you just create a different tag or encounter type on how you're going to track dates and minutes and specific, I need the specific date, the specific minutes, and what was done, you know, to support all that time throughout the calendar month. And then think about templates and macros for gaining consent. Of course, we talked about making sure the care plan, again, if the patient's not on the patient portal, you still have to document that that care plan was delivered to them. And then this would be a month-end billing process. So, at the end of the month, any time within that calendar month is billable. So, how are you going to operationalize that on a back-end billing perspective? Next slide. And again, this is just to show you some of the reimbursement examples. If you think, if I got, you know, anywhere from $160 to, you know, $80 per patient per month from CCM, would it be worth, you know, taking the extra time and investment to document and kind of operationalize some of these things? In fee-for-service, it really matters. Next slide. The other option, it talks about it in your resources. I'm not going to go into care plan oversight. You can't do both, but maybe you have a lot of home health patients in your, that would be when you're spending 30 minutes per calendar month on very specific billable activities related to coordinating their home health services. And it can't, it has to be provider time, not clinical staff or hospice. There is something called care plan oversight. So, just know that that might be something that you want to explore, too, if you don't think CCM is the right fit for your practice. I like CCM just because it's a little bit more flexible. It counts the clinical staff time, and it can be managed, medical management for all of their needs. It doesn't have to be tied to those specific billable activities of coordinating their home health services or hospice. Next slide. Again, these are just the codes and the reimbursement. We can move on. I just put these here for reference because I do want to spend some time talking about, oh, these were the certification codes I mentioned earlier. Again, just for signing the 485 and being the one that the home health agency is going to call. So, this isn't care plan oversight. A lot of people confuse this. You can bill the certification codes and chronic care management for the same patient within the same month. You just can't do care plan oversight and chronic care management for the same patient within the same month. Those are the ones that are bundled. Next slide. Okay. So, if anyone has any questions on CCM or anyone has any success stories or feedback on CCM, feel free to put it into the chat. Otherwise, we're going to move on to remote patient monitoring. So, again, like any coding activity, we want to make sure that we're doing it compliantly because it's never worth, you know, the event of an unfavorable audit. And care management opportunities like CCM and RPM do get looked at from time to time. So, understand that, you know, RPM is when you're using, you have to have a technology vendor because the patient has to have something that meets the FDA's definition of a medical device that's automatically and digitally transmitting, you know, physiological data, so blood pressure, blood glucose, weight, pulse ox, to the practice. And someone's reviewing that, and then you're creating a care plan. RPM needs to have a care episode. You need to have clear treatment goals that eventually could be obtained, right? It's not just a never-ending process. Again, very similar to CCM, there's some interactive communication. This is when you're having phone time and conversation with the patient. It doesn't have to be all of the time. But generally, if you're rolling out an RPM program, you would have some dedicated clinical staff that's helping review those readings and get the appropriate ones to the provider, but helping the patient's care plan and communicating with them about your needs. It could be a really helpful tool for you when you're trying to manage, for example, COPD or diabetic patients, to have real-time actual data on how they're doing in between visits. So, you know when you need to make an adjustment. Next slide. So, there's a set of codes, and I'm going to kind of go in sequential order. So, first, the first month, you set the patient up with a device. You provide the initial education. That's when 99453 can be built. Once every 30 days, because it's a practice expense for them to have that medical device, is when you can build a 99454. That's for the device supply, right? Lots of technology vendors out there that need them more now. Find a quality one. Ask for your associations or your colleagues which ones they use. But lots of ways you can partner to get this done. And if we go on to the next slide, this would be an optional code, but if during, in theory, the way that CMS describes this is after the first month, you set the patient up. You get all of the data back, and let's say you spend 30 minutes at the end of that first calendar month really creating the care plan and going through all of the data to kind of set up that RPM care plan, then there's an option to get paid for your time, 99091. Other important note to make about RPM services is it's only billable if within a 30-day calendar period you have 16 days' worth of data. So, right, it's not, this isn't self-reported vitals. You know, there's lots of geriatric-friendly devices that they just have to press a button to turn on, but if you don't have 16 days' worth of data, none of this is billable. I forgot to mention that earlier. And then these are the care management codes, and RPM, so remote patient monitoring and CCM, chronic care management, can actually be billed together. It's not bundled. You could do it for the same patient within the same month. You just count what they call double dip, right? The time that you spend on the RPM, reviewing the data and the readings and the care plan for that is that time, and then chronic care management would be anything else. So, if you can keep those separate and distinct, you can do both RPM and CCM, and this is when, again, provider and clinical staff time, 20 minutes per calendar month. There's a lot of work, you know, once you get all those vitals, going through it, checking in on the patients when things are abnormal, you know, making adjustments, and then 99458, if you spend 40 minutes, each additional 20 minutes of time can be billed for RPM services. And just some of this requires interactive communication. They want to make sure you're at some point either verbally or via telehealth communicating with patients, but it also does count, you know, just the non-face-to-face or non-live time, if you will, going through the data and making those adjustments. Next slide. So, if we're going to implement an RPM, again, think about your vendors, you know, partner, ask your colleagues. This is a great group to network with, which ones they've found success with. Your associations may have recommendations. Also, think about the ease of use. I've heard the most common is blood pressure devices or weights for CHF patients. You know, certain, I've heard some negative feedback about certain glucose devices for patients. So, again, just think about, this isn't going to be something you would do for all of your home-based primary care patients. You need to have a use case. So, what is the target population that you want to use this for? Do they have a caregiver or a patient that's even competent of kind of using these devices and wants to participate in the program? Because otherwise, you're just wasting, you know, money and resources. And then, what kind of care team is going to help you manage the patients and kind of provide that patient and caregiver education? So, these are all kind of almost business planning questions I would ask myself before I would launch an RPM program and really kind of build out the operations behind it. Next slide. This was an example of a home-based primary care program that started RPM. Again, their use case was for hypertension, CHF, and also COVID-19, right, and COPD patients. They partnered with a third-party technology vendor that, you know, they had a separate digital monitoring platform because it didn't integrate with their EMR, but they found it pretty seamless. I know some that integrate with EMRs as well. They were using remote blood pressure cuffs, remote scales, and pulse ox and thermometers for their COVID patients, post-COVID patients. The practice had to pay a flat fee. For the devices, and they used smart tablets for their assisted living patients. It was really helpful for them to connect because they actually had the facility staff help facilitate some of this. And then, they were able to kind of review the readings and go from there. So, again, they started small with only about 3.5% enrollment of, again, 3.5 of their total census. But then, within two years, they saw that grow up to 7.5%. And overall, the feedback was the providers felt very satisfied. They felt like this data helped better manage their patients. It helped with improved clinical outcomes. They even are starting to track some avoidable ER visits based on the RPM interventions. And it was really, they were, you know, the point of care kits that they were using for patients in assisted living settings were really beneficial to them. Next slide. So, this is, again, a revenue example. I like to kind of tie this all together on practice sustainability and on why RPM could be a good thing for your patients and for your patient population. And even in value-based contracts, I feel like RPM is sometimes left out of that PMCM or that contract, so know which ones might still be an opportunity for you. Next slide. The other thing to think about from a quality perspective is annual wellness visits, right? So, especially if you're working with Medicare Advantage plans, they may require it. So, you know, the patient gets their once-in-a-lifetime initial visit. Almost all your patients are going to be the second one. But again, annual wellness visits do have very specific, you know, requirements. So, make sure you understand them. We've given you a resource for that in your workbook. I know some practices that also use nurses really just do the bulk of the preventative screening and set up the AWB for the provider. These could be done via telehealth right now, too. So, the thing about annual wellness visits is another kind of tool in your toolkit. And if we go, this is some of the resources I was talking about. I think by now, most of you are familiar with the Medicare regulations for telehealth and the public health emergency. But if not, we do have a separate resource about, you know, telehealth during COVID-19. And, you know, we know right now we can get paid for those video visits the same way we do for a house call that is contingent on the public health emergency. But the good news is there was legislation that was passed that whenever the PHE is declared over and all the waivers technically end, they're going to give, you know, a grace period. I think it's like 120 days. I can find the specifics and confirm tomorrow where you can continue using telehealth services. There's a lot of legislation trying to advocate for permanent telehealth legislation. But we're not there yet. But something that definitely needs to be monitored. For those practice managers on the call, if you guys don't subscribe to your local MACS listserv or CMS listserv, that's a great easy way to stay up to date. You can just go on their website. I can put some links in the chat later, you know, find what your MAC is and just subscribe to the listserv. It's a great way to stay up to date. And then this was the other resource I mentioned to you all. This goes in way more depth. Every single guideline for those advanced coding opportunities, you know, this could be your cheat sheet for your team so you can think about what meets your clinical model and what you need to do to optimize them. All right. So again, it's not something you want to be taken lightly. No one wants to be in a negative audit standpoint. So if you're going to do coding, you know, think about the operations, think about the compliance. How do we also balance efficiency and reduce provider burden and support each other? But again, just get paid for the work you're already doing. You're doing a lot. These patients are really sick. You know, how do you get strategic with getting paid for the work that you're already doing? So if you have any questions, please put them in the chat. Again, this is only day one. We have day two together. I'm going to welcome my colleague, Amanda, on with me here. But welcome to the, you know, happy to watch the chat and answer the questions that way too. Yeah. So I'm going to invite Amanda to join me in kind of hijacking five minutes from this presentation back because we actually, you know, assuming you're all still there, we would like you to turn on your videos and we'd like to hear from you. We've presented a lot of information this afternoon. So before we go into our last two sessions, which is on, you know, sustainability of your practice and self-care for your team, we want to hear from you. You know, what burning questions do you have from, you know, regarding the coding talk, regarding any of the sessions today, any tips or tricks that you are doing that we haven't mentioned, what can you share? So I would just invite you, if you have something that you can share with the group live, raise your hand and go ahead and unmute. We want to hear from you. I love that. I see Amanda's eyebrows going. She'll wait all day. I'm telling you Okay, so is have you heard anything today that surprised you or that you didn't know Amanda, do you have any burning questions that you want to before we move into sustainability that you want to get from this group? Um, I don't have any burning questions. But when we get to the self care, I was going to talk a little bit about workforce recruitment, because that one we don't have. And it's certainly, we don't really have a lot in the next two days on workforce recruitment, but it's timely. So that's kind of been on my list. It's absolutely a concern we hear about a lot. And it's not that we have easy answers, right? Because, you know, there's a profound workforce shortage, particularly in home based primary care. So, you know, I mean, that that's something that maybe we can learn from each other. I'm going to take a moment on that one and make a suggestion. If somebody hasn't thought about this, you have a lot of nurse practitioners out there, students, and you have a lot of PA schools and students. And I can speak for my program, for example, at FSU, we're often trying to place students in good quality clinical rotations. And I reached out to a local practice recently to see if a provider was interested in taking a student and we do pay. So you may find that there's other similar programs in the area that will pay you to take a student and teach them. And even if that provider can only take a student for one day a week, that's a great experience for a student and really kind of gets their feet wet and exposes them to a whole new way of seeing patients. So one, it could be a way to kind of supplement your provider's income if it works out that way. But the other thing is it's a recruitment tool because then the students are seeing opportunities that they didn't really understand but didn't want to ask because they didn't want to sound ignorant to what the concept is. That's a really great point. And I'm not sure if any of you realize HCCI has a number of resources that we make available to residency programs, to training programs, who, you know, who are precepting these students. We can help supplement what you're doing during your shadowing to make that a really meaningful time for the students that you're training and kind of take some burden off of you. So that's another resource as well. Great suggestion, Megan. Thank you. How many of you are training students in your practice? All right, Therese, I see your hand. David Meltzer, thank you. I had no idea you could get paid. It's not every program. Oh, I knew that. Yeah, yeah. It's a lot of work. But ask. There are several that do because they do have stipulations. They may say that you have to have only one student at a time. They may have other rules that go with it. And that's totally reasonable. But another thing, too, that you may find that they will make you a faculty member or assistant professor, depending upon your license that you have. And then they'll open up their medical library as an option for you to use. And you're talking that could be thousands of dollars of resources and references that you have at your hands in mobile applications. This is David. I'd love to learn more about how we could find opportunities to teach. One of our big challenges as a teaching institution is people come to us wanting to do teaching, but our clinical volumes have grown so much that a lot of our work is actually not teaching. So I think I could attract providers into doing more of this sort of work if we could really develop it as a teaching opportunity. So I'd love to hear more about how to get more learners. The other thing I'll just share is that our learners in an ideal circumstance are really contributing to care. And so one of our big challenges is when we have small numbers of learners and have them irregularly, it makes it actually harder for us. So building volume with learners could be spectacular. So any information that could be shared about how to create opportunities would be wonderful. Does anybody want to share anything on that before I comment that they've done? To start with, I would say, reach out to, you know, in your area, there's there's probably there's 200, almost 250 PA schools in the country, number one. So I would start by looking at what schools are in your area and reach out to usually it's a clinical education director program or similarly, even from the medical schools and just kind of see what they're doing or from a jury, ask them about their geriatrics programs, because I know that our College of Medicine does that. Yeah, we've actually done that on the inpatient side, but it literally never occurred to me that we could do it for home care. Yeah, we use that in our geriatrics program. We have a couple of sites from a home care medicine standpoint. You know, it's like anything. Some COVID made a real mess of some of this stuff in the past couple of years. But as we're coming out of it, it's really an opportunity. Another example is like eye exams. You know, I send the students to go spend a day with an ophthalmologist once a week, you know, on their geriatric rotation. And that's been a great experience. But so are house calls. House calls can be a real opportunity for you as an organization to network in and say, hey, look at what we do, what we offer. And then if nothing else, they can take it out and talk to their colleagues and say, wow, that was really amazing. You've got one to two students every year. Yeah, it's an opportunity. And it's building that pipeline for the field, you know, giving those students exposure to something that they otherwise wouldn't have. I'd add to not just about providers, but, you know, hourly staff trying to compete with the Amazons and the Walmarts and, you know, just a few notes, see how helpful they are, you know, but we have four generations working in the workforce. And I've never, I'm there's never been a generation in the history of the world that hasn't thought the generation after them is super lazy. So, you know, we are being challenged by this new generation coming in and Gen Z. But, you know, even when I've hired providers in the last 18 months, I'm hearing a lot of things around flexibility, time flexibility. You know, I would say years ago, we got rid of like tardies for hourly staff, you know, like there's there's really basic stuff for hourly staff that you could start to do to kind of set up their day four 10s, four nine fours, different ways you can start thinking outside the box to create flexibility and options. And not everyone will take them, but they're going to, you know, the workforce is starting to lean, especially after COVID in how is my how does my work fit in my life, not how do I fit my life into my work. And so, you know, there's, I think, going to be a lot more coming out about how to kind of create flexible workspaces. And I think what I really like about home based medicine is it really allows that I mean, it's inherently kind of allows that for providers to set up your own day, right, and then your staff to go with you. So is there a way to kind of extend that to the entire team to have some flexibility and find kind of that that missional work connection? Yeah, so Dorothy, thanks for sharing on here about how you handle your training with students that, you know, some of them have been challenged, because they didn't want to drive in Chicago, and they were meeting you and there were some scheduling issues. You know, I know people who do take students a lot of times they use that car time with the students, if they can if they can schedule it that way, for some additional conversation and training discussion. So if you're able to do that, any other comments on training students or things that have surprised you about what we've talked about today? I do have one question about students. You know, we're on the south side of Chicago and safety is always a concern. Has anyone else had experiences with safety issues and students and special things we should be aware of? So typically, they're going to be covered under liability and in the malpractice from the school the school knows what they're getting into when they reach out to coordinate a rotation like this. So I that hopefully answers that question, but usually the school is supposed to coordinate. Yeah, I was more interested. I mean, I think I have some understanding of the liability issues. I was more concerned about sort of learner interest and anxiety and those sorts of things. Yeah, that's a good question. But on the same token, like for our students, they have to do six weeks of behavioral health and they're in the inpatient psych ward. So if they can handle that, I think they should, I would hope that they could do a one day a week visit for four weeks. But you know, I get it. I mean, it's a fair question. Every student has their own tolerance. Yeah. And I mean, we know house calls isn't forever. And even when hiring providers, they say like, be honest with people, let them shadow and see if this is really something they actually want to get into because it's really hard. You don't want to spend the expense credentialing and things. So I mean, I think a little bit of transparency. And also from the patient and caregiver perspective, from the ops perspective, like we always let patients and caregivers know, like, hey, is it OK? You know, Dr. Chang has a student riding with him today. We try and not create crowds and have too many students with one provider because then they can make them feel uncomfortable or overwhelmed. So also just a little bit of transparency and letting people know when you have students with them, generally, you know, not necessarily a safety issue, but otherwise you might get some unhappy patients and pushback when they see multiple people walking into their home. Yeah. Yeah. It's not only a safety issue. It's a HIPAA issue as well. You just want to let them know that, of course, patients have the right to refuse and then the resident or whoever can just sit in the car and take a snooze or something like that. Regarding the safety concern, yes, we live in Chicago and we just hired a provider part time to join our practice. And we did talk about, I did talk about that with her a little bit. So never say never. But in the many years I've been doing this in the suburban Chicago area, fortunately have not had any issues. We did go visit challenging areas in the suburb, you know, bullet holes, gang violence, gunshot wounds, drug dealers. We have entered those service kind of environment, but I've never felt that I was threatening in any way. Having said that, I think it's really important for you to have a safety plan. And we actually just reviewed that a couple of weeks ago with the staff. Now, obviously we are focusing on the staff that's out in the field. What is your safety protocol? Do you have a code word? Do you know how to use a smartphone on calling 911? Should you wear a badge, not wear a badge? There are people who feel differently about that. And also about, you know, having a tracking, not a tracking device, that sounds awful, a safety app on your phone that people can see where you are. Again, different people feel differently about that. You know, like, why did you stop at Starbucks for 25 minutes? That's the flip side of being able to follow somebody. But I recommend that you work with your public safety folks. We actually, and Brianna knows this, we had a Wheaton Police Department officer was here giving us a talk on that. And then go over what policy you have for your providers in the field. The common one that's often used is calling the, of course, you can use your phone to dial 911. I think that's five presses on the, I have an iPhone, I think it's five press on a power button. You'll count down five seconds and it will ring. It will call 911 for you. But if you don't want to do it that way, you can call the office and say, I need to talk to Dr. White. And for many practice, that is the code word. You know, I'm with Mrs. Smith, and I need Dr. White to help me with something. And the staff would know where you are. They can call the police department for you and help you out. The final comment is, if it doesn't feel right, like the police officer said, just take off, just go leave everything behind. We'll figure out stuff out later. Just leave. Yeah, we have a good safety talk tomorrow too. So we'll be coming up on that. Lizzie, you had your hand raised. Just, I appreciated the question, Dr. Meltzer too. And I know that we have those conversations within Rush at Home and very similar to what I'm hearing from Dr. Chang. And I'm also wondering too, if we could partner or what immediately came to mind as you guys were talking about this is, are other partners out in the communities, like Thresholds and Trilogy, if people are familiar in Chicago, of how they, you know, provide support to their staff and students, et cetera. And if there could be synergy there, but just wanted to throw that out. Thank you. All right. So I think we're going to go ahead and dive into the next talk. Thank you for your input here and keep the comments coming in the chat or, you know, we'll have another open mic session here at the very end. So I'll go ahead and I'll come back to our slides and invite Amanda and Breanna to start us off. Thanks. Well, we're just going to tag team this. We have some more on the economics and value-based care and budgeting and stuff tomorrow. So we're going to kind of, like I said, just go back and forth on this and I'll take this one and Breanna will start the next one. But, you know, let's go through a couple of different types of revenue stream, the importance of diversification, talk about your sustainability model of service, virtual and in-person care. And obviously sometimes that changes with the global pandemic. And then talk about kind of core components of a program for optimal expense, resource utilization. So when you think about kind of revenue, you have different revenue streams, right? Again, we talked about the importance of, you know, not undercoding and getting paid for the E&M services appropriately. How are you getting paid for, if you're fee-for-service anyways, that non-face-to-face care management, other procedures and other services, you know, those infections, all that's super expensive if your providers are doing it and not billing for it. Immunizations too. So are you appropriately, you know, allocating, you know, flu vaccine season and on those kinds of things and then deciding what immunizations just really doesn't make financial sense for you to provide in the home and where can you partner and refer out? It's a really exciting time for value-based care. I know we get into this more tomorrow, but you know, if you're not following CMMI, which is the Centers for Medicare and Medicaid Innovation Center lists or some new alternative payment model opportunities, Medicare Advantage plans have had big time attention and all of a sudden the cost savings and the quality for patients wanting to be cared at home. So how can you partner with them? Telehealth and remote patient monitoring, use these tools, right? Especially from an efficiency standpoint, you may not be able to drive to that area and make a visit that day. So how can we use virtual tools? You know, some practices, you know, building in rooms and schedules for those telehealth and those virtual visits and using them as a check-in. And then also do you want to go into skilled nursing facilities or do some nursing homework or medical directorship? You know, what state programs, you know, might be available? States sometimes have their own alternative payment models type, you know, value-based contracts or innovations that you can get into and partner with organizations at the state level even. And I know that when we think about kind of fee-for-service, that's typically, you know, let's say anywhere from 100% to 80% of most of how we start out. I know there's the one practice starting in value-based care and kidney failure. But, you know, as you think about that too, so, you know, think about how much of your revenue, so as you're diversifying your streams, how much can be in one bucket versus the other or if you want to put sensitivity around it. So let's say Medicare cuts reimbursement by 10%, right? What happens to that? So building just sensitivity around the, you know, how reliable or how dependent you are on one area also helps if you feel like you're too dependent. In my tenure as CEO, that's been a lot of my work is trying to diversify our revenue streams. So we're not too dependent on one or two contracts, but a variety of contracts that are coming from different payers or Medicare and, you know, and that just takes a lot of work to really kind of think through those things. But, you know, what if some of those things go away? You know, especially when we talk about other income, medical directorships, grants, state income, those are really great places to explore. But you also have to look at, okay, well, what if they bring in a new medical director? How much of my, you know, can I afford to lose one or two facilities if I'm in 10? Or can I really not? You know, is my expense of my bill fixed expense around that? And same with grants. You know, if it's a three-year grant, really prepare that it will end. What will that look like? And then how do you hire appropriately if you have a temporary revenue stream? You need to think about temporary expense to go with it. Next slide. So as we think about kind of how to diversify your revenue, we talked a little bit about this. Again, the biggest bucket is gonna be your revenue cycle management and truly optimizing that. And Brianne is a great resource. We talk a little bit more about optimizing that. And then where are the stable incomes that you can get? I would still call, you know, medical directorships, a stable income, you know, a partnership that maybe they pay you additional dollars. We have a couple of partnerships to be in facilities, not just for medical directorships, but to be doing some short-stay work, maybe more stable and then variable. How do you think about like grant income, variable care coordination, things like that, that might come into play. And so what is the right mix for you? It also depends on what your expense looks like and what you're trying to hold up and if what your growth plan is. And so it's kind of important to kind of monitor all three of these buckets. And again, you know, test some sensitivity around these to see what you need more or less of in case something goes away. Yeah, and from the revenue cycle management perspective too, you know, understanding how important that intake process is and everyone's on their own team. Every patient thinks they have Medicare, right? Like Medicare Advantage doesn't exist. And even all my family members, right? Like they'll all tell you they have traditional Medicare. None of them do. So just like we say, don't get consent and go see the patient. You can't take every payer, especially for those, you know, there's a couple of new programs just starting out. HMOs might need a referral or you might not be able to see them for a house call, not an issue with the PPOs and the traditional Medicare, but you need to understand that on intake because it's a lot harder to end that care relationship after you've made a visit that you get, you know, can't get paid for then. So thinking about that on intake, you know, making sure that if the patient pulls insurance out or mentioned something during the visit, your medical assistant or your provider would take the initiative to want to take a picture of a new insurance card for you, whether it's their role or not, really understanding how that can impact and making sure that you're verifying active insurance before, especially, you know, at the start of care, but for every visit, you know, changes, things like that. Put in the, one other thing on kind of denial management too, we're going to kind of talk through these and we're going to talk through the strong intake process, but I just went to a financial conference, MGMA did a big financial conference and really talked about, and it's harder for smaller practices, but as you get your arms around denials is really understanding what's the cost to work a denial. And at what point are you, what is the old phrase? I'm horrible at these phrases, the juice isn't worth the squeeze or something like that, right? Like at what point are you putting in too much work to work a denial? So, you know, I think the kind of most of the stuff you see as a denial management is manager denials as a takeaway. I would also say, figure out how much people effort is going into a denial and where you cut that off. It's at a hundred bucks, it's at 200 bucks, it's after a second denial, whatever that looks like. And then use that work to get that claim submission rate so it passes your clearinghouse the first time if you have some sort of systemic piece on the denials. But I'll let you take that back, sorry, Rian. No, that's all great information. Yeah, I mean, I know like last study from a year ago, the average cost of a Medicare denied claim was like $15 just for it being denied, right? That's probably closer to 20, 25, I think I've seen more recently now. But also like this matters when you're picking an EHR vendor, right? Like who's gonna do, and your practice management vendor, like what kind, if you're using an external billing company is that worth it for you? Or are you getting timely reports? Are you even attuned to what denials are going on and correcting them so that you're not just losing money and actually reading the fine print on those payer contracts before you're committing and starting relationships, getting appropriate reimbursement for all types of your providers and things like that. So yeah, I would just say to you, I mean, don't just assume that because they denied something, sometimes it does have to be appealed or resubmitted or it's an easy fix or the payer just honestly denied an error and it just takes someone calling them. But that is a manpower and expense of a people expense and resource to do that. So think about your EMR and revenue cycle solutions or even external billing companies or maybe you wanna hire someone to have that role, lots of options. And one of the notes on the hiring and external revenue cycle is we did this a few years back and they wouldn't let us change the billing statement to have our phone number be the one you call. And most people won't call because most people will say, oh yeah, that was a bill and I'll pay the bill. But you do have the small percentage of people who will call or complain or something. And we learned, and I don't know if everybody feels this way, but we really, we actually ended up, that was the straw that started being like, we have got to do this ourselves because we couldn't get, they would not change to call us directly. And we just didn't feel like they really had the customer service and the understanding of our actual work to be able to interact with patients. And so that was just a note on kind of revenue cycle. From a couple other perspectives, again, I've been thinking about the world a lot lately, really in a binary setup. There is revenue and there is expense. And those are the only two things that are playing into your day-to-day. First and foremost, you're running a business, right? And we talked about diversifying your revenue. We talked about revenue cycle. There's certainly payer contracts. Those payer contracts can be through CMMI, through CMS directly. They can be with Medicare Advantage, local payers, D-SNPs, I-SNPs, C-SNPs. So you have a lot commercial plans. You have a lot of options on kind of the payer contracts, but there are also partnerships. And we talk about this a little bit more tomorrow, but if you are doing all the cost and quality work, you're improving the quality and lowering the cost, you're saving someone money. Sometimes it's the payer and sometimes it's a partnership opportunity, right? Like sometimes the lower readmission is really important to the nursing home, and it's not just a medical directorship. It's something more. It's more important to them. It has a cost dollar amount to them. Sometimes it's to the whole facility, like the senior campus, the senior campus group. It could be to the primary care clinic. It could be to the health system. And so think about those partnerships and how you leverage cash out of that relationship. And finally, and Brianne is an expert kind of on the revenue side of productivity, but monitoring that really closely, how do you find that balance between I'm not trying to push everybody over the edge, but we certainly all have the understanding of what the productivity needs are for our practice. And then what that all looks like, and we're really clear about that. There used to be kind of this old world where we post everything, we post productivity, we post quality, and we compare it. And I would say generally in the last couple of years, I've been hearing that going away. That's contributing to stress and burnout in jobs. And so more private discussions around productivity to keep that at the level you need it to be for your success. Generally, and my final thought of productivity, I guess I'd say, if I see someone who's producing lower than they typically do or even if maybe they're not producing on average, I generally don't think of it as, oh, they're doing something wrong. I think of it as more of like a cry for help. There's something inefficient in their workflow that I'm sure that if we could figure out, they would want to have that figured out. So if you generally go in with, kind of this altruistic attitude of everybody's really trying their best, they know the clear expectation on what they're trying to get to, but they're having trouble getting to it. Well, there's some, if your first thought is, oh, they're not just lazy, but there's probably some systemic thing that's preventing them from being successful here. How do I get to that? Starting at that operational approach can build a relationship. Yeah, we'll talk more on productivity tomorrow, but I know with some of the, one of the position leaders I've worked with too, it's just really big on transparency, right? This is what I need to employ, right? Like I can't, especially if you're new to home-based primary care, you can get sucked in. And if you're not checking in with those new providers and they're spending two hours every visit, have they gone on a ride along with a more experienced provider? And do they know how to use the EMR, know how to document, know how to do a graceful exit? Again, there does have to be a balance and our scheduling team needs to know what, taking the time to make sure schedules are appropriately filled and things like that. So we can move on. I know we talk more about that tomorrow, unless, I'm sorry, Amanda, do you have anything else on expense? No, we'll go into how to think about expense. One thing I would say just on expenses, keep your ratio in your head. How much am I spending on people versus how much am I spending on admin overhead? What does that look like? And where are those opportunities? And kind of that percentage ratio is going to be a lot lower. You're gonna spend a lot more on people than you're gonna spend on overhead. But that's a stat that you can use, again, to market yourself. You can say, and it's true of our staff, for example, out of every dollar, 90% goes to people infrastructure and only 10% is going to overhead. And so when you're talking about that with payers who wanna work with you, that's way different than 30% going to fixed overhead heavy buildings. That immediately puts you in a more nimble position than anybody else they're working with. Next slide. So when you're thinking about practice standards, again, I know, especially during COVID, you may or may not, but thinking about the balance of in-person versus telehealth, even the need, like when you're triaging the need, is this a visit I need to see the patient in person for, or could this be effectively and quality done over a virtual visit? And then using your clinical team and using that interdisciplinary team. I know Elena mentioned earlier about using the MAs, facilitated to a provider. When does that make sense? How do you be proactive about care management, collaborating with other partners, using that home health nurse to make a visit so you don't have to go outside of your geographic schedule for the day. We're gonna spend more time on scheduling tomorrow. But again, thinking about what are my practice standards, and are you talking and developing with those teams and what creative solutions can we use, especially in the era of telehealth, to be efficient and to optimize care and really only be in person when we need to be in person and have the right provider in person for the patient's needs. Yeah, and I just add about a couple of these other things on kind of like risk stratification. I think the group that wins healthcare first is the one that can really apply the right resource at the right time, right? And so how do you understand who's on the cliff, falling off the cliff, walking up the mountain? How do you understand where everybody is? And I talked earlier about just sometimes the challenges of locating the patient. Once you locate the patient, understand what services they need. And this will allow you to kind of, again, move your resources around. And you might say, hey, we have a, if you're falling off the cliff, you're having this major acute event, we have a much heavier resource intensive versus I know I just see you or check in with you every two months. So even within such a complicated high needs population, there's still stratification of needs at each given time and understanding what that is. And it can be electronic through your HR, or it could just be, again, on Excel and paper and part of your process that you can build that in. Slide. So, oh, were you gonna say? Oh, so hopefully we gave you a couple of ideas around just sustainability as you think through your work, especially those kind of starting out, what is your model of care? And those who are not starting out, who have been doing this a while, I would say we are in the phase where I think in the next couple of years, we're gonna go through a healthcare, kind of healthcare redesign. We re-look at everything that we built. What is the fixed expense we built that really is the thing that we can't live without? And I would challenge us all to say, the work we do today is talking about the four Ms, right? The four Ms is the framework. Anything you do inside of that, the special thing that makes your practice special, that secret sauce, that's a tool. And so sometimes we get used to tools being the special sauce that we can't change. And I would say the framework is the one that doesn't change. The tools can change. And so how do you continue to keep that nimble? That will allow your fixed expense to feel a little bit more flexible at times when you need it to. So we talked about private home facility-based, what some of the diversification of revenue can bring you, staffing model and cost structure. We go through some staffing options too tomorrow. So any other things you would add on this slide? I mean, just with the facility-based versus private home, I know some practices, just like you might limit payers, have a cap on private home versus their facility patients. Especially new practices, understanding senior living communities, that's minimizing windshield time. So understanding what that looks like for you and what makes sense is something you wanna consider for your practice too. And it's not like AL and IL don't bring their own challenges, right? Like they're still complicated enough to feel really good at the end of the day. So, all right, slide. Any questions for us? Okay. I'm just gonna take a couple of minutes to talk about building up and caring for the house call team. So slide. And my interest in kind of empathy and sympathy and stressors and burnout and self-care developed slightly before COVID. So probably about a year before COVID, but it's become super sexy to know about these things. So it's just really great to be in this know and talk more about it. And it's all things that we're thinking about, both to retain our existing workforce and for new recruiting. So I think there's a lot there. So there's a short video on the next slide around empathy that's really fun if you haven't seen any of Brene Brown's work. So what is empathy and why is it very different than sympathy? Empathy fuels connection. Sympathy drives disconnection. Empathy, it's very interesting. Teresa Wiseman is a nursing scholar who studied professions, very diverse professions where empathy is relevant and came up with four qualities of empathy. Perspective taking, the ability to take the perspective of another person or recognize their perspective as their truth. Staying out of judgment, not easy when you enjoy it as much as most of us do. Recognizing emotion in other people and then communicating that. Empathy is feeling with people. And to me, I always think of empathy as this kind of sacred space when someone's kind of in a deep hole and they shout out from the bottom and they say, I'm stuck, it's dark, I'm overwhelmed. And then we look and we say, hey, I'm down, I know what it's like down here and you're not alone. Sympathy is, ooh, it's bad, uh-huh. Uh, no, you want a sandwich? Empathy is a choice and it's a vulnerable choice because in order to connect with you, I have to connect with something in myself that knows that feeling. Rarely, if ever, does an empathic response begin with at least. I had a, yeah. And we do it all the time because you know what? Someone just shared something with us, that's incredibly painful and we're trying to silver lining it. I don't think that's a verb, but I'm using it as one. We're trying to put the silver lining around it. So I had a miscarriage. At least you know you can get pregnant. I think my marriage is falling apart. At least you have a marriage. John's getting kicked out of school. At least Sarah is an A student. But one of the things we do sometimes in the face of very difficult conversations is we try to make things better. If I share something with you that's very difficult, I'd rather you say, I don't even know what to say right now, I'm just so glad you told me. Because the truth is, rarely can a response make something better. What makes something better is connection. Thank you. Any thoughts on that? We talk about it tomorrow and there's a cultural competency webinar that you can get as access as well on the HCCI portal. But when we think about... Could you go back a slide? Yeah, oh yeah, yeah. When we think about empathy, especially with our patients, think about the position of power and Dr. Cheng talked about this as well. Think about the position of power you are walking into their house. You're completely able-bodied. They don't have to be homebound, but often they are or home limited. So they're not able to leave their house. They have chronic conditions. We talked about places that you're going that have bullet holes that are not safe. How many people in your life, you're kind of circle of five, your family, you're growing up. How many are you experiencing kind of the sameness that they are, right? So you have to find this other piece of empathy inside yourself that can really connect because if you can't break down your walls of judgment to really connect in that way, you're not gonna get to their authentic goals of care. So it's just something to think about. And then when we think about this also from a patient, it's almost easier in some ways to think about it from a patient perspective. When we think about it now towards our colleagues, how do we make sure that we bring in empathy, right? How do we think about, especially when we watch during COVID, people had to be home with their children. Well, what if you don't have children and you never wanted children, right? Like, how do you still have empathy for needing to be home to teach your kindergartner kindergarten work? And then what does that look like? And how does that come across? And the number one reason people leave their jobs is their boss. And so, you know, as many of us are running practices, it gives you a lot to think about why people are leaving. Slide. But the other reason to kind of think about is when I want to talk about today is burnout. So stress is this, you know, I'm not clinical. So it's this physical clinical reaction. Burnout is more defined as long-term stress marked by emotional exhaustion, the belief that I can no longer help the system, that I'm no longer adding value and I'm completely exhausted in my ability to make real change. Slide. And so this is just the Medscape National Physician Burnout. The AMA just did one as well and they did all healthcare providers, but burnout is on the rise. And so you can see here, a couple of years ago, I had the 2018-2019 slide in, and I believe both of these have gone up a few position points in the last couple of years, but family medicine, internal medicine, more often those are the specialties that are in our practice. Really of the, you know, these numbers suggest that basically every one and two people you're running into are burnt out by the work that they're doing. And that's really overwhelming as you run a practice, again, to keep spirits high and keep people connected and grounded into their work. And part of the importance of grounding in this work is you get this immense privilege to be in someone's house to start addressing real change. And if you really can't connect in that way or feel like you're part of the system of change, you're not making that kind of impact individually that your practice is hoping for. The AMA survey came out and they said that for work intentions, 28% of respondents are likely to leave their organization in the next two years. So we're at a spot where one in every three are thinking about leaving their organization. So again, I'm kind of on this retention, burnout, how do we think about this work? It's like some of the top stressors here are, and we've talked a lot about this and luckily we have Lizzie here too, but mediating patient's family conflicts, right? How do you, how many times have you left and you're like, I have to deal with the patient, but I'm spending all my time dealing with the family member and the caregiver. Inefficiency, so electronic health records, paperwork complexity, but just general inefficiencies in practice is becoming a top stress, it is a top stressor, but inefficiencies of practice is one of the reasons people are looking for other jobs. Financial pressure, inadequate funding. How many of you guys in starting your practice or in some journey, even for those who've been around, you know, 15, 20 years, Dr. Kaplan, since 1990, you said, we've almost been like, nobody's funding this well enough. Why am I the person in the basement? Why am I the person that's fighting here when I'm the one doing the real work, right? Patient adherence, you know, how many times are you going to watch someone not self, like not care for themselves in these moments? Scheduling, logistics, traveling, being in a car, all of these, I mean, you know, I'm really preaching to the choir in so many ways, but just feeling generally unsupported as I'm by myself, I'm doing all this work, I'm not getting the attention or the funding or the need that I deserve. And just like all of healthcare, it's completely fraught with inefficiencies of how we do our work. So you could probably all make this list too. Slide. The real risk when you combine these things with stress and burnout is they can be really bad outcomes. So there's the individual, like so as we grow bigger, the individual health outcome for, you know, us as a provider, us as a team member, depression, exhaustion, dissatisfaction, depersonalization, higher rate of addiction, sense of failure, job, career change, and suicide. Of the specialties, the 2018 Medscape reported that 80% of people have never thought of suicide. So of the physicians surveyed, 14% have thought of it, 1% has tried it, and six prefer not to answer. So one in every five cannot definitively say they haven't tried or thought about suicide. So there's a lot of individual outcomes that can occur for an individual, again, one single provider that feels like they are not part of the change. And then there's the outcome for the patient they're caring for, lower satisfaction, quality of care, higher risk of malpractice claims. Again, because there's this disengagement. It doesn't mean you're not a good provider. It's you're disengaged with the work because you're burnt out. And finally, system outcomes, right? The system never gets better. New ideas are squashed. Innovation is stalled. Ideation can't continue because you're not able to participate at your highest, most authentic self. Slide. So a couple of coping strategies. We've talked about a couple of these joint visits to manage tension, documentation, how we find efficiencies in documentation, how we think, Brianna talked about templates, how we think about templates and still customizing those, but providing those as an opportunity to at least structure some of our work, timing ourselves, right? How do we, again, become efficient in our work? A financial model overhead here is, lower flexibility for potentially of the numbers we're seeing. We don't necessarily have to see 25 patients. We still have to see a high amount and they're very complex, but value-based care is ever more becoming sexier. And maybe this is an area that we'll continue to see a lot of growth. That's certainly my hope. The team approach, and continuing to connect to that team. I'm not alone. I'm not a sole provider. I'm doing a daily check-in with my team, a weekly check-in. And then administrative support is how do we work to our top of license? And these are just some ways, again, that you can build inside of your practice to cope with the burnout and stress. Slide. I won't spend too much time on this because Lizzie talked really, really well on resiliency. So, but just as you think about it, I would say one thing. Historically, it has been that we need to continue to work on resiliency in the face of negativity and how do we kind of internally fight that. I'm trying to remember where I heard this, but just in the last couple of conferences I went to, they did a survey and it was very clear that it wasn't that our healthcare workers are not resilient enough. It's that the work is incredibly complex. When we talked about kind of the top stressors, it's not necessarily on individuals to be more resilient. It is on systems to continue to improve, to support individuals and how they want to work. So, slide. Slide one more, I'll take the key take, please. So we talked a little bit about the difference between empathy and sympathy. We talked about kind of the same stressors as many other medical practices face, but how we as home-based medical practitioners maybe can use some of the strengths of our ability and flexibility and low overhead and partnerships and flexible schedules to continue to cope with some coping strategies. And I didn't talk too much about kind of self-care because I think it's just overall, this period of kind of rest and recovery, I would say is becoming more individualized by generation by individual. And so really to understand what is the thing the individual needs to recover and how would they personally recover, I think will be a successful strategy in the future versus a kind of one size fits all. Everybody gets the same week off, super nice. And what else are we gonna do? What does this quite look like for an individual to cope as needed? So, questions here for me? There's some questions in here. It's fun to end such a content heavy day with just thinking a little bit about our teams and self-care and addressing burnout. I, it's my distinct pleasure to tell you to fill out your learning plans. So we really use those and appreciate those. And so continue to work on those tonight and tomorrow. Yeah, thanks. And I, you know, we're gonna just cover some housekeeping things for tomorrow in the last few minutes here. But before we do, and this is a real serious ask, I would love for each of you to please put in the chat at least one thing that you are especially glad that you learned today. That will just help provide some feedback to our faculty. You know, we meet again before the workshop tomorrow just to kind of touch base on where things are at. And, you know, one thing you're especially glad that you learned and any other feedback. You know, I mean, I would open it up for you, not just for Amanda, but for the whole group here. Any other burning questions or comments for our faculty? While they're typing, Melissa, I wanna say that the positivity component, I've watched a lot of providers come and go in the emergency department, which is a high burnout rate. And the biggest difference is A, being positive, trying to see the good in people and not trying to determine why or why not they didn't do what you tell them or whatever somebody else has told them to do, or why did they show up in your department? Just realize that everybody has their issues and they're doing the best they can. And have a five-year plan, five-year goals. Every five years, you really should be saying, what am I doing these next five years? Where am I pushing myself to go next? Is it gonna be with house calls? Is it gonna be something different? And open yourself up to it. If you've got new goals and new things all the time, you're gonna find that it just keeps your interest and your satisfaction levels up. Yeah, and thanks for everybody that's putting things in the chat. Please keep them coming. I just wanna call out Shalane's comment. She said, I learned there's a lot that Lightways would need to do to implement home-based primary care. And I hope we didn't overwhelm you because yes, there's a lot, but I mean, that's why the members of the Illinois House Call Project are working with us. We're here to be a resource and to walk alongside you in this journey. And it certainly is attainable. So I don't want you to feel like, throw your hands up in the air and it's gonna be really, really impossible because it's not. I think those of you who have started house call programs can attest to the fact that it's doable, right? Anything else, anybody else wanna share verbally something that they're glad that they learned or something that they're really hoping that they're gonna learn tomorrow? I got a question real briefly. This is Alex Tan. We touched on this very briefly about new practices and accepting different payers. Are we gonna go over that in future days or well, my main concern is right now, I'm new, I have a new practice and scared to take on other payers because it's a more intensive process I heard or I don't know the process and I wanna know how hard it is and what is the benefits and the negatives to those. Yeah, Brianna, I wonder if you might be the best person to answer that. Yeah, I mean, so we do, tomorrow is a lot more like practice management heavy too. I mean, just a little bit of the talk about that now, but I mean, so you're probably taking mostly traditional Medicare right now, right? And you're wondering about like Medicare Advantage commercial payers or can you clarify just a little bit? Yes. Okay, yeah, I mean, so Medicare Advantage, I mean, first off PPO, you don't even have to be, I know some practices, I would say a pitfall for new practices is feeling like they have to contract with every single payer in their area because if they're a Medicare Advantage PPO plan, they may have out-of-network benefits anyways, but there's also, you can find research on what are the top plans in your area, like the percentage of the penetration. So I'd probably start there. Again, I would be careful with any HMOs or any managed care plans unless it's a value-based contract. Again, juice worth a squeeze type thing, but there's also a lot of opportunities for you to directly contract with Medicare Advantage plans. It's easier said than done, especially for a small new practice. That's where you're gonna have to start building your relationships, looking on their website, trying to find out who their medical director is. Do you have some data you can present and patient stories on outcomes and how your practice might be a solution to them? And then keeping an eye out, like primary care first, and I'm sorry, the payment model out of CMMI was traditional Medicare, but I mean, it was an opportunity for more smaller practices to potentially get involved. So I would say it's still an opportunity, but you don't have to also, don't feel like you have to, I feel like where people go wrong is trying to contract with like every single plan, every single payer, so I would discourage against that. And I would also look specifically at your geography to see what, I believe Alex, you're participating in the Illinois House Call Project, and I know they plan to give you some data and some resources around that, that I think will be helpful in kind of prioritizing that. Brianna, would you recommend a credentialing specialist in this case for him if he, if that were- Credentialing is such a pain, I mean, yeah, I hate getting credentialing questions myself because I'm like, I don't even, I know it has to be dangerous, I have to deal with it, but yeah, I mean, there are people out there, but I've also heard horror stories of people paying for credentialing specialists that they don't find the right one, or they don't get it, so I mean, I think that's a really tough one, but there are, yes, I mean, again, think about you're a provider running your own practice and you have so much clinical work to do, so what does make sense to pay an external company or partner a little bit, but just try and do the best you can from a quality perspective too, because I recently worked with a new practice where that was his mistake too, he had then had to hire a second credentialing specialist because the first one wasn't doing what she intended to do, but Brandy, I see your hand up. Yes, I just wanted to say thank you to all of the presenters on today. Great information shared. I would like to know, will this be, will we be able to access this at a later date to go back and review certain things? Yeah, yeah, this session, both days are recorded, and so you'll be able to go back into the HCCI Learning Hub. I mean, give us about a week to get the recording all set up for you, but we'll send out an email when it is, and then you'll be able to view that again and again. And Melissa, I thought earlier someone was asking about confirming the start time tomorrow and maybe just confirm Central versus other time zones, if you don't mind. Yeah, no, so these are our reminders. Yes, tomorrow, we start on Friday, June 3rd at 9 a.m. Central time. So it's the same Zoom link that was in your, that you received for today. So use that same Zoom link. And the other reminder is just, if you have a learning plan that you completed for day one and you wanna start fresh tomorrow, go ahead and email us your day one learning plan. That's at theeducationathccinstitute.org, and we'll give you another reminder tomorrow. So any other questions or comments? Melissa, I think there's a question about handouts on PowerPoint. Oh, thank you. Are the handouts in PowerPoint? Yes, so we will, same in the HCCI Learning Hub, we will post today's slides, a PDF of those slides. All of the handouts are in your workbook. So that's already there in your workbook, in the HCCI Learning Hub. And if you are still struggling with how to access those resources, you can email us, Sarah can help you offline. Okay, so I'll just, I'll leave this just a reminder. You know, I mean, we're, HCCI is privileged to work in this, you know, in this area as a national nonprofit. We have a special emphasis in the Chicago or Illinois area, as you know, which spurred the Illinois House Call Project. We work with a number of great provider, or partners rather, to make this happen. And so another thank you for the Johnny Hartford Foundation, our partners at Rush University Medical Center, and then we've also been supported by the RRF Foundation for Aging. So if there are no other questions, we'll go ahead and conclude for today. And we look forward to seeing you again tomorrow, 9 a.m. Central Time, using the same Zoom link that you received for today. Thank you. Thank you so much, everyone. Have a good evening.

mental health

trauma-informed care

medication management

elderly populations

comprehensive assessment

personalized care plans

referral

appropriate resources

impact of trauma

cultural differences

social determinants of health

addressing trauma

supportive relationships

accurate documentation

coding