Good morning, welcome back y'all. Morning everyone. I was waiting for folks to come in but it stopped at 28 participants, so maybe that's what we have first thing. Yeah, we're still admitting here slowly. Okay. Is it a click? Every person? Yeah. Oh, that's tough work. Okay. I'll tell you, I haven't ever had to be on the admin side of zoom. I feel like I can barely be on the participant side of any of these. I think we have everyone so far as people trickle in, I'll be monitoring that. All right. Well, thanks for joining you guys. Welcome back. My head cold has cleared up a little bit, so I have a lot more spunk. We have a fantastic day scheduled for today. I'll do the next slide. Huzzah. Huzzah. So we'll start with Christina and oh, yes, Sarah. Great. Start us off with the welcomes facts in the chat. I think we had a little bit of a quiet group yesterday. I'm hoping we have a little bit of spunk for our Friday heading into the weekend. I'm reminded that weather is so different everywhere. It's 75 degrees here and poor Megan's in a tropical storm. Hopefully it's nice wherever y'all are. Paul and I will talk a little bit about cultural competency. Megan will talk about medical decision making. A couple of us will talk about improving workflows. We'll take a short break. We have a great one of the big topics yesterday was safety. So I think safety is going to be a really robust discussion. And so we'll talk more about safety. Megan will lead us through that. And then we'll talk community resources. And so we have a fantastic set of new social workers here today that will take us through those. Take a break for lunch. Talk about some more operations. I think that came out a little bit yesterday. Staffing and workforce. So think more about your staffing questions. We're going to try to get kind of creative. Putting it all together we'll do as a group. And then I'll just do a few minutes on the future of value-based healthcare and how we kind of set up the advanced course to be additive to this and kind of be progressive on our next stuff. So I think it will be a really fun day. So a 9 to 4 schedule. And thanks for joining us. One of the things that we talked about kind of when we left was we saw our Brene Brown video. And so I want to kind of talk about kind of the boundaries. I think we have a video for that. No? Okay. Good, good, good. We'll get to the video. I don't know. We created some word clouds from the input from our learners yesterday. Do you want to talk through that? Yes. Yeah. Sorry. My slides. Okay. Great. So what we asked yesterday is what do you hope to get out of this workshop? And some people gave verbal responses and some in the chat. And so if you've ever done a word cloud, HCCI does these fantastic word clouds where they take the number of times it's mentioned, it makes it larger. And so the larger words, it's not necessarily color specific, but the larger ones are the ones the group identified as what they're really hoping to get out of this. And so, you know, let's go through this, jump in, you know, especially as you think of your day two, we want to make sure all your questions are answered and that you're also getting everything you want out of today. And so even overnight, we gave you stuff to think about, and there's new stuff that you'd like to add to this list. Let's do it. A couple of big ones that popped out were partnerships, workflows, community partnerships, practice management, efficiencies, boundaries, safety. And so you see we've covered some of those things already. And now emotional care, right? That came out from the beginning. We talked about burnout and self-care yesterday. And now we're going to spend a lot of today going through and tying some of these clinical examples with a lot more workflow, efficiency, support, staffing. And so I think some of those more practice management pieces will come out today as well. I'm going to check the chat. Anybody throw in there if there's anything else you want to see getting out of today. So then at the end of the day, we ask the question, what are you glad you learned today? And then people put thoughts in. And again, size indicates volume of people here. And I love that the popping one is billing. I used to say when I would teach, Tom and I would teach, and I would say something to the effect of, you know, I have the easy job. I'm just trying to figure out how to pay for it. You guys have the hard job of the clinical work. And I remember he kind of put me in my place and was like, I actually think that's pretty hard work. And so we're trying to give the tips and tricks to how do you think about revenue, billing, productivity, efficiency. And I'm really happy. This is Brianna's billing talk always is a standout from our time together. As you have other billing questions, this is the time to use Brianna's brain to get those out and talk more. So anything else that anybody wanted to add of what you glad you learned yesterday? Okay. So any other day one debrief, any other challenges? We got out all of the correct resources. And so hopefully everybody has and has access to the LMS and that's working correctly. Other successes people want to talk about. Did you just completely shut down, grab a glass of wine and go to dinner? Or did we get you thinking all night about something? So, you know, unmute, share your video, throw in the chat. Maybe they just want to watch Brene Brown with their well, I get that, I get that. We can get it started here. Do you have anything else you want to say or you want me to queue it up. Yeah, well I wanted to talk about it actually that popped up in one of the word clouds and boundaries, if you notice that and so, you know, if you're not sitting down and reading a Brene Brown book, that's fine. YouTube. She has a number of articles I think she does she do a podcast I'm brand new to podcast so if anybody has. She does okay podcast tips put in the chat because I feel 100 trying to use this platform. I haven't talked about her I think this is a great video we typically assign at night one. And then we talked about in the morning. So, you know, let's, we're going to talk about it right after so be prepared for your thoughts around boundaries. Was the idea that the most compassionate people I have interviewed of the last 13 years were also the absolutely most boundary. Because they saw give me a great definition of the definition of boundary that I use in the book boundary is simply what's okay and what's not okay. What I think we do is we don't set boundaries. We let people do things that are not okay, or get away with behaviors that are not okay, then we're just resentful and hateful. May I'd rather be loving and generous and very straightforward with what's okay and what's not okay. And I did not that I learned from the research, I was the exact opposite. I, I assumed for the first 35 years of my life that people were sucking on purpose, just to piss me off. That's what I assumed that. Yeah, right. Whether it was someone who worked for me or it was someone who family member who was constantly like I was always critical and judgy. And I was like, why are they choosing these things? Why are they making their choices? They should know better. And then when this thing came up for my therapist, what if people are doing the best they can? I thought my husband had the most beautiful answer to that question. He said, I'll never know whether people are doing the best they can or not. But when I assume people are, it makes my life better. So now I think I am not as sweet as I used to be, but I'm far more loving. Was that just some like technique so that you can do that? That's really like a way of being to like nurture that soil. Yeah. Generosity to assume the best about people is almost an inherently selfish act. Because the life you change first is your own. Yeah. And so it's so my question is big. B.I.G. What boundaries need to be in place for me to stay in my integrity and make the most generous assumptions about you? But generosity can't exist without boundaries. And we are not comfortable setting boundaries. Because we care more about what people will think. And we don't want to disappoint anyone. We want everyone to like us. And boundaries are not easy. But I think they're the key to self-love. And I think they're the key to treating others with loving kindness. Sustaining. Sustaining. Nothing is sustainable without boundaries. I think compassion and empathy are different things. And again, I'm relying on my data for this. I think compassion is a deeply held belief that we're inextricably connected to each other by something rooted in love and goodness. I call that God. Not everybody calls that God. My dad would call it fishing. Fishing? Fishing. Is it fishing? No. There's no G in fishing. But I think compassion is a deeply held belief. I think empathy is the skill set to bring compassion alive. So empathy is something we can teach. I mean, it's something we've taught our kids since they were very little. It's about how to communicate that deep love for people in a way so that people don't know they're not alone. I think there's a lot of new and interesting information out there about empathy not being a good thing. About that, you know, there's an argument that says, you know, if Travis is in struggle and I practice empathy with you, I'm taking on your darkness. And it leads to burnout and it leads to… But empathy is not feeling for somebody. It's feeling with them. It's touching a place in me that knows where you've been so I can look at you and say, me too, brother. You're not alone in this. And I find empathy to be infinite. I think it gives back tenfold what you put out. It's sustaining. It's sustaining. If you've done the work and you have your boundaries, I mean, you could tread that water forever and never get tired. Okay, so empathy. I'm quoting Travis here. Empathy. If you've done your work and set your boundaries, you can tread that water forever. Amen. It's not finite. And it keeps giving back to us. And so this idea that… But here we go back to where we started this conversation. Empathy minus boundaries is not empathy. Compassion minus boundaries is not genuine. Vulnerability without boundaries is not vulnerability. So you see that there's a huge riff here, which is boundaries are freaking important. And it's not… They're not fake walls. They're not separation. Boundaries are not division. They're respect. Here's what's okay for me and here's what's not. So we put up a couple questions, reactions to Brene Brown's video, What Keeps Us From Setting and Sustaining Boundaries Needed for Self-Care? And this can be related to your work. This could be related to your personal life, or it could be related, you know, like your employee-employer interaction with your employer, or it could be your patient care. So thoughts on boundaries, boundary setting? One of my favorite lines is, I assumed people were sucking on purpose, right? Isn't that fun? And I think about… I know everybody's kind of done talking about COVID. And I'm with you. I don't… I'm not really interested in another webinar on COVID. And there is this moment where you look back and you're like, I'm a different person since that. The people around me are different people. And my patients are different. And people experienced a lot of things, including a lot of trauma. And I would say this from our practice. We have 185 total people. I've been here 10 years. The number of short-term disability or even just kind of sabbatical leaves that we processed in the two years of COVID related to something around mental health or addiction was four times what I've ever done in a year, in those two years. Four or five times. I mean, it was unbelievable how many people needed support in that. And I think some of the trauma, as people have come back, is not completely solved. And so this accepting of boundaries are frigging important, is what she's describing, of how you set and keep you good to be able to care, be, provide empathy, provide compassion for others. So thoughts? Amanda, can you hear me? Yes, sir. You know, we talked about yesterday that people will go into this line of work. We tend to be mission-driven people. We see the need. We want to help our patients and their family members. And that when we're at the home, there's that special tug when we see there's such a need, whether it's groceries or picking up the medications or even just doing some cleaning around the house. There's that compassion in our hearts that many of us feel when we're in the home. Let's just do something for them. And I think sometimes that what Brene Brown is talking about, that boundaries can get really blurred when we feel that compassion to do something for our patients exceeds really what our job descriptions are. And it's really not a sustainable model, meaning picking up groceries every week or picking up medications every week for the patient. So I think all of us need to be aware of that tension that's in our hearts between our love and compassion for our patient and what is really sustainable for you as a professional caring for our patients at home. No, and I would say for the non-clinicians, too. I mean, I describe it as I care for people who care for people. And so I'm watching people, you know, just give and give and give and sometimes not recognize. You know, if you feel like there's never enough that you could do for someone or there's always more to do for someone, then you also don't give credit for the wins. You don't give appropriate credit for those wins and take those wins. And sometimes you don't make the kind of impact that you thought you would as an employer working with employees, as someone taking care of patients. But we all can relate to having someone in our family. Maybe it's a sibling. Maybe it's a child. Maybe it's a parent. Maybe it's an uncle or a grandmother where we've looked at the situation and we're said, I'm not sure how much more I can do. I'm not sure how to help. And it's so deflating and defeating for us. But I just I describe it as kind of like, you know, I think of like a bullseye in the center is you. If you're good. Right. Then, you know, maybe your marriage is next. Right. You and your spouse are good. You and your then you can provide for the children and then you can provide for your work and your community. If you if you're not good at your core with you, it's it's hard to keep giving out to others and without running into what we talked about last night is burnout and needing self-care beyond sometimes how you know how to help other thoughts. I still feel guilty after 15 years. I still feel guilty saying no to appointments. Or what about the guilt of someone? Someone has canceled on me two or three times. I know they really need me, but I need to stop. I need they can't. I need to stop going or I keep I keep doing something and the patient compliance is not there. And I need to I need to stop. I can no longer help anymore. I think it's OK to fire a patient. I think we have to be that has to be normalized that you have to recognize when somebody is is causing problems for your staff. They're caught if they're causing problems for you, they're causing problems for others. And so sometimes you really do have to make that decision. And quite honestly, you'll you'll feel bad at first and you'll feel guilt. But then you'll also realize that you've also you have to remind yourself your staff is feeling better about this decision. You feel better because then you're better able to manage those things that are really important. Yeah. Being able to fire a patient is setting a boundary. Yeah, absolutely. OK, well, I appreciate that. I think it's a good way to kind of tie last night as we set into today because we're going to talk about all the more components and more things to take our attention away. And so or to focus on. And so I'll turn it over to Megan to kick off meeting Christina. Thank you. Great. Thank you. All right. So we're going to meet Christina. Christina is kind of a good example and a segue into some of the things that we're going to talk about this afternoon. So I want to have you put this idea of Christina in your mind when you think about our discussions on consent and safety and capacity. So you're asked to see Christina. She's by the home health agency. And they've been in the home since her hospital discharge. Christina is a 68 year old Romanian woman who lives with her 50 year old daughter, Veronica. Over three years ago, Veronica brought Christina into the emergency department with significant abdominal pain, nausea and obstipation. Christina has been ill for several months in Romania and could not obtain what Veronica considered adequate care. At that time, her abdomen was somewhat firmly distended with a protruding umbilicus. There are prominent lymph nodes around the umbilicus as well. She has evidence of ascites on exam. She was diagnosed with stage three ovarian cancer, underwent debulking surgery and then subsequently had chemotherapy for six months. She had well for a period of many months, but her tumor markers have lately begun to increase. She's had recent surgery. First of all, the obstruction caused by adhesions in his home with health home health for the three weeks post-op. And Christina's case is in the workbook on page 45. If anybody wants to kind of get more in depth or detailed with her. Let's go to next slide. So. You go out to Christina's home and the issue is, is that she's got several kind of things going on at once here. She's got. Where she's really feeling fatigued, she's just she doesn't even speak English. So her daughter is the translator and her daughter has to. You're relying on her daughter to tell you everything. She's, you know, again, also now having a rash on her chest and with her past history of ovarian cancer and hypertension, hypothyroidism, hyperlipidemia. You're trying to make sure that you're giving her the best care that you can, but you're really not sure. What does Christina need? So this goes back to consent. So we'll scroll on down. We've got her past medical and social history again. And then as we get into our physical exam. I believe there's a picture of her rash, I thought, which. Yeah, we'll keep the scroll down. Let's go all the way to the bottom to the assessment and plan for. There it is. So we see the vesicular rash, the T8 dermatome. And again, we're relying on her daughter to translate for us. She's been tired. So we have all these kind of multi issues with the fact of ovarian cancer. And let's scroll down some more. So we've got to go back to thinking, what are the four M's in this case? What are her goals of care? Veronica, the daughter, hopes for her to have more energy and improve her functional level. Veronica needs to return to full time work, and she's used her FMLA. Veronica wants Christina to restart chemotherapy as soon as possible. Again, keep in mind, is this Veronica or is Christina the patient? And let's scroll on down. So first of all, we have to ask, what matters for the patient? What do we do in a case like this where the patient we're not communicating except via the daughter, this is where you have to really start saying, do we need to get a translator? Have any of you looked at some of the translational services because this situation does happen. At least in my area, we have a large population from Ukraine. We have a large Hispanic population, Creole is another language that comes up. So those are things to think ahead before you walk in. Do I have the necessary tools and resources to be able to make sure that the patient wants the same goals as the family? And then we have to make sure from a mentation standpoint, does that person have capacity? And we'll talk about that in a bit, but how are they doing? What's their mood? Do you know if she's depressed? And then we're still trying to assess mobility, taking a look at their medications and the overall multi-complexity of the patient. And let's go back to the slide deck. So again, we're looking at what matters, the mentation, the mobility medication. Those are the real key things we've got to kind of formulate our plan towards because she is such a complex patient. And let's go down. Next slide. And keep Christina in mind as we get to the next parts of these discussions because she's that classic patient that you'll be facing. Dr. Chang and then Damana. Can you? Oh, there we go. Huzzah, thank you. No, I really, I appreciate that. We wanted to spend a few minutes talking about cultural competency and considerations of DEI in the home and specific to home-based medicine. Slide. So here are a couple of objectives. We're only spending roughly 15, 20 minutes on this discussion. This can be a very deep, robust discussion. In fact, I'm speaking in June, at the end of June, just on LGBTQ cultural competency at an all-day DEI event. So, I mean, DEI has really kind of a new place and always been important, but it has a new place or new position of importance for our education. So let's talk a little bit about culture, just shared decision-making, cultural bias, and impact on healthcare, and review the way home-based primary care can enhance cultural awareness and we can create the goals of care that are really meaningful together. Slide. We're just gonna talk about a couple of these concepts. There is a home-based primary care DEI module, half-hour module for free. It was created under a grant on the module. So any of your staff can take it. You can send it out as required for your staff. That goes into a lot more depth. But one thing we kind of want to talk about is people have often talked about the golden rule, do unto others as you would have them do unto you. And that's really treat others like I want to be treated. And DEI is teaching us the platinum rule. Treat others the way they want to be treated. And it demonstrates a deeper and greater sensitivity to cultural differences. It really focuses on the core. The other person is being the person where you're coming to meet them versus them meeting you on treat me the way I want to be treated. And we start acknowledging values and beliefs that are maybe different from our own. And so this can, the etiquette of a visit, we're gonna kind of do a case study. This can depend on the culture, the family of the patient or the family. So any examples of any cultural situation you've walked into, and don't just think race, income, certainly race, socioeconomic, like if you're of a different race, if you're of a different gender, but there are so many other cultural differences that we might run into, right? I'm a city provider and I'm going two hours to a rural community. I'm this political belief and I'm working with other political beliefs. Whatever those might be, straight, gay, disabled, something that maybe you've learned kind of in your work. Are there any chats about it? Anybody want to jump in? Paul's going to go through an example too, but anybody have a personal example of? Okay. Amanda, there was a comment in the chat about Dr. Joy said, taking my shoes off at the door and in honor of certain cultures to do dentures and cleanings, et cetera. Sure, absolutely, yes. Absolutely taking your shoes off. One example is also, maybe women of certain generation, it's heavy weight in kind of the outside waiting room or different genders prefer different providers. And it's not personal. It's just, if I'm a male provider, or if I'm a male patient, I'd like a male provider. If a female patient, I like a female provider or caregiver. Absolutely. Other examples? I think the key takeaway of this slide, and we're going to kind of go through areas to kind of think about, but the key takeaway too is understanding just where someone is coming from. And sometimes it just takes a pause to identify those things. So slide. Oh yeah, Jennifer put some patients prefer an MD. Absolutely, absolutely. Sometimes there are provider specific. I think some of that comes along with education too for us. And you're not going to get everybody. There might be a cultural difference in which really a physician is the only authority in which someone will hear care news or prognostication. And we use the opportunity to manage up. So if a physician can really in front of the patient say, this is my partner in crime, this, you know, my APP, and they're really great. And they're the person I trust and you could work with them or the RN. Those are the opportunities to manage up other specialties too. So, you know, it's not just understanding medical conditions, it's also how you make decisions and how decisions are made about an individual's care, who the patient wants involved, having these discussions early and reviewing them regularly, especially as things change. If the caregiver's present, making sure you understand that you're reading the non-verbals in the room of what is the relationship. Sometimes it takes asking a direct question, you know, is it okay if they sit in, would you like me to share information with them? And understanding when emergencies happen, when, if you have that information on the front end, you can better respond and respect the information you've gotten versus I really don't understand what, who the patient wants in this emergency situation or what they're really looking for, you know, and especially when we think of end of life care, regardless of if they should be on hospice or comfort care, if they have stated, I wanna go to the hospital, those types of things of understanding that patient, that patient kind of care. So a couple of steps here, click out of the chat, explore religious and spiritual beliefs that may impact healthcare preferences. You get advanced access to that being in the home, you know, seek understanding of historical and political context of the patient's life. That's part of the storytelling. I'm understanding who they are. We do a five-step method in our practice. And one of them is tell us about your, you know, tell us about your life, you know, and we find out a lot about, you know, who's fought in wars, where have people lived? How many children do they have? Address communication and language barriers with best practices. It is historically best practice to have a translator present. Sometimes it's not always possible, but there are biases if you use family members that can come into play or things that they're not willing to translate or sensitive questions that healthcare translators can be more helpful with. And then involve people, you know, who's really, ask the patient, who's really part of your care team? You know, is that a spiritual leader? Is that a community leader? Is that a cultural leader in your community? So understand those things as you start your relationship. Next slide. So steps into kind of shared decision-making, understand cultural beliefs regarding kind of truth-telling or withholding information. And sometimes that occurs, sometimes it's not. It might be more culturally sensitive of like, hey, we don't tell mom these things. She really doesn't know about her own health condition. You tell me everything. You know, elicit the patient values and preferences, understand, again, who's on the care team? Who's gonna be involved in the care? Who would you like information to go to? How would you like me to give information? You know, and then again, how can I participate in the best way in your care? You know, be aware of preferences of family-centered decision-making in many cultures that it may be a group versus an individual. So I think there are a couple of things. One thing I would add to this slide though, is before you step into someone's house, start with your own biases. And this goes with, you know, even your relationships with your employees. Start with your own biases. And there are some great tools on the webinar, but we can send it out too of just implicit bias tests. I can't remember who put the, Harvard who put the implicit bias, Project Implicit Bias is a website that you can go to. And you can do different kinds of tests of, you know, racial bias, gender bias. And it will give you and say, hey, you're biased maybe against this group or you lean this way versus the other. And I just give one personal example because I just don't think we talk about this enough. My mother, my dad died when I was really young. And so my mother entered the workforce much, much later in life. And so she didn't work for many years. And then kind of when we were getting a little more stable, tried to enter the workforce and fell into, I would say pretty extreme ageist bias or, you know, an ageist culture. And it took her three or four years, even with an MBA to get a job. And so when I hire, and I'm responsible for a lot of hiring, but when I hire, I often have a bias to an individual who has taken time off for their family or I know is experiencing ageism. And I just identify that to my hiring team. And I say, look, like this is kind of a bias I'm coming in with. You know, I'm more likely to hire someone who has taken a few years off and kind of give them a chance. And you may not all be on the same spot and now you know it. And you tell me your biases and we've talked about those things open and honestly to make sure we hire the best person for the job. And so just an example of a conversation I have to personally have out loud to make sure we're always doing the best thing for the business. Slide. So I'll turn it over to Paul to give us a great example of Mrs. Chang. Thank you, Amanda. Mrs. Chang, I think is it on, is her case on page 56, is that correct? Of the workbook? Yes, and I'm pulling it up. You should see it on the screen now too. So I will give all of us a little bit of time. This is a real case that I encountered years ago. It's kind of interesting what Amanda said. You know, I grew up in the East and I spend my time out many of my years now in the West. So I have a little bit of maybe a duplicity in my own mind when it comes to dealing with patients of Asian descent and so on. Maybe my bias is that, oh, I automatically assume that I should be talking with the son rather than to the patient because I grew up in that culture and I kind of understand that culture and I default to that bias, if you will, when I see somebody like Mrs. Chang. So let me just walk us through the case. She's 84 years old. She's a Chinese patient that I'm seeing after she was in the emergency room for weakness and her falls. Her past history is limited because she hasn't seen a doctor in a long time. Her exam, she has very limited English skills. She's very frail. She looked pale. She's got something going on in her right lower abdomen. Her legs are swollen. Her short-term memory is a little off and I've had a chance to review some of the records from the emergency room. She's microcytic. She has microcytic anemia. Her kidney function is not great, stage 3A CKD. Her liver functions are a little bit elevated. Her albumin is low and a CT scan of the belly and the pelvis shows there's something going on in the sacral area, suspicious for a neoplasm. Henry, the son, is a very nice guy. He works very hard. He cleans restaurants and bars in the city at nighttime. Henry's the firstborn son. There's no official power of attorney paperwork at home, never been done, but Henry has been the one that's been involved in making medical decisions for the patient per the emergency room physician's record. When I was finishing up, Henry asked that I have a private moment, have a conversation away from the patient. He said, I can still remember. He doesn't want to burden, remember there's that hope thing and so on, doesn't want to burden mom with any of the findings that I've noted on blood work or EKG CT scan. She is a worrier. She looked for things to worry and dwells on that, these problems, don't tell her that you found anything abnormal, okay? Because if you told her that, it will create a lot of turmoil and anxiety for her. I want her to be comfortable, peaceful. Just tell me the abnormal findings. I know my mom, she has complete trust in me regarding all of her needs, okay? So I go back to the bedside table, well, her bedroom, and I sat on my little stool and she asked, is everything okay? So I'm gonna pause a minute and maybe open up the mic and let me get back to the chat box here. What would you do in a situation like this? How would you navigate this relationship? How would you maybe try to honor the American, the Western concept of patient self-determination and then also honoring the more traditional Eastern idea of working with family, in this case, particularly the son? Oh, Tony, Tony, you're muted here. There we go. I think it's my own bias on this, Paul, but, you know, from my perspective, the only person who can give me permission not to share information with them is the patient themselves. And I know that's applying my sort of values to the situation, but when I faced this situation in the past, and I've also faced this situation, it's been resolved with a conversation that included the patient. Because I've given the patient permission to tell me that they don't want me to work on the details with them or share the details with them, and they'd rather me do that with the family, but I couldn't go there and do that unless the patient had requested that. Playing the devil's advocate here, if I did that, and the patient says, tell me everything, I could potentially burn the bridge with the son, who's the primary caregiver for the patient that I kind of depend on to deliver care for mom. So there's that risk on that side, you know, find out what the patient want. I see that, Samantha, that comment there, but there's that tension there. If mom says, yes, talk to me, and the son is there saying, hey, you know, what's the problem, doc? You know, I told you to, don't talk to her about any of this. So any other comments? Thank you, Tony. I really appreciate your comments. Anybody else? I probably would just ask the son to come into the room and say, well, let's bring your son in and, you know, have this discussion with him and then hope that he could kind of like guide how that conversation goes. Yeah, yep. Thank you, Jennifer. Other comments? Tell my son that I have an obligation to the patient and meet on a common ground. Yep, absolutely. That's it. We're trying to find a landing pad for our conversation here right, a place that is, that's hopefully a workable compromise for everybody here, not being a cultural elitist actually either way. Right. I will probably have more conversation with the sun to push him on his thoughts. Okay, Mark I'm wondering what do you mean by that, so that I can better understand that. Would he come to my side, that sounds terrible so yeah there's a bias comment there right. Right. Would it would be you want to do the western side or maintain on the eastern side. And you know how how us as providers need to kind of navigate this kind of a landmine here in some ways, because we want we know we want to provide care and yet we want to be respectful of cultural differences. Any other comments, we only have a few more minutes. Yeah. Yep. The client goes with what the person in charge wants. Yeah. Yeah. Tough spot. So, Paul, what you do, and as a real quick like in this case, and Christina's case that Megan introduced. If there's a language barrier, do use a translator, if at all possible and not depend on family members because we have no idea what's being said or not said especially when it comes to, to difficult conversations like this because I can say a lot, a lot and then the sun translates to mom in like two words, and you're like going no I that can't be you know I, you know, it was a paragraph, and, and, and you said, you know, like, that's it. So I'm a little suspect so if you can use a translator service, that'll be great. So what I did was I did bring the sun in Jennifer. And, and I say, Mrs Chang. You know, I hear that. I can't remember. Oh, this is I think this is how I remember saying it. I want to be respectful of your culture, and I want to continue to work with your son, in terms of delivering ongoing care for you. Now, as a doctor, I would like to share what I know what I found in the lab work and emergency room etc something like that with you. However, I also would like to respect the culture that you're from. And the culture that you're from says that often family members defers to XYZ family members to make medical decisions for them on their behalf. Okay. Having listened to what I said, is there one way that you prefer over the other. Okay, and the sun is in there. I did try to find common ground landing pad, so to speak, having respecting what the sun said and at the same time trying to fulfill my duty to tell in truth telling for my patient and putting the decision making hopefully more in her court, then completely on me, I have to make this decision for her and see what she will like to do going forward. So make a long story I'll conclude, ultimately she decided after some thinking, she said go ahead and just continue to work with my son on this regarding my care. The concern I have in my heart before I started this is that if I told her that everything was fine. You know our patients are not. They're not stupid. They know something is wrong with them. Okay. And if I told them that everything was fine. Will I lose their trust. Will I lose the patient's trust in me. So those are the points of tension, and I will stop there and appreciate any comments feedback. Thank you. You know, thank you, Paul for sharing, you know, if you've met Mrs Chang and Henry, you've met, you know, one family. And so the other thing, you know, to think about is, we don't necessarily need to apply all assumptions are all cultural learnings or, you know, shared norms to everyone in a specific population. And sometimes, sometimes in healthcare we can kind of generalize and so I'll give an example we have a large Russian population and sometimes I'll hear the care coordinator say, Oh, our Russian patients don't believe in hospice. And again, that's not necessarily all patients right that's that's you've met patient you have and maybe many of your patients are feel that way, but that's not specific to just the Russian population either of how we think of end of life care so there, there are a lot of things that, you know, maybe sound like more benign comments or they sound like kind of grouping together it's easy to kind of group together again and in healthcare, or kind of take shortcuts. But as we think about our true and ultimate goal, it's to get to honoring what the patient really wants. And we can really only do that if we get to know the individual and what their goals are and what their preferences are and what their background and And I'll say this. One more one more comment on this. We're all different right so we have 7 billion people so we have 7 billion existing lives today right many billion before this but 7 billion individual stories. So, you know, again, you know how do we this extrapolation can be kind of challenging, and it requires this this personalizing of healthcare. Yeah, thank you slide. So I'm going to read through this brand is going to jump in but there's this slide and then you can go to the next slide. These are called the Z codes. And I'll give you two examples and you can kind of read through them. These are social determinants of health codes that are actually able to be submitted through the 1500 process right there ICD 10 codes, they don't come with reimbursement. use for the government to, to, to gather data on patients and I would just put a plug in and Breanna is going to add to this but they're not really using being used this way but in a future world I envision being able to identify and use these codes as ways to help funding be targeted to patients and so again, right now we're not there's no dollars assigned to it they're not in many ways you have so many other things to think about that you say hey I'm not going to think about this but putting, putting, you can go back to the other slide is we've looked at these but like putting these putting these Z codes down reports to the government, the kind of practice you work in. It also reports to the government, where there might be funding opportunities relating to county and state funding opportunities and and quality outcomes could be future linked to this so just want to put this on your Yeah, I mean I think it's interesting. I don't know if you all but I feel like the past six months a year or two it's like everyone's talking about Z codes right and we're all focusing on social determinants of health as we should. And, you know, put reimbursement in the corner of course I'm the same person that's going to tell you it's important, but the ways that I've seen practices using these in a meaningful way is more of a quality improvement initiative say okay we're, we know that our patients struggle with the social determinants of health. We're going to use these Z codes so that we can report on them and then we're going to track interventions and see what was actually done or see, you know, so you could consider it in that way. I mean you think of all the ICD 10 codes that you assigned to a patient encounter it doesn't hurt to report it or add it to their problem list. If you were going to think about it in the way of quality improvement I would say CMS is putting a lot of focus on the social determinants of health. I think the infographic that I have linked on the next slide is one from CMS and I think this will continue to evolve, we've already seen them saying that the direct contracting model needs to have some social determinants of health tracking. So I think it'll be interesting when they start making parts of this required for certain payment models. It's not that you couldn't use it on a claim. It's just that, you know, to Amanda's point right now, the feedback that I get from providers is like oh well these aren't HCC codes they don't risk adjust so like why do I care about them. But this just something to know about if you're looking for a quality improvement initiative and you want to try and more systemically track social determinants of health. There is a way to do that through diagnosis coding that I think will continue to evolve like Amanda said. Thank you. Okay, I'm turning it back over to Megan. Oh, I'm sorry. I'm sorry, I was just wrapping up. Thanks. Thank you. These are the key takeaways. Okay. So, in light of when you have a situation like a Christina or Mrs Chang. The next issue that really comes up is the decision making capacity. Does that patient have the capacity to make the decision. And sometimes that can kind of answer the, or solve the scenario for you. Alright, so next slide. So our objectives, we're going to try to define the difference between capacity and competence. We want to look at the clinical approach to assess medical decision making capacity, and some scenarios that illustrate some of these complex situations which we've even already touched on. All right, next slide. Alright, so decision making capacity, it's a clinical term, the ability to understand and appreciate the nature and consequences of a decision regarding treatment or foregoing treatment, and the ability to reach and communicate and inform decision. In even simpler terms, if the patient, you know, maybe doesn't quite follow that rationale. You're asking the patient if you decide to go skydiving and jump out of the plane, do you understand that if the chute doesn't open what will happen to you. Well, yeah, I understand that. Great. Well, let's talk about your treatment your cancer treatment, the cancer treatment may have a good benefit and getting rid of your cancer or it may actually have lots of side effects, and you still result in having in dying. And what, based upon your decision, what is that going to mean. So we want to make sure we put it in very clear terms for them. Next slide. Whereas competence is more the legal aspect of legal term, a person can be to be determined by a judge to be competent or incompetent. Next slide. And this is where we get into then informed or valid consent, because before they can give consent. Even though you've given adequate information, you include the nature and purposes of the treatment risk and benefits alternatives, they've got to be free from coercion. They have to have that medical decision making capacity, can they make a valid decision. Before they can actually give consent. Next slide. So, how do we approach this. So, we intrinsically we assess the decision making capacity at every clinical encounter right when you go out to see the patient you're out at the visit. Even when you have the medical assistant maybe call to make the appointment or or the practice managers making the appointment. We think on the phone that they have this ability and capacity to make make these decisions. But really that's kind of an assumption until it's been proven otherwise. So, one of the easy tricks that I've used before in the emergency department is I'll ask the patient, can you tell me how to get to your house from here. I mean most people can reasonably answer and give directions on how to get to their own home. But often, this is where you'll start to suddenly pick up on who you thought was a reasonable person who could make decisions and seem to have capacity. So, we tend to overestimate their decision making capacity. Next slide. So, really, you've got to document a formal assessment, you really want to make sure that you have that in your chart somewhere more explicit structured assessment, particularly if they have any kind of neurodegenerative disease. So, really, you've got to document a formal assessment, you really want to make sure that you have that in your chart somewhere more explicit structured assessment, particularly if they have any kind of neurodegenerative psychiatric illnesses substance abuse. And as we approach any kind of end of life care in the acute medical illness, sometimes you have to repeat that structured assessment and put it back in the chart so that way you've got that to rely on. As we already mentioned when you've got different cultural backgrounds, different education, language barriers. Again, we want to really make sure that we have looked at can't do they have capacity. And then as a result of having capacity, did they give consent. Sometimes consent can be given too quickly, particularly if it's a high risk procedure, all they can see is the benefit not necessarily the risks, or they'll say I didn't understand the risks. And they weren't really given the time to explain the pros and cons or understanding of the risks. And the decision can be in conflict with prior decision without clear reasons validating their prior concerns, meaning they just kind of seem to flip back and forth. You want to really be careful of that patient who one day says yes I want treatment. The next day says no. That really should tell you right there that we really need to reevaluate their capacity. Next slide. All right, so the steps to assess capacity are kind of based upon these four specific decision making abilities. Can they make a reasonable decision. One, they have to understand it. Do they understand what's happening to them. Do they understand the decision they face. Two, can they, the patient, communicate a choice. Do they understand the differences and options they have. Can they can they repeat it back to you. Do they appreciate. Do they appreciate the difference between those one, it can be beneficial and the other is very risky and can have a bad outcome. And lastly, can they reason through it. Do they have the reasoning. Do they understand that process they can appreciate the risk and benefit, but can they reason through and tell you why, why they made the decision to to decline treatment, or why they choose to fly to a out of country treatment facility, and they understand those risks. Next slide. So going back to understanding. Can they tell you in their own words, can you tell me in your own words. What have I told you about your condition, can you actually repeat it back. Can you tell me how to get to your house. Do you know the recommended treatment, the risks the benefits alternative treatments. What do you think will happen if you choose not to have treatment. Do you understand that. Next slide. And then, again, make them that you want to and you want to document this but make them tell you in their words, based upon what we've just talked about what is your choice. Do you have. Do you choose to have this treatment, why have you decided to do what you're doing, but really you want to make that sure it's very clear. Next slide. What do you think the treatment is for or going to do to you, how do you think it will help or hurt. What do you believe will happen if you're not treated. And why do you think this treatment, why do you think that we discussed this, why do you think I brought it up as a recommendation for you. Next slide. And lastly, again, why did you come to this decision, what was your, what was it because your daughter told you this is what you're going to do and that's it, or is it because you have feelings or thoughts one way or the other. Next slide. So, we get into the spectrum of capacity, it can have varying degrees that's that's always the tough part. In that capacity threshold can change according to different specific issues risk benefit analysis. And it's important to consider and be aware of the capacity of not just the patient but the caregiver as well. So if you have a husband and wife team, you might the husband might be your patient but there's a wife also have a capacity and to understand what's happening to the husband. Next slide. So, going back to capacity. They really have to have the cognition, that's the main determinant of capacity, and that can be distinct from each other. So this is where it's really important you have a current MMSC or mini mental status exam on your chart. If they're lower than 16. They're all day long if you've documented they have a 1514 on the chart all day long, how are you going to be able to explain that you that they had the capacity to make decisions. So you want to make sure that your, your documentation is an alignment. And if they have in between a 16 and 24, you definitely want to make sure you have additional documentation to explain why you may have said that they had the capacity to make decisions for themselves about their treatment and or their living situation without asking for additional resources or help or reaching out to a social worker to say, what do we need to do here to have some help with their decision making? And if it's above 24, again, then that good, that correlates with what you're trying to do. Next slide. So that goes back to dementia. Again, making sure you have a mini mental status exam on the chart. If there's a documentation, if you've put down that they're demented, again, that's, you really want to make sure that you're documenting their level of dementia and have additional documentation to support if they're making any decisions for themselves. And again, start reaching out to a social worker, whether it's even by utilizing somebody with a home health agency, somebody in your own organization, if you have that, but you really need to start looking out for those additional resources within the, even their own family to make sure that everybody's having the same decision making, that they understand the issues, you're communicating the different choices, appreciation, that they understand and appreciate what's happening and that they can all reason through it. Next slide. And keep in mind, so dementia, you start to see this real quick breakdown in their ability to reason through these decisions. So again, very, very slippery slope, but psychiatric illness, interestingly, although patients with schizophrenia, they're more likely to lack that decision-making capacity, whereas you might have somebody who's just depressed and they they have capacity, they have cognition. So make sure, again, you want to start using some of your documentation to help support these decisions. And recognize that sometimes with schizophrenia the other psychiatric illnesses, they don't have much insight into their disease. And if that's the case, if they don't recognize that they're really not functioning well on their schizophrenia, that's going to be a real predictor that they probably should not be able to have decision-making capacity for themselves. Next slide. So what to do when a patient lacks capacity. Okay, so consider how long is this going to last? Is it temporary? Is it because they're having an acute psychiatric episode? Is it because they are progressing in their dementia, etc.? So if there's something that's reversible, they've got an acute illness, by all means, we want to try to address that and treat it as quickly as possible. And then for patients with that mild to moderate cognitive impairment, discuss, educate, get the family involved, make sure we have healthcare power of attorneys that we've talked about what's going to happen when they lose that capacity. And who's going to be the substitute decision maker? So guardianship and surrogate laws vary by state. So if there is a, sometimes you get a court appointed emergency guardian, that process and length depends upon where you are. You also need to make sure you've already identified a willing guardian or family member. Sometimes we're seeing more and more parent and child estrangement. So this is going to get even more interesting. And we see it a lot here in Florida, where the patients here in Florida, family scattered across the US. So then suddenly you're having to make a decision, do you call them in, have them fly in last minute and to check on a parent. And you got to make sure that that family member has access to bank accounts if need be. Sometimes we get into Lutheran services. That's a third party ward that that's using adult protective services. Lutheran services then becomes the guardian and checks in on the patient quite a bit because they don't have capacity. So those are a couple of options, but I think the overall key is, is communicate these issues early. So that way, you know, right off the bat, who is that next in line decision maker and that you make sure that they, they understand they need that paperwork in order. We have a resource here in Florida, the Senior Friendship Center, which usually has an attorney available for free of charge one day a month. So that way, if some of this paperwork needs to get drawn up and it's a financial issue, sometimes that's a way around it too. And again, I would utilize a social worker to try to see if you could get some help. Most home health companies will have some sort of access to a social worker or might know of one that is available to you if you don't have that resource. Next slide. Tools to assess capacity. These four listed here are great examples. You'll have to Google them. They're not really like in MDCalc or some of the other apps for easy usage, but I would make sure you take a couple of these, screech on it, because you really, if you have anybody that you're questioning after you've done an MMSE and they're scoring in that questionable zone before below 24, you're going to want to have some additional documentation to say that they're able to make these decisions. Next slide. And this is the payment aspect because it is, this does take some work and it does take documentation and this is something you should get paid for. Yeah, I can chime in here for a second too. So I know Dr. Kaplan mentioned this yesterday too, but those of you who may not be familiar, there is a relatively new service called the Cognitive Assessment and Care Planning Visit. So I mean, this is intended to be a pretty extensive visit. Medicare says typically 50 minutes and I'll put this link in the chat. Medicare actually has its own website for this exam that even has a provider education video that you could share with your team, but it's intended to be, you're seeing the patient just for their cognition, right? Like it's a very extensive visit where you're either, you have to use some sort of standardized tool assessing for dementia or trying to reestablish the stage of dementia. And you're working with the patient and the caregiver that has to be a caregiver or independent historian available in part of this visit to develop a cognitive specific care plan that could just be within your know. It doesn't have to necessarily be a separate care plan like it does for CCM. But where I hear sometimes logistic challenges from providers is like when they're trying to do this with all of their other, you can't fill an E&M and this, like this is your visit for that day. I know some practices that have made it a best practice for any of their memory care assisted living patients, that this is the first or one of the first visits that they do. And they kind of build it into their practice in that way. Again, it pays nationally from the CMS fee schedule, $283, but it is what you make it. So I would say that, you know, the challenge with this is it should be a meaningful visit when you have the time and you're setting expectations with the patient, like, okay, I'm going to come back in a couple of weeks and we'll revisit your diabetes and hypertension. Like today, I want to just talk about your dementia or today, I really just want to focus on this. So there is a little bit of logistics challenges, but it is, again, and there's, this can be done once every six months, if needed, if, you know, clinically indicated. So again, it would, it would put, need some thought into how this fits into your practice model and how you can really make it a meaningful visit that's just focused on that one condition. Last time I'll make two, some, this, some use this as a training for their new, like new providers, nurse practitioners, and then PAs, I know some that are like specialized, you know, for their memory care patients, or even some practices that might have a psychiatric nurse practitioner, that's like, they do this and their psychotherapy services as kind of specialty services for practices. Yes. Thank you, Brianna. So make sure you get paid for it and be very careful about assuming a patient has that decision-making capacity. You want to start out, you want to do that, the cognitive visit, assess them for cognition, MMSC, get that documented in the chart. Then you can kind of start and use your capacity tools to make sure that do they have the decision-making capacity? Let's make sure we document that as well. Have we identified a healthcare power of attorney in the event that this starts to go south on us? And let's be realistic. Everybody there, there's, death is unavoidable. So we're all going to eventually decline. And this happens to every single patient. So it should be one of those first things on the list as part of what matters is making sure that we've addressed this and we have kind of that plan in place. And family may not be ready to answer it in the beginning. They may be uncomfortable with it, but at least you started the conversation and got them to start thinking and talking amongst siblings, particularly if there is estrangement, you want that to start now versus when you're in the crisis situation, because then it gets kind of ugly. And that's not where you want to be caught as a provider going back to safety. So explicitly assess capacity using a structure to point approach, excuse me, make sure you're documenting your approaches and then consider the impact in specific clinical situations, sensory impairment, health literacy, language, communication barriers, you know, culture norms, how this can kind of vary. And it is sometimes a different conversation depending upon the fit with the family needs and the patient needs. Next slide. Questions. Megan, I appreciate your comments. And I think capacity is a great topic to talk about a little bit. I think I just want, I think it's worth emphasizing your point about capacity. Capacity is not a all yes or all no kind of thing. It's really dependent on a specific decision and actually a specific point in time. So when we as clinicians make a declaration about capacity, patient's capacity, we can make a statement that says at this moment in time for this particular decision, I do not feel the patient can understand the choices and the outcomes associated with the choices. In a good example, that might be a person who gets delirious. You know, they may be completely unable to engage in a conversation at one point in time, but 12 hours later may be entirely able to engage in that conversation. So we really make that point in time for this decision determination for patients. Absolutely. And then not to complicate it, but then you get into implied consent. And just as that's how kind of the emergency room operates, is that if somebody comes to the emergency room and they're so ill, they can't make decisions, you're operating under implied consent that you, that they would want treatment like a reasonable person. And so that's where, again, it goes back to making sure who's that healthcare power of attorney, what's the family and, you know, making sure that they're involved in this, because that can really also make it a little bit trickier because you want to really have that documented. Because as Tony is saying, 12 hours later, they suddenly come out of it and they say, what's going on here? What have you done to me? And at that point, sometimes then you have to realize they can rescind treatment if they're, if they have capacity 12 hours later, and they've made a decision that they don't want to continue and they want out. And that's, that's reasonable as long as they've got capacity and the cognition and you can document it. Okay. Well, thank you. I appreciate it. And we'll move on. Okay. So we're going to make a turn here into efficiency and improving workflows, front office, back office, and what it means for efficiency. So Brianna and Amanda, you want to get us kicked off here? Thanks, Megan. Yeah, so Amanda and I are going to present this session, we can go ahead and move on. I know workflow efficiency is big on topics. And Amanda, you want to start us off? Yeah. So a couple things that we're going to talk about is kind of front and back office within the house call program, various types of professionals. And so we'd love to jump in and hear about some models, and then people, processes and technologies that can improve your operational workflow. So, you know, I think I want to say on the, the cloud that of what people want to get out of it, workflows, efficiencies, people, they were all listed on there. So I think it's a really exciting one right before we go into break. So slide. So I really love this slide, because we talk about team roles and responsibilities. And we're going to talk a little bit about licensure too. But as we, as we look at this, these are everybody who could be involved in home-based primary care, right? You see clinic-based primary care have way fewer people because this, it really is kind of this team sport. So just a couple of notes, you got kind of the clinical team on site, you got kind of the practice management, you got the operations and the triangle, and then you got the positions and the boxes here. Other ones that you see that you're working with that aren't listed. Every home-based practice is going to be different. It's what resources are available. What, what is your scope of work? Are you, you know, we have again, a group who's, who's focusing on kidneys. So you might have in wound care, right? So we have specialties, specialty home visit patients inside of this group. But again, you know, are you mostly in a rural, are you mostly working with waivered services? Tony asks, is the caregiver, I'm trying to pull up things, a caregiver on the slides. Great. Paul said we don't have a social worker. Absolutely. And sometimes you don't, these don't all have to be ones you necessarily employ. These are ones involved in care. We're going to talk about how you think about employment. I think we talk about that, about staffing and workforce after lunch, but you know, these are folks that you're interacting with. So I don't, caregiver's on the slide, but absolutely. There's a question about, I'm curious how many practices have social workers. So if you have a social worker and you're on this call now, maybe just throw that in the, in the chat. But Brianne, I know you work with a lot of different practices. What's been your experience? Yeah, I would say it's pretty mixed and definitely early on. It's probably not reasonable, right? Like I would say it's probably more rare unless a practice is a staff further established or in value-based care for them to have their own employed social worker. You know, it's a pretty good mix. The comment I wanted to make on that, though, Julianne was to Amanda's point, like these don't necessarily have to be employees, especially if you're small. And those of you who are new, you're probably gonna have like yourself and maybe one other person, or maybe you can't scale too quickly. So I kind of appreciated Lizzie's comment yesterday about identifying your ecosystem of community resources and people that you work closely with. You need some person to handle and help with the social aspects of your patients, right? We talked a lot about that yesterday. Obviously home health is mentioned, but they're not the only option. Local area on aging, senior services, other community partnerships. There's a big in-home counseling in Chicago that you could, you know, that that's all they do is they have in-home counselors. So I really would encourage you to just kind of think about who on the team is going to address that. And that very well may not be your own social worker. I would say it's probably a smaller percentage of practices that get to the point to hire and employ their own social worker and nurses can help with some of this too. So sometimes we did see different people coming in and out of the social, you know, the operational and clinical care for patients. And I think another example kind of in that vein is pharmacists. Really the only groups that I'm hearing about pharmacists are well-established and usually they're part of a large health system or academic health system where they can buy a portion of a pharmacist time to do maybe some case review. My old boss always used to say, you know, you can get kind of the pharmacist role for free. You can always get someone to comment on that. So why pay for it? We have over time again used portions of pharmacists but never a full pharmacist. And only in the last year because of our size and our work have we added education. And so now we're doing a lot more education because we find that if we can do, especially in the assisted livings, more on-site education, we can reduce hospitalizations because, you know, they see our faces more often and they're learning interesting information for us where they start to build that trust relationship. And so again, didn't start anywhere close to that. Great. A bunch of people put in the chat if they have social workers. So some interesting things there. Slide. So a couple of things, you know, and we really define this as the opportunity. We'll talk about front office and back office. The opportunity to define the job description. And so as we talk through kind of staffing later in the day, one thing I would always say is, you know, make a job description potentially a little bit bigger if you want and then narrow it as you get going. But you certainly always want to list the expectations on a job description, even if it's part time, even if it's a portion of their work. If it's we do sometimes second jobs where they'll pick up another shift outside of their 40 hour workweek. Again, that has to have something written in place. And it's really easy as you as you're just starting out to just have verbal conversations about, oh, go do this, handle this. Even to the extent of every year on someone's review, re-looking at the job description just to make sure you're on the same spot. Because these front office and back offices roles really make your day. So here's some roles and responsibilities and jump in the chat or jump if you have other ones to add to it. But really the phone calls, rounding messages as important. Sometimes they're actually doing the geographical, the geographic scheduling. So it depends, you know, what kind of system you have. And sometimes it's easier just in your app to do it. And sometimes it's the, you know, they've really laid out your day for you. Paperwork, faxes, appointment reminders. And Brianna talked about that yesterday. You know, verify a general week a couple of months in advance. Then a week before this is the day. And now, you know, you get your a.m. p.m. and a long window there. And so you're really relying on the front office to collect everything correctly. And the final note is that practice billing and coding. The intake is one of the number one reasons that claims are denied is because the intake and the insurance verification in that process has not been set up successfully. Or PDSA has not occurred at which we fix stuff when we find errors in that process. Other responsibilities, Brianna, would you add or anyone else? I was just going to say, too, as we think about the next couple slides in the front office and back office. You know, we're using this as pretty broad terms. And I do, for the newer practices on the terms, it doesn't mean that you have to have different people doing both. Again, you could have multidisciplinary roles or someone that's filling both your front office and back office responsibilities. You know, like the care navigator is always kind of like that catch-all term when you're starting a newer practice. So, and I will say home-based providers are some of the most creative people I've met. I guess what you wanna highlight is there's a lot of administrative responsibilities that come with running this practice and you're gonna have so much clinical care. So even if you're new, not that I would recommend it, but I know people that have found like students on internships that need hours or family members that are bored and they're stuck at home and they wanna help out. Again, not that I necessarily recommend your family, but I mean, get resourceful and just be realistic, especially if you're new, that there is gonna be a lot of administrative burden that comes on. And sometimes it's worth thinking of, you know, without scaling too much, who or how you can get some support to do some of these things. Yeah, like we've hired students just to work on like a specific compliance because I couldn't pay someone to be a compliance officer. I've been the compliance officer for 10 years because nobody wants the job because it's not fun. You know, but, you know, again, you could just take one portion to have someone do a deep dive and have a student do it. And now, so my background is health, I have a master's in healthcare administration, so I can grab students from the graduate program, but many states, when we're talking about students, and Megan was talking yesterday, many, many states are starting to grow their public health undergrad health administration. And again, grab them for a semester to help with a little project that you're working on or to create a workflow. They need opportunities to build out bigger picture workflows. Slide. And so here's the back office. So main roles and responsibilities. And again, these are things, now we've established care, we've got you on your way, and we have a couple of examples I think Paul and Brianna are gonna put in here, but these, and then jump into the chat if you have other things here, but really how are we processing the order, the hospice and home care and DME referrals or certifications? How are we processing the death certificates? I mean, the number of times I have to, I feel like I have to talk about death certificates at this company. Obtain medical history, making sure that you're getting callbacks, care coordination, especially setting up services. How many times do you go in and you're like, oh, they need a lot of things, right? Like we talked about that one chart that had all the patients on there. It'd be great if you could get all their names, right? When you walked in of all their care providers and who's their community liaison and who helps them with transportation and that may not exist. So really making sure you have those services available. Other thoughts on back office? Again, not necessarily two people. These are roles and responsibilities. And I think the other kind of interesting role that you might have to think about, and I know this came up yesterday too, is if you have medical assistants, we know that medical assistants can wear so many hats and can be so crucial, but is it gonna be a traveling medical assistant or are they gonna help you with things from the back office or the remote office or a virtual medical assistant and things like that? There's pros and cons and there's not one right way to do it. I know some comments that came up yesterday was the benefit of having a traveling MA with the provider. Some of them, I'm sure not all of them and I'll let Paul chime in, but for safety reasons. Also for efficiency reason, if the MA can drive while the provider documents and does call back in between visits. Again, that may not be financially realistic. We've seen generally practices that have it to someone traveling and to driving can see two more patients a day. So that's kind of how you would make financial sense of it. But again, there's also lots of opportunities for virtual assistants, which when we have such a workforce shortage, Amanda brought up a good point earlier though, depending on your contract, you may not be able to employ people outside of the US, but you could still hire someone that works here that's just not physically with you. You don't have a physical space for them to work. They're just working for you virtually. But Paul, welcome your comments. I would add one thing about the, yeah, so we did explore because of the relationship with HCCI, right? And this is, you're getting to know 40 of your best friends right now because you're gonna use this network forever and ever and ever. Because of that, I learned about using medical assistants outside of the US. And I, so I started exploring it and one of our quality compliance people who works with our state contracts said, it's in our subcontract language that you can't work with anybody outside of the US. And so I didn't know that. So just a note, I'm passing along for those who are exploring that there's certainly US-based companies that can help with virtual systems. So check your contracts. Paul, sorry. Oh, no worries. That's great information. You know, for me, the past several months, one of my focus here running the office has been staff retention and concern about staff burnout and so forth. So a couple of things I've tried to do here. One is having scripting to, well, number one, I went and asked my front end and back office staff, you know, what are the top three pressing points for you? Because as I tried to understand their stressors and I think I can hopefully come up with better solutions. So one of the solution was having more scripting regarding how to handle patients' calls and streamlining prescription refills so that there'll be less back and forth with the providers and for orders and so on. And also being creative with the medical assistant that I have here. There was concern, well, there's ongoing concern about a burnout with any position of people that's working here. So I'm trying to be creative coming up with maybe rotating models. Some days you go out with the providers, other days you are my virtual MA here in the office and rooming patients virtually. Again, trying to come up with creative ways to keep the staff fulfilled and happy in their work and yet holding them responsible to the work that they have to do for the practice. Thank you. I think that goes great. Thanks, Paul, into kind of our next slide. And what we have historically talked about is you have these roles, these are sample positions. There are, I think, some sample job descriptions either on the website or in the, I think on the website, on the HCCI website. So jump in on the chat staff if I got that wrong. But here are some kind of high-level bullet points of what some of these jobs could do. And these, you're looking at kind of all three different licensures here. Sometimes when you start out, we really are kind of like, yeah, you're gonna hire someone and maybe you hire them a little bit larger. Maybe you're hiring an LPN, but you're asking them to do some layperson stuff, some medical assisting, and then some LPN, or you're hiring an RN and asking that. And then as you get larger, you start to kind of partition out that work. And now what we're hearing Paul say, which I think is really where the workforce is going is, even if you're large enough to partition out that work and have set job descriptions, start thinking about flexibility for your staff. The flexibility, not just for the generation that's coming up, not just for Gen Z here, but after everybody of COVID is looking for, how does it fit into my life? We talked about it a little bit yesterday. So I think that those who will be, there's a different discussion around recruitment, but for retaining talent, I think really thinking about flexibility and being, how can I adjust? How can I stretch someone if they're interested in learning more? And again, give them new opportunities to have diverse work and often virtual now or flexible work. So when we think about process development too, I mean, often, again, there's a lot of examples on this slide, but if you don't have, a lot of the times when we're brought in to help practices that are struggling, we see some miscommunications, we assume two people know how to do that, but then it's documented. And then you sit down and you say, okay, show me, and people are doing things differently. Or when you really don't have lack of structure, then things go through the crack. Like, what are our standard refills? Or am I getting the same messages for the same patients because I haven't set that expectation or I haven't actually taken the time to training? I think what I wanted to highlight here too is just actually taking the time to train your staff and develop the onboarding guides and develop processes, and then continue to talk about how things are doing and refine them over time. We mentioned a little bit on the topic of boundaries earlier about patient dismissal and no-shows. Sending a provider out to a patient's home to provide a service on that, no one being there is really hard, right? That's gonna happen sometimes, but if the appointment was confirmed, do you have a two-warning policy? And then three is a witten warning without dismissal, or with potential dismissal if it's a continual problem, or who's gonna have a really respectful with the patient and caregiver and just say, hey, I understand this is the second time it's happened. Can you help me understand the miscommunication or what barrier it was? Because we can't afford to keep sending someone to your home if the patient's not there. And was it someone didn't confirm the appointment or was it that you didn't have something noted that you should have? So understanding that, I'll talk more about geographic scheduling in the other slides, but also the emergency preparedness and safety plans. And Megan, I'll talk more about safety later, but Megan is a great example of there's a tropical storm in Florida today. When you're doing restart a patient or when you're taking it on intake, are you considering patients with oxygen that might be at high risk if they lose power? Or what are you gonna do if there's, we're in the Midwest, but tornadoes, snowstorms, are you gonna lighten schedules? Are you gonna be monitoring the weather? So thinking about things like that. We certainly talked about documentation and compliance yesterday. What are your standards? How are you educating your staff? Are you doing some annual peer review and annual auditing from an internal perspective? Are you keeping up on patient's bills and statements or looking into financial assistance, things like that. So there's a lot that goes into it, but I would just say be thoughtful when you're developing things, but also don't just assume people, right? Like a lot of the times you hire people and then you don't, you just expect them to do their jobs, right? So really taking the time to document and then train your staff and think about what works for you and ask them for feedback, ask them to help be part of this process. Next slide. So again, like I feel like intake is my new favorite word for this session, but a couple other things to highlight here on the intake side of things. Certainly we talked yesterday about how there could be electronic things. Again, just typing in the insurance information incorrectly is gonna cause a claim denial. This is also a good opportunity when you think about the first conversation that someone's having with the patient. I know some, I think someone brought it up yesterday and it comes out a lot. How do we stop inappropriate referrals, right? What kind of questions do we need to talk before we, with the patient or with the caregiver about to really decide if this is someone appropriate for our services and appropriate for our care. So again, you may have paper-based forms, you may have electronic, a smart phrase or an electronic form that you've developed in your EHR. There's also electronic solutions where patients can complete those forms online and the information goes directly to you. So you don't have to necessarily worry about that data validation. But Amanda, I see you chime in. If we can go to the next slide, I'll let you chime in first. And then I wanted to make a point about the screening questions. Yeah, I was gonna say on the intake is, so have your intake people also keep track of, so you know the insurances you're not taking, but if they start to see a theme, then you can really use that. And because if you're not taking them, you're not gonna collect any data. So if you know you don't have a Humana contract, but you're getting 10 calls a month on Humana, that's maybe worth thinking about. So again, the onesie, twosies, no, but empower your people to start thinking about what am I hearing a lot of? Because maybe that's an opportunity where I could leverage it. So that's just, we've been doing some of that too, so. Yeah, there was a question, Amanda, I don't think you were on yesterday too, about like how do I, when should I start thinking about other payers or how many payers should I think of? So maybe you can put some thoughts in the chat too about when you're deciding outside of traditional Medicare, you know, what else, how do you think about accepting other payers? And I think that's a great suggestion. The other thing that's unique on intake is, do they even live in your service area, right? You know, you have to, there's more, you need to develop training for your staff and say, does this patient live in our geography? Are they appropriate for our services? Do I take their insurance? And then so on and so forth. But these are just questions that someone can ask over the phone. And that person should also be taking the time to, you know, go over services and set expectations with the patient to really also, and these can be helpful for the providers. You're either gonna get the patient that tells you everything, or maybe when you say, well, when was the last time that you saw a doctor and they say, oh, someone was just here yesterday? You know, do they potentially have another home-based provider? Are they getting you confused with home health? Or you all of a sudden find out that, you know, you thought this was a routine referral and then they're telling you they fell and they have a, you know, something went on. So this can be really important information that again, could just be getting verbally, you know, to understand in your office. But yeah, the geographic creep too, as Paul mentioned, we're talking about boundaries. You can't help everyone. So my recommendation there is find a list of other providers that serves other areas that you don't go to, so that you don't just have to tell that patient, no, you can say, oh, I'm so sorry, our practice actually doesn't go to that area, but here's some resources that do, or here's some other programs that might. And you may not have, if you, you know, again, senior services are great resources if you can't find anyone, but the American Academy of Home Care Medicine and HCCI actually have a national provider directory tool online that you can search by state for other home-based primary care practices too. So you certainly do want to have, you know, not just say, okay, well, it's only five miles outside of my service area. I'll do this one, or I'll do this, you know, it's a family friend. You do have to be really careful about boundaries there. And geography is really important. You cannot go everywhere. You want to try and not drive more than 15 minutes. It'd be a 30 minutes, maybe in between an appointment and then be seeing patients along that route. Amanda, did you have something to add? Great. Next slide. So triage is so important. Again, we talked about triage on intake, but also, you know, how are you going to use everyone to top of licensure? And what kind of, you know, sometimes when I say triage, I'm not talking about the really complex nursing protocols in the hospital, right? Or things like that. I'm talking about what are the common questions or what are the common needs of your practice? And how can you empower depending on the licensure and the scope of practice that you have on your team to address those needs? So if you have nurses, for example, and, you know, Home Health's just calling for continuation of Home Health, or they want approval for simple wound care orders, or, you know, you're going to have your staff set up non-opioid medications for 12 months and verify the pharmacy and have all of that information done before it's routed to the provider. Making sure you do refills during the visit so you're not getting calls for patients that we're just seeing the next day. You'd be surprised how those calls start to build up. So I'd encourage you to kind of talk to your team and think about, you know, what are the common needs of our patients and caregivers? What are we spending the most time on the phone call? And how can we just set practice standards and say, okay, this is how we're going to handle these calls. And this is what you can do as a nurse before, and then it's just routed to the provider as an FYI, or maybe it's just, you know, close for review. So start to think about that. We've given you just some examples of common things that might come up, but how can you empower people on your team to reduce the number of touches I like to call before a provider has to get involved? Someone should always be calling that patient back to triage that need and get more information before you're tasking the provider to call them. And I won't jump in on all of them because I know we need to make up a little time, but I would say this. FLSA does have very specific guidelines around LPNs and RNs, and really RNs are the ones, RNs and above can be called triage and LPNs cannot. So as you're creating a job description, don't use the word triage anywhere on the job. It's intake, it's gather information, it's relay information, it's that kind of, you know, it's those pieces, but it's, and it might be follow certain procedures, but they're not, you know, official triage protocols necessarily. And so again, you know, watch the creation of job descriptions because this is by far an area that you need to focus on and, you know, stay within FLSA guidelines, so. Yeah, good point. I think if we talk, we can move on. I think we talk a little bit more about scope of practice too later. So we talked about scheduling yesterday. We want to spend a little bit more time on it too. So again, you have to understand where are the patients you're going to serve. You can't have too far of a geography. I'm going to let you know on a future slide what technology resources I know home-based primary care practice is using, but you do have to also assign zones, right? One provider should, as you grow, shouldn't be going to, you know, too very far areas. Start to cluster patients and then develop an actual scheduling guide. It doesn't have to be fancy, but that says, you know, Monday through Friday, tentatively, these are the areas on which days that this provider is going to be in. So that when you're proactively scheduling that one month, that two month, that four week follow-up, you're already scheduling them on a day that you intend the provider to see patients in that area. Really important. And this takes a lot of review. Someone liked, which I agree, described it as playing Tetris, right? With the schedule when you're moving patients around and before you're calling to confirm that appointment. Again, if you have to add an acute or post-hospital visit, can you push the two month follow-up that's stable till the following week? This does take a little bit of human touch in addition to using the, you know, the tools and the geography that you have. Making sure that when you're at a facility, knowing who your patients are there so that everyone that, you know, medically needs to be seen is seen when the provider's in the area and they don't have to double back that same week because they missed a patient. So calling facilities ahead of time to confirm the day before too, or faxing them a list and asking them to call you with any patients that aren't on your schedule that need to be seen, yeah, and keeping in mind traffic patterns and rush hour, like Dr. Chang said, too. Also, we talked about safety, too. Are you going to, certain areas of the neighborhood or certain neighborhoods, are you only going to go in in earlier hours of the day before 2 o'clock or 3 o'clock? You know, those are all things that you have to keep in mind. We can go to the next slide when you're scheduling. And then, to just kind of tie that home, where does your provider live? If they're starting from home, right, we're all home-based providers, are you starting your schedule with the closest patient to the home? Generally, you start either with the furthest patient and then make your way back to wherever they're ending that day or, and again, sometimes you have to accommodate patient dialysis and other things, but you have to use some sort of map-based tool to do this because you could have two zip codes or patients that live in the same town that are actually like front and back door to each other. You can't just assume that everybody in these two, you know, this zip code is near each other and would make sense to see on the same day. And this came up in the video the other day, too. The key here is flexibility. I would never recommend telling your patient, we'll be there, you know, two days when you're seeing them for a visit. We'll be here on, you know, July 3rd at 9 a.m. No, don't ever give them an exact date. Say, we'll be back in about a month or two months, and someone from our office will call you a few days before a week, you know, a day before, a week before to confirm the appointment. And then also give yourself a timeframe because what if you have an urgent patient in between or what if something came up that morning? So, certainly keep them in the loop, but we've seen practices give anywhere from a two-hour timeframe to a four-hour timeframe. You know, all, you know, all morning patients are given the same block of time or all p.m. patients are given the same time, making sure you're making notes if you have to call on the way because the daughter has to open the door because the patient's quadriplegia, you know, all of those things need to be taken into account. And then you also don't want to overwhelm your staff, so if you are traveling by yourself, you know, can you stop somewhere in your car in between patients to answer a few messages or do a few callbacks if you have Bluetooth and you're not on your phone? You know, I know one provider that she was like, you know, it took me a really long time to figure out I could start doing all my callbacks in between routes and then I'm not spending all of my time doing documentation and callbacks at the very end of my day. And also, if you have staff, you know, they may not be available at the very end of the day. So just be mindful of how you're going to address all of those needs while you're on the road, too. Next slide. Hey, and Brianna, there was a question. Oh, I see. Okay. There is a slide coming up to address Tony's question. Okay. Okay. Sorry. So I think I hit on many of these points. Again, you're going to have to spend some time reviewing and confirming schedules in advance. You can certainly get your provider's weigh-in as well. Don't confirm too hard in advance. We talked about acute and urgent yesterday. You also want to understand what a full schedule is for your providers versus what's not and when you need to have some wiggle room in there. And also, what we didn't talk about yet is visit types. How many new patients can you realistically see in a day? Because a new patient or a transitional care management visit is going to take a lot longer than a follow-up visit. So on that scheduling guide, you should be noting those kinds of things, right? Some practices consider new patients as two or TCM as two. So be keeping those things in mind so that you're not overwhelming your providers as well and you're considering how long they need with the different types of patient visits. Next slide. I think this is the one we're probably waiting for if we go to the next slide. So I would love to hear if you're using something that's not on this slide. All of these are potential map-based geographic scheduling solutions. CareLink is probably the more costly and more expensive one. It also is a, you could do just scheduling or practice management software but actually plots all your patients and you can draw maps and create reoccurring schedules. MapTib and MultiPlide are pretty straightforward as far as plotting patients kind of like a Google Map. You can do, I believe Megan did this, a Google Maps business account that is HIPAA compliant that also allows you to, you know, color code your patients on a map and it's easier if you're going to use something like this to start when you're newer rather than doing that. But like BatchGeo, you could upload a spreadsheet of your patients from your EMR and it'll also do that and plot it and categorize it for you. MyRouteOnline is another low-cost solution. RoadWarrior is only for route planning but if you have the free version on your phone and you're by yourself, it would help you plan your driving route. So, I could put up to eight addresses in for free. This is where I want to start, this is where I want to end, and then hit Optimize and it also tracks mileage for you so that can be, you know, beneficial. We'll love to hear if you're using other things. These are the ones that I'm aware of home-based primary care practices using. Next slide. So, IDT meetings, again, this is certainly not an all-inclusive. This is an idea that, you know, interdisciplinary team meetings are really important. A couple things I wanted to highlight here. One thing that's not on the screen is a patient story. When we're talking about retention and how we keep people engaged, we're reminding people while we're here, right? This work is hard. So, you know, I used to even have a binder of all the letters we would get from grateful patients and when we've had a hard week, maybe just huddling really quick and reading that patient story. But a couple things I wanted to explain. This is also how you kind of get team buy-in to the mission and the vision and really helping people understand that regardless of their role, regardless if they're front office, back office, everybody's contributing to the mission of excellent patient care and they all have a role in that. So, you know, even if it's just, you know, recognizing that and sharing the accomplishments and sharing how you're doing and the outcomes, that really helps. The waste identification, waste is kind of a practice improvement term, you know, lean six sigma, that could just be simply asking open-ended questions that say, hey, what's one thing that didn't go well this week? Or what's one thing that we feel like we've been struggling with that we can maybe do better? And it just like allows for that group feedback and problem solving in real time to kind of bring issues forward when things get so busy and maybe people aren't highlighting, well, actually, you know, two times this week, my schedule has been messed up. Or, you know, it seems like we're getting a lot of denials from this particular thing. It just opens that, but I love ending every meeting with recognition too, whether you're just asking for that on the spot, you're asking for someone to chime in. Paul, I know you've also done some clinical education that you've incorporated in your IDT meetings. Yes. So, not only do we troubleshoot issues in the office, which, you know, in this environment, it is so important to find out what's troubling my staff and how can we fix it, but I also intermingle educational meetings because our patients are sick and complex, and we want to do the best care for them. So, I've invited speakers in our community, specialists in dementia and heart failure, CKD, diabetes, or endocrine, wound care to come and do in-service for all of the providers here because we really need to keep our skills sharp. And a final comment is this, and Brianna, you know this, I have three buckets here in the office. One bucket is the thankful bucket. I encourage my staff, you know, we live in a culture of outrage, right? We are outraged at anything and everything. Take a minute to be thankful for fill-in-the-blank, something that you're grateful for. The other is what I call the Jedi skill bucket. Yes, I'm a Star Wars fan, and the Ben Kenobi series is excellent, by the way. It's the Jedi skill bucket. It's what I call pearls. We all have pearls that we can share with each other in terms of making our lives better and so on. And the last bucket is the wish list, you know, what could be better in the practice and so on. So, you can come up with your own buckets as a way to encourage and communicate and build team spirit. Thank you. And we can move to the next slide, and Tony, I see your question about any root cause examples or documentation tools to track hospitalization. Rush at home, I know you guys use a spreadsheet and talk about hospitalizations. Maybe you could share a little bit in the chat. Amanda, if you want to share anything else in the chat. I'm not aware of necessarily any tools. You know, sometimes it's a good old-fashioned spreadsheet or tracking to talk about, you know, the patient that, you know, diagnosis for the admission and kind of huddling about that. Certainly recommend reviewing that week or depending on how often you meet that month's hospitalization. It could be a report from your EMR to, you know, check your practice management system and your EMR for reporting capabilities or what you could potentially set up. But welcome to others' thoughts on that. And I'm sorry to pick on you, Jennifer, but I know the Rush at Home team has a strategy for that. So, maybe you could share in the chat. Again, go ahead. Oh, I'm sorry. I didn't. No, go ahead. Yeah. We, we, our RN is, gets the discharge notifications and she goes back through the chart. But we just use an Excel spreadsheet. Thank you, Jennifer. Quick huddles, you might want to consider. I'm going to try and make up, I want to make sure we get our, our break here. But, you know, really just taking the time, team, team communication is so important. We have some examples of a huddle board. So, maybe you do a huddle every morning and you just talk about, okay, where is everybody today? You know, what happened overnight? Who potentially called off? You know, what are, what are needs to know? What are we waiting back for? That's a potential, you know, really important thing to talk about. Again, even if your staff's all over, maybe it's a phone call. I've seen some practices do a huddle text where their practice manager just sends a text out every morning. You know, you can get creative with how you do this. But if we go to the next couple examples here. So, again, just one board that shows how many patients they all have, what areas they're in, who's on call, who's potentially called off. That red sheet is, you know, some emergency numbers. They also have their hospital discharge planner and care management numbers, front and center. So, everyone can find it right away. If we go to the next slide, this was an example of a little bit more in-depth huddle board that a practice was using that had metrics on it. They also had like a value spotlight on here and some recognition, like those things that we talked about and processes that they're working on. Next slide. As far as identifying inefficiencies, you know, it's important to take time with your team, too. Usually, if there's, you know, especially if your team has grown, if you potentially have a lot of staff and maybe you take a half day or a day and you have the phones rolled over to the call service or you have someone watching them and you all just take sticky notes and say, okay, what do we all do every day by roll? And then you kind of look at that and see where there's overlap and then treat them to a nice lunch or, you know, end the day with something fun. Sometimes it's just, are we really using people for the same things or why are, you know, the medical assistant and the, you know, front office all doing, you know, some overlap tasks or some administrative tasks that we could reorganize? And then from a, you know, workflow inefficiency point, you know, understanding when it's a, you know, maybe we're not prioritizing referrals as you come in and you're scheduling the first available appointment and then, you know, the patient that really needs it isn't seen. But Amanda, I saw you come off mute. I was just going to add one other thing we do. So twice a year with our office staff, we actually have them do a week-long time study and it's not to be punitive, it's to go through their work. I think three employees make the best relation or three things about employees make the best employee-employee relationship. One, does the business need it? Two, is the employee good at it? And three, do they like doing it? And so we kind of go through that list of, you know, where are you spending your time? What do you not like doing? And how can we kind of make that efficient, too? So it doesn't, again, it's not punitive to see where you are every minute of every day. It's more how do we work out inefficiencies, duplication of our work, someone else is doing something that we didn't realize they were doing. And then how can we continue to make it a worthwhile job for the employee? So it's a week-long time study. Yeah. And your EMR can do that, too. I mean, we've pulled phone logs, too, to understand how many phone calls we're getting a day and in an office I worked in, or how many in-basket messages the nurses and the providers by type. You know, I know Dr. Chang has even broken down by labs, messages, you know, other things you have to review. That can really just, again, it's not to be punitive. It's to give you an understanding of how much work needs to be done by different things. So there's a lot of things you can do with that. And that kind of gets into the next slide about using, if we go on here, using kind of communication strategies. This was actually from a previous presentation that Dr. Chang and I were like, what's the secret sauce to a great team, right? And so we've talked about a lot of these things, you know, having staff that has patience, you know, doing that training with them, understanding that scripting, that you're, you know, you have that open communication, that they feel supported, that you have, you know, that regular team meetings and you're recognizing everyone's contributions and the willing to change, right? You can't have that person who says, but we've always done it that way. Maybe they do, but that openness. There was a director I used to work with that said the only thing in health care that's constant is change, right? Things are always changing. Our practices are always changing and we have to evolve for that. So how can we kind of foster these kinds of things in our team? Can I add one thing? You know, I will say we're all going through a transition coming out of COVID into work, into potentially more value-based care and Medicare than we've ever seen in the last 10 years. And as we think about all those things happening, the other thing that I, there's this built-in fear, too, of losing people, right? And sometimes you work really hard, you know, and you get them and sometimes you have a stellar person and it's OK that they leave. So I just, there is a piece of we're so afraid to lose someone or it's so hard to hire someone that we're also then afraid to lose anyone else. And that change in employment and that new vision and that new energy that comes with new employees can sometimes be a good thing. You know, and we can't solve everybody's individual burnout. We can do a lot as the employer and we can try to align those mission pieces. But I also don't want to see the group of health care and health care leaders get completely, you know, sidetracked or stunned or in, you know, some inability to move because people are leaving. It's going to happen and we're going to see a lot of it in the next couple of years. And it's not a lot of it's not going to be personal. So, yeah, that's a good point. You know, someone that started out five years ago that was a really great, you know, person for your practice may not be the best person for that position or for a different position as your needs have changed and have you evolved and that's OK. So that's a great point. At the same time, as we want to focus on retention, we need to recognize the people, the culture and the skills that we really need to do our job successfully. Next slide. I got to invite Dr. Chang, I know if you want to say anything about pre and post visit workflows from a provider's perspective. Yeah, I'll keep my comments short. We're running short on time. I think that the background of this is I want to make my visits as efficient as possible. So pre, pre-review, pre-charting, having a template loaded in your EHR, having macros built in or smart phrases, whatever the term may be, so important to keep. Remember, one of the things I said to you, not only do you need external organization, that's EHR, and then also helping your internal organization, that's your mind. So you can stay focused on the patient because they got a gazillion issues they want to talk to you about. And I want to stay focused and not be looking down on my laptop and try to look for things. You know, one patient, even with me doing this, one patient sarcastically said, you know, I thought you came to visit me, not look at your computer. OK, her point well taken. And also making sure that after the visit, I'm not sure, pre and post. So after the visit, making sure that, you know, your charts are completed. You can go to the next slide. Oh, that next slide. Your charts are completed and you can submit it for billing. That's really important. We don't want incomplete charts for many medical reasons. Right. And then also for billing. And when you're finishing your visit, make sure you write down and summarize what you recommend for the patient. Write it down, explain it to the patient and family. You know, any follow up labs, what to expect. Your x-ray company is going to come hopefully today, tomorrow, get the x-ray done. If you recommend a recommended any CT scan, make sure that, you know, call this number to schedule for a CT scan at the hospital. All right. And tell them that, you know, I will be back in four to six weeks. But this is the number here. Call me right up here down the instruction sheet. If there's a problem, I want you to reach out to me. We're going to do our best to care for your need and keep you out of the hospital. All right. And communicate that with the patient and family. And also with the family members not there, pick up the phone, call the daughter, call the son, give an update so that everybody's in the loop and feel connected and supported and feel like you have done what you can to care for mom or dad. Next slide, please. Thanks. So, again, this is a team sport, right? We need an interdisciplinary team and that's going to look very different for all of you. So what do you need and what kind of people and skills and licensures can best help you do that? And that's going to change. What can you afford to do right now? Maybe it's just yourself with some interns or yourself with a virtual support person or yourself with just a medical assistant. There's lots of ways that you can do that. Geographic scheduling is probably one of the most unique things about home-based primary care that will make or break your practice. So do not underestimate the time and the resources that should be given to kind of successfully do that. And communication is key, especially when you have people that may never be in the same office together or may live very different parts. So how are you going to foster that communication on a daily basis? And I apologize. We went a little over. I'm confident we'll make it up. But Melissa, I believe we have a break. Yes, we do. So why don't we go to break for 10 minutes? And we will. Don't forget about your learning plans today. Be filling those out as well. And we'll come back in 10 minutes. That's about 11.13 central time. you know is it is it more that you're protecting yourself is it by carrying something is it because you're just following protocol and procedures are we just talking about accidents you know what exactly does that mean and it's going to be different for everybody it's different for providers it can be different for people back in the office even on the phone sometimes you know you can get where people can get really aggressive on the phone and make threatening comments sometimes so it's really you've got to decide how sometimes you need different policies for different staff members and for different pieces of your organization next slide we're going to meet Nora in the next slide and in this we're going to see the example of the clinician and kind of what they face as they go on to a visit and then we'll talk about it let's go ahead and start Nora meet Nora a nurse practitioner who's on her way to a home care visit with Sylvia who lives in a rent-controlled fourth-floor walk-up apartment Nora's getting ready to leave for the appointment she takes some cold medicine before she goes she has a bag with her tablet PC and charger here's her box of supplies after packing up her car Nora checks her navigation app to remind herself where she's headed then she checks the weather app she text messages Reg the coordinator at the office to let him know she's getting on the road for the day there's no response but Nora heads out ah here's Reg with a text message response hello Tony this is Nora from house calls I just wanted you to know I'm about five minutes away can I ask you Tony to make sure that the cats are secured in the bathroom before I arrive thanks to Reg's message Nora avoids the accident area and arrives at Sylvia's on time she parks in the first available spot since Sylvia Street is usually tough for parking Nora's phone shows it's 820 a.m. so she thinks she can be out of the spot before 9 Nora gets out of the car quickly so she won't be late she gets all of her bags onto her rolling cart she places her phone and keys in an accessible pocket her shoe covers go in her other pocket it's a quick walk to Sylvia's building Sylvia's stairwell light is out again even though Nora's been to visit Sylvia before she shows her badge before entering the apartment she also pulls her shoe covers out of her pocket and slips them on hmm Sylvia's daughter wasn't able to get both cats into the bathroom at the end of the visit Nora goes through her mental checklist to be sure she's repacked everything she brought it all goes back on the cart so that she doesn't have to struggle down the stairs Sylvia's daughter Tony grabs a flashlight and escorts Nora down the stairwell after Nora leaves Sylvia's she notices her cell phone is below a 50% charge she pulls her car charger out of her glove box so she can charge on the way to her next appointment she remembers to text Reg before she starts the car okay so when I watch this video and I see Nora's example of her visit and kind of her day-to-day operations with a visit there are several things from a safety standpoint that come to mind one and I'm gonna list through a couple of them and then I really want you to kind of chime in and mention what you've got concerns about or what you'd like to see because safety is such a broad topic but we're talking about Nora she's you mentioned some cold meds you know her navigation app you know then there's the weather you know how much gas does she have did she charge her phone but what are some of the things that that have you as a provider when you go out that are first in your mind that that you think of that you have to do or that concern you is it the patient's environment is it more that you're worried about you know what your equipment is that you've brought with you you and likewise what are some of the good things that Nora did you know that you might have noticed when she made sure her phone was charged she asked for the animals to get put away she was paying attention to how much fuel she's got she looked at the weather the traffic and then of course like I said the bad things would be is you know that she took a little bit of cold medication maybe not the best idea you got to be mindful of talking on your phone while you're in the car but overall in this visit when she goes to into the the see the patient she showed her badge well definitely yes I agree Sarah the the new thoughts on this is that if you're sick it used to be a little bit more tolerated five years ago that you were supposed to come into work even if you had a cough or sniffles that clearly now we recognize it that's it you need to stay at home and and call off and I agree on that that's a safety issue because these patients don't need to catch what you have yeah Megan and post pandemic as I come into work I have to do many of you know what I'm going to talk about you have to do the checkboxes you know I don't have symptoms etc then I'm allowed to work for the next 24 hours and I have to repeat the process the next day that I'm at work also pendant post pandemic and provider safety one thing we have been doing although we've been getting a little not so consistent on is doing when we are confirming a visit we are calling family members and say anybody with Colbert and so on again that's a safety issue for the provider whether we need to bring in more safety gear and 95 or whatever else or maybe convert it to a televisit or even just a delay the visit to another time so that's another safety thing that's post pandemic that we've been having to modify absolutely no getting that that information and even you know it's important to ask that and do the screenings and that's something that when if you've got a medical assistant who's calling to confirm your appointments make sure that's something they can help you out with is to ask those questions ahead but ultimately so we've see the good things that she does she made sure her phone starts she checked the weather she checked her navigation app she texted Reggie to say hey I'm on my way so Reggie knows where she's at and we talked about there briefly some of the the not so good thing she took the cold medication she should call out sick if she's not feeling well it's disappointing for patients I get it but I think in the end they understand now and that's okay but what else I mean what has you what's your biggest worry from a safety standpoint as a provider or even as a practice manager is you know medical assistant what has your what's your biggest concern is it the provider going out to see a visit is it and do a visit in a in an area that maybe they're not familiar with or is it being back at the office people that call and might be overly aggressive Everybody feels comfortable? I know it's hard sometimes to say what has you most worried. Yeah, I think the last point about having a dismissal policy is very important for the practice, not only from just an emotional struggle standpoint. We all have those patients. I can hear my staff now talking about, you know, that particular X, Y, Z patient is so difficult to deal with and so on. So having that dismissal policy in place, having scripting in place can really, I think, empower the staff and give them an option. It's not like you're just going to have to sit there and take the beating forever because, you know, we are house call providers and we're mission driven oriented people and be kind of a doormat. I think given the society that we're living in now, we're not going to take any rude behavior, either over the phone or obviously in person. That's just not going to be tolerated. So a couple of things in the chat. This is kind of the feedback I wanted to make sure. So I go in the right direction. What's what are the biggest concerns? We have drugs, areas with drug activity, safety in neighborhoods, sending people into high crime rate communities. I can tell you I had a referral once into what's considered actually one of our, I would say, problem neighborhoods. And when I got there, the patient himself said, sweetheart, you need to get out of here as soon as you can. And we had a shooting the other day and I just you know, I think I'm going to be just fine. You don't need to come back. Let's just keep this simple. And I said, OK. But point is, is is ask your patient, I would say, when you call to set up to visit number one in some of these neighborhoods, if they have any safety concerns, they'll tell you what their neighborhood is like. Ask them when is the best time to come to see you. Traditionally in the morning, an area like that earlier during daylight would be better because then there's less activity. Most people are usually sleeping at that point. They're problematic. And so if morning is better, you want to make sure you kind of take advantage of that. So you might need to plan your route around this. You might need to make sure that those visits come first. So that way you can go in and do that and not be bothered. But, you know, definitely ask the patient. And go with your gut. You know, it talks about here become Sherlock Holmes. Observe, observe, observe. If you feel really uncomfortable, if you get into that situation where you've walked in and you think this just doesn't make sense, I'm not comfortable. It is totally reasonable to say, you know what, that's it. We're going to need to. I have to go. Usually, I try to make sure that that's done in a positive redirection, meaning, oh my gosh, you know, I've got to move to the next patient. Let me make sure to see if I can check with the office as to what we might need to do. You don't have to give extended explanations in those cases. It's time to go. And if you need if you need to go, even, you know, because you're concerned that they're really getting violent, you don't have to explain anything. You get in your car and you can leave. Joy mentioned she said family members wait outside for me. You know, absolutely. I've seen people in their garages or on their porches because they were embarrassed about their home. Paul mentions how in wintertime some practices don't schedule any visits in risky areas after 2pm. Again, there's a reason why the police department typically if they're going to go do a knock and enter kind of situation, shall we say, or a raid, they do it early in the morning because everybody's sleeping. If you go early in the morning, again, that's most people are not going to give you really a hard time. Another example I had a situation happen. It was really a homeless camp that I wouldn't this was not a house, by any means. There were many holes in the floor where you could see through it. But this is where this gentleman lived in his one room, he actually did manage to have some sort of portable air conditioner. But it turns out later on that one of the other men in the home who drank on a regular basis pulled a gun on the home healthy. They called up they said we won't be back, and I supported their decision. And I said I won't go back either then. Nobody says you have to go back if you feel uncomfortable. Again, listen to your gut. If it if it doesn't feel safe and you're not comfortable with it, you can say no. And if home health calls you up and say we have a lot of concerns. Yeah, again support support your agencies and make sure that you've got that in mind. If you're in an actual situation where all of a sudden it's gone back and you can't just walk out the door, you need to make sure that you have some sort of policy in place that that you can either call somebody with a code word as we've mentioned before, whether it's Dr. White or what is your plan for if you need help and you're not really in a situation where you can easily call 911 or something else. I've not had that happen to me. I think that is rare but we do want to make sure we plan for it. And then, you know, make sure you've got the code word, make sure you're telling people your staff, what your route is for that day. That way they can check in on you if suddenly you're not answering the call or coming back or, or going on to the next visit if they're calling and saying hey where's Dr. Chang or where's Megan she said she was going to be here. And then I was looking at the chat and it talks about, you know, ALF, and some of the, we call them sniffs down here nursing home facilities. If sometimes you know if this is something from a safety standpoint, you may find that starting out and doing your visits in more of a controlled environment so you get comfortable with your process and flow might be a good solution. And then also, does your practice have a dismissal process in situations where you feel uncomfortable or unsafe. Make sure you have a letter. Often these things have to go out by certified mail that's that's the policy in some practices but you want to make sure that you've notified them. And, and just make sure you talk about this and even be upfront when you take a patient on, you know that you have expectations that you should be able to go in and feel safe in the environment. If they have any concerns that they need to let you know if that's not possible. So there's there's a lot of potential hazards that can happen. Make sure before the visit you schedule responsibly during daylight hours in the morning if you have any concerns in some of these areas and plan appropriately. Make sure the directions you know that make sure you go to the right house. Make sure you've got good directions. You've reconfirmed that with the patient. I know that sounds very simple but it does happen. Dress appropriately. You know good shoes that you don't slip or fall. Stay connected with your office. Make sure to let them know where you're at. Be aware of your surroundings during the visit. Take precautions. You know look around for animals. That's another common one is you know dogs. People don't necessarily they think their dog is the best dog in the world. I would highly recommend you don't pet anybody's dog. I don't care how friendly it is. I would be cautious of that because sometimes they change their mind. A lot of times they change their mind. You know so ask about those. After the visit let your office know if there's a problem there. If they're not putting the dog away or if there's a family member that makes you feel uncomfortable tell the office. Start making sure to document that so that way if you do decide you're going to go back that that you can take the necessary precautions on that return trip or if there's if there is a family member that makes you uncomfortable that two of you go so that way you're not by yourself. I also I would always make sure that you're conducting these visits in the front room or living room. I would not go deep into the house. I wouldn't you know I know we talked about doing the refrigerator biopsy previously and yesterday but keep in mind if you're in a home I wouldn't do this if you're in a home and you feel at all uncomfortable. I see in the comments that somebody had a provider they got bit by a dog yesterday. This does happen so it's and a squirrel attack that that would be very unfortunate. Yeah you just never know so always be aware of your surroundings and make sure you notify the office. Tony that's a good question. He says any recommendations on what not to take with you and how to minimize being a target. I mentioned yesterday that you'll notice Dr. Chang's car didn't have any kind of signage on it and that's hit or miss. Some people want to you know have signage for advertising. I personally would prefer not to have signage on my car so that way it doesn't become a target because they realize if you've got signage that you may be bringing computer equipment wallets and stuff. I agree with Samantha. Don't take your person. Don't you know keep it to a minimum locked up you know that way it's just not obvious. It's not sitting in the front seat of your car if somebody wants to come by and take a peek in while you're inside and I would keep equipment to a minimum. I know we talked about that yesterday. I am NOT a big fan of less is better. If you have to take in a trailer of stuff with you that's a sign that it's time to trim down because you're there's no way you can use all that equipment and it's costing you money anyway just you know and supplies but if you have to leave suddenly that's really hard to get all that out and then you're gonna have to leave it behind anyway. Yeah Megan I agree. Tony I think that's where chart prep is important. You review your chart you pack what you need for the day. If you don't need all the wound supplies then it's probably not necessary to pack all of that. Not only perhaps you'd be less of a target but also save your back from carrying all that weight up and down up and downstairs. Limit a wallet probably it's a good idea as well. I don't know people still use have whistles or whatnot. Is that even a safety device anymore to blow a whistle to get attention? I'm not sure. I'd be interested to see what other people think. You know the other thing too you can always you've got usually you're gonna bring your car keys in with you you can always hit the panic button on the car alarm although I'm not sure again how effective people listen to that as well as they used to. But yep not staying for your car and long stretches in the work. Right if you need to do chart work I would make sure to leave and go to an area where you feel safe doing that. I wouldn't hang outside in the car for any length of time and if somebody comes up to your car you know you don't necessarily need to be in it's a stranger. I wouldn't roll the window down all the way. I don't even know if I would necessarily roll the window down. Things have changed. I know you want to be nice and that's our nature that's why we do this business but not in certain neighborhoods if I can help it. Yeah and I agree with you Jennifer. I like said that you know the homeless camp I didn't have any problem with that patient that I was in but and again sometimes it's all on how you navigate and you de-escalate situations. As we all know sometimes it's on how you try to approach it the patient and whoever is in the home. So I agree but it's it's entirely it's a personal decision. Make sure you do what you're comfortable with and you can always kind of take it and go from there. Any other questions? Oh interesting Shalane. So does it video record or is it just is it kind of like an Amazon thing where you're taking a picture of the package on the front porch? You there or? You can do multiple functions with it. We have a push button that is on our badge but then there's also the app on the phone that can record you but it shows your GPS. It can do weather alerts. It does all kinds of stuff on there. It's actually pretty cool because it is a huge safety thing that if you feel unsafe you can just grab your badge and it doesn't look like you're doing anything. Excellent yeah because you're trying to be subtle about it. That's a great suggestion. Yeah they're actually local in Illinois. Anybody else? Anything else that they've used? Joy says that she hasn't had any problems. She goes into some various neighborhoods but she makes sure to get there. I would agree early in the day families wait for her outside or by the front door. Agreed. Yes and again most families I it's been my experience they know that neighborhood there they know it's not ideal but they also want to get help for their loved one like everybody else and so they if they should work with you. If they're not willing to work with you from the very beginning that's kind of your sign that maybe this isn't the the client for you. I would approach it that way. That's you can find that out from your initial screening. Thank you everybody. All right and all right thanks so much. That's actually a really good segue into our next session on supporting caregivers. We talk about how a house call provider is treating the dyad right the patient and the caregiver and so it's so important to do that. So we're welcoming back a member of the social work team at Rush University Medical Center. Allie Vernasco are you there? Yep I'm here can you hear me? Yeah great. Yes my name is Allie and I I'm a licensed clinical social worker with a program at Rush that provides service to caregivers and to to patients and so today we'll look at the importance of caregiver support for both patients and caregivers and discuss the impact of caregiver burden. Caregiver burden it obviously impacts the caregiver but can also impact the patients we're working with. We'll describe how to assess caregiver stress using different screening tools, identify resources for caregivers and provide support to reduce burden and define types of in-home support to aid both patients and caregivers and identify resources. We'll go to the next slide. We're looking at the case of Minerva a pretty classic case. 86 year old recently discharged home with CHF and complications with edema. She has had multiple hospitalizations and presents with decline. So in this case the daughter is the caregiver in the home and the son is the health care power of attorney. As I said the patient has recent multiple hospitalizations and signs of decline and the adult children of the patient have different views around what the the important health care goals are and as well as the understanding of disease and disease management. So why is it important to care for caregivers? It's really you know we look at caregivers as as a unique part of the health care team. They're able to provide some important insight to providers that they may not always see with visits to the home. So we need to make sure that we're caring for our caregivers and prioritizing them. They're often expected to provide care to care recipients without reimbursement and without adequate training as well. They rarely have other resources you know caregivers need to manage different life roles and so how do you do that when you're you're caring for an older adult and you might have you know children at home too with the standard generation. And caregivers are a limited resource. So caregivers are definitely caregiver burden is definitely a public health concern. We're seeing an increased number of caregivers caring for individuals who you know and caregivers are responsible for social health, emotional health, physical health. So it is a public health concern. A lot of people are impacted by caregiver burden and about one half of caregivers rated their burden as moderate to high. And caregiver burden can be you know the when patients present with more and more need for for physical assistance with their activities of daily living. And caregivers don't have they might not have the training necessary for this. So that that can increase burden. Knowledge is power. So we want to make sure that we are providing adequate training. We're also looking at caregivers who might be managing their own health needs. So when they are caring for care recipients who have increased need for taking care of their ADLs, how do we account for you know what the caregiver might be experiencing themselves? Caregivers are often female adult children of the care recipient. So like I said before, they're meant they might be managing a lot of other life responsibilities. So how do we take that into account? And we're looking at caregiver burden. Many caregiver caregivers, as I said, have other health issues of their own that they might be manager managing chronic injuries, chronic health conditions, and they varying levels, we see varying levels of anxiety and depression among family caregivers. So we want to pay close attention to that and look at any other resources that might help them manage those symptoms of anxiety and depression as well. So providing care to patients with dementia and cognitive decline can be very, very problematic or challenging for caregivers. They tend to be managing their care coordination, medication, making sure that their you know, that their loved one is eating is taking care of themselves. And that can definitely increase caregiver burden as well. The next slide has some more information on different caregiver burdens, tools to assess caregiver burden. So as I said, primary support, how are we supporting caregivers? What do we do to to help kind of evaluate their support when I'm working with caregivers? And I'm asking this early on to see who are the other family members, friends that they can rely on and support can be either, you know, directly related to the caregiving, but also different sort of peripheral things like even grocery shopping or meal preparation to so that the caregiver is able to to focus more of their energy on the care recipient. Okay, go to the next slide. So again, education, caregivers often are managing this role with limited tools, limited resources, you know, they're expected to understand a lot of nursing related skills, physical therapy related skills, and they don't necessarily have the the education. So I'm making sure that they that that they feel supported that way that they have the tools. They have the knowledge about what they're doing. And this can, this can absolutely reduce the impact of caregiver burden when they have access to this. So home visits are most effective for those who live with a care recipient. And in the case of Minerva, what do we do to support the caregiver? referrals to other agencies, the Alzheimer's Association has a lot of education, a lot of support. I have a list of different support groups in the community that might not be meeting in person right now. But a lot of virtual support groups can be helpful to to caregivers. Any support in the community to provide education to the caregivers on different diseases, what the progression looks like what the treatment looks like. And also educating family members on communication techniques, especially for dementia, and Alzheimer's. You know, what works with this population, I have a lot of caregivers who come in, and they, you know, they, they talk about like the different challenges with communicating, and how do we help the caregiver in that situation with providing some useful, useful skills to practice at home and different things to try? You know, because a lot of people like to really try to reason with their, their care recipient, and they might not always be in the place where they can reason with, with caregivers, and it can be frustrating for both the caregiver as well as the care recipient. And making sure that the family can, you know, the other family members as able and willing can be involved, offering family meetings to provide larger education and get everybody on board. And the support team, it's not always possible, but it does happen. And when families have that network, and are able to rely on other family members, it can be very rewarding for the caregiver. So some more recommendations, exploring other stressors, as I said, caregivers who are managing multiple responsibilities. It's all, it's all related, right? And then we give the caregiver Bill of Rights to caregivers in the beginning. And that's essentially permission to feel frustrated and permission to, you know, feel supportive. As well as, you know, caring for the individual, how do you care for yourself? So exploring different finances, that can be challenging, especially with the caregivers that that we typically see. Finances can be a hard one. So how, what is the ability to, to help with, with other services? In Minerva's case, what, what might, what is available to further help the daughter? So consider the role of Medicaid waiver program, referral through a agency, area agency on aging for financial assessment, and is adult daycare or respite care an option? Some of the formal supports for home health aides through an agency, they can cost anywhere from $18 to $50 an hour, depending on the services, sometimes even more. The agency would do the annual background checks, coverage for call offs and training for aides. This might not be an option for, for some caregivers, though. Independent providers, the caregiver is responsible for training, responsible for background and reference checks and responsible for contract and taxes. Respite is often short term, time limited. It can be in the home, but it's usually in a facility. Some respite is covered by Medicaid or long-term care insurance. Again, long-term care insurance is a resource that not many caregivers have access to. And Medicare only covers for patients who are in hospice. So again, some of the takeaways, caregiver burden comes in the form of financial, emotional stress. It can lead to burnout, mental health problems, and even abusive situations or, you know, neglect too. Caregiver burden can be assessed by utilizing the burden interview and the caregiver strain index. There are many supportive services available to decrease caregiver burden and promote a healthier, more satisfied caregiver. By ensuring the caregivers are well cared for, you are ensuring a higher quality of life for your patients. Okay. Thanks so much, Allie. Yeah, I mean, this is such an important subject and I, Paul, did you have anything that you wanted to add from a provider perspective? Oh, Allie, number one, great presentation. Really appreciate it and supporting our caregivers are, it just so, I think such an important part of our work. One of the habits that we have important part of our work. One of the habits that I've gotten into is at the end of the visit or towards the end of the visit, I closed the laptop and if it's reasonable, I get the caregiver perhaps slightly away from the patient and I just ask the caregiver, how are you? How are you doing taking care of mom, dad, grandma, and so on and focus and devoted focused time addressing or talking to them about their needs. And often than not, it's when that's the moment when the lips quiver and the tears starts to flow because usually providers just talk to the patient, address the patient and so on. And the caregiver is just kind of in the background. And yet they play such a huge part in the delivery of care to our patients. So please take a moment, acknowledge the caregiver, talk to them face-to-face, laptop close, and give them the time to see if they can pour their heart out to you a little bit. And you can maybe again, find resources that would better meet the needs of the caregiver. Again, if the caregiver falls down literally physically, emotionally, then the patient will suffer as well. So those are some of my comments. Yeah, that's a really good point. I can't tell you the number of times where I have a caregiver where I'm doing their assessment and just going through our caregiver burden scale, they become very tearful and emotional because they haven't had anybody ask them about how they're doing and they haven't had the time to really consider how they're doing. So it's often the first time that they're really thinking about what an impact this really does have on them. And I will say that more often than not, the caregiving does fall, tend to fall to one person. So even if there are multiple, multiple family members that could help. Yeah, thanks so much. I mean, and I think everybody realizes if it weren't for caregivers and their ability to be there for these patients, those patients would be unlikely to be able to be at home, right? And so, you know, which is where they want to be. Thank you so much, Ellie. I know we're going to move into the next session, which is working with community resources to enhance home-based care. And so we're pleased to welcome Sujin from Rush to help us out with that. So, Sujin. Good afternoon. I don't know. It's good morning. Hello, my name is Sujin Eimer. I'm a licensed clinical social worker. I'm working as a community practice social worker in partnership with the AGI Options. So today, I'm here to discuss working with the community resources to enhance patient care. So jump right into the objectives. So we want to focus on how to leverage community resources to support homebound patients' health and safety, identify the various community resources for patients and caregivers, understand the aging network in respective states, understand the importance of integration of health and social care, and describes your role in advocating for patients' access to resources in underserved and rural areas. Next slide. OK, so I want to start off by reading this quote. It will be necessary to address an individual's function, social behavior, and needs largely through the provision of social and community services that today are not typically the province of health care delivery systems. So I think this emphasizes not only providing health care, but also social care to go along with to be more holistic and take care of the whole person, I think, from their perspectives. Next slide. OK, so first, I want to talk about what kind of supports are available to enhance patient care in homebound patient population. So for in-home supports, assistance with a day-to-day task is available, typically in a non-medical setting. And there are in-home caregiver, private duty caregiver, caregiver, housekeeper, companionship, homemaker, and home care. And you can apply for this in-home supports for your patients through Medicaid Home and Community Based Services, shortly HCBS, or waivers programs. Later, I talk about how to apply, what website, what number to call. OK, so in-home care resources. So who provides in-home care? It can be family or informal caregivers, paid professional caregiver. Or these services can be subsidized through the government benefits, which is a committed care program for people over 60. And also, DHS, Division of Rehabilitative Services, a home service program for people under 60 living with disabilities. And also, respite programs are available. And in order to receive these services, they have to receive a down score. It stands for determination of need score to initiate the services. And also, they need to do annual redetermination by care coordination unit. Usually, care coordination units are senior or serving community organizations in your area. Next slide. OK, so we want to look at a big picture, the umbrella structure that's put in place to support our older adults and also people living with disabilities. So at the top, the federal government is called the Administration for Community Living, surely ACL. That was established by the Older American Act in 1965. Let me see. And then underneath, there's the State Department on Aging. And also, there is a phone number dedicated to help seniors. And then there are area agencies on aging. This is a nationwide network of community organizations to support older adults. And under the city of Chicago and for suburb of Cook County, there's a separate office. And at the ground level, there's care coordination units. And also, there's a city, village, townships, government offices there to support any needs for older adults. Next slide. OK, so these are the programs people can tap into to support people and remain in their home and live independently as possible. So what is the other day programs? Usually, these are local senior centers. And you can go to this website to find their programs. And also, home health care is available. Typically, it requires a doctor's order. And it addresses medical rehabilitation needs. There's a home-delivered meals available. And also, for our technologists, EHRS, Emergency Health Response System. And also, medication dispensers are available through this program. And in-home service, system equipment and therapy services, such as speech, physical therapy, occupational therapy. Also, they can utilize environmental accessibility for modification. And also, PA, you know, respite program. PRS stands for Personal Emergency Response System. Also, behavioral health services are available to support to stay in their communities. Next slide. OK, so in terms of a community care program, you can receive these services through Illinois Department of Aging. So, you know, homemaker assistance and or other day services. Again, this is a senior, local senior center. And I talked about emergency response system. And in order to be eligible for care management and also for the general community care program, you have to be Illinois residents, U.S. citizen or eligible non-citizens within the specific categories, 60 years or over. And also, there's asset limits. So, you have to have, you know, a certain amount of money, no more than. So, that's, you know, there's some dollar amount. And also, you have to be in need of assistance with the ADLs or independent activities of daily living skills. Next slide. OK, so in order to access the Illinois Family Caregiver Support Program, you can access through your area agency, sometimes they call, you know, like AAAs. So, caregiver specialists can help you to access this program. And respite is available. Also, there are support groups, counseling, training and education. I think Ali did a terrific job, you know, talking about what kind of programs and services to support our caregivers. Next slide. And there are some websites, you know, you can go to do research, you know, to find out, you know, what kind of government benefits or, you know, programs are available for our elderly, you know, patients. So, there are two, you know, benefits checkup. The website list is on the slide. Also, there's a phone number you can call. The other one is Eldercare Locator. Again, there's a phone number and you can call for information specialists who can guide you to find, you know, or, you know, in these categories of, you know, services such as medications, health care, income assistance, food and nutrition, housing, utilities, and et cetera, et cetera. So, this is a very comprehensible tool so they don't administer programs, but I think this is, you know, great, like, you know, research tools you can utilize. Next slide. Oh, so, you know, I see in the chat, so... Excuse me. Yes. Hello? Okay, so there's a question came in, what is the emergency health response system? So, I think, I don't know, this is called a life alert. So, you know, they wear a necklace in their neck. I think if they don't like a necklace, you know, also, I think there's a braces, you know, options you can wear on your wrist. So, you know, if they become incapacitated or if they are experiencing medical emergency, you know, they can push the button and, you know, they'll send, you know, a message to the, you know, the emergency responders, responders so they can, you know, receive the help, you know, right away. Oh, so then what is, so eMERGENCY, eMERGENCY health response system is a, is through aging waiver program for people who are older adults and the PRS is designed for people living with disabilities. So, I think they are pretty similar in a way, but, you know, they are just designed for two different people. They are just designed for two different groups. So, one is for older adults, the other is for people living with disabilities. Okay, moving on. Supporting individuals with disabilities. Okay, so you can, you know, find programs and services for people with disabilities through DHS, under DHS, there's the DRS for people under 60 year old. And, you know, we don't want to be like a Chicago centric. So, I guess, you know, I strongly encourage you to become acquainted with your local resources in your area. So, you know, you can look up and Center for Independent Living to support your patients, you know, in your local area. So, for the city of Chicago, there's Access to Living is there. And for a suburb of Cook County, there's a Progress Center for Independent Living and this phone number is listed and they have, you know, comprehensive, you know, tools and resources to, you know, support the people with disabilities. Next slide. Okay, so let's look at the DHS Home Service Program. So, I think these are, you know, these services, you know, overlap with the services under DOA, Department of Aging for Older Adults. So, similar in a way, there's personal assistance, you know, homemaker services, you know, home health, again, electronic home response, you know, home delivery meals, other daycare, assistive equipment and et cetera, et cetera. Next slide. Okay, additional community providers. So, you can, you know, reach out to township, city department of human services or senior services. Also, they have like a transportation program you can apply. Usually, it's volunteer run. It's free of charge, maybe very minimum, you know, charge like, you know, a couple dollars. You can also utilize faith communities, you know, church, synagogue, you know, temples, community-based organizations. I think some of them, you know, have, you know, wonderful programs for people. Private practitioners, hospitals. Also, you can, you know, look into local resource pairs, you know, for usually rural, you know, very far away areas, you know, where there's a lack of resources. Next slide. Okay, I think transportation is, you know, I guess can be, you know, pretty significant, you know, tool to support, you know, some of these populations. So, PACE, ADA, paratransit, you know, you can help your patients to apply for reduced or ride-free car to use a CTA or METRA PACE. And I think they're overseen by First Transit. And as I mentioned, you know, there are transportation resources can be tapped into through township or local communities. And also, Medicare organizations, you know, health insurance companies, they also provide a Medicaid transportation services to clients through mobile care. And also, you can use Uber Health, Lyft PACE, Lyft Pass for health care. You can, like, open a business account, and, you know, you can order rides for them if they need to go to hospitals or, you know, outside of service providers and family and friends. Next slide. For food, Mirjam Wills, you know, local senior center, they provide, you know, breakfast and lunch, food pantry. And you can go, you know, look into, look at the website, you know, like the Greater Chicago Food Depository or Northern Illinois Food Bank. I was looking at the Southern Illinois, like, you know, food, like a pantry. But I think there's, you know, some, you know, what can I say? You know, there's a lack of, you know, food resources in Southern Illinois, but there are some. So I think we have to be, you know, creative to find, you know, locate food pantry in Southern Illinois. But if you go to their website, you know, there's a, you can find the schedule of a food pantry, you know, farmer's market, or mobile, you know, food pantry where they bring food trucks to the area where, you know, they, where, you know, there's a food desert, you know, or food swamp, you know, where people have a hard time finding food. So soup kitchens, faith communities, and also you can help your patients to apply for lean car, et cetera. Next slide. For utilities. So I think the main program is called the LIHEAP. It stands for Low Income Heating Energy Assistance Program. And I think they used to also offer heating and cooling, but I think they dropped cooling. So now, you know, they can, people, you know, can apply for just heating assistance. And you can apply for this benefits through your local community action agency in Illinois for Cook County. You can contact the CEDAP, the Community Action and Economic Development Association. Next slide. Okay. So I, you know, listed all available different types of housing you can, available for these, you know, people. So when it's private home, assisted living facility, you know, for more, you know, affluent people can, you know, have a private pay and supportive living facility, usually for people with disabilities or who are on Medicaid. What else? Okay. So I think, you know, there was a, so just to, you know, to be eligible for supportive living facility, you have to have a Medicaid. And for others, 22 and over. So for a 65-year-old and also between 22 to 64, living with disabilities, you know, they're eligible to live in a set up. And nursing homes and, you know, private pay, and there's a retirement communities. And also there's permanent supportive senior housing. These are, you know, some options you can, you know, consider if they need housing assistance. Next slide. Okay. So lastly, CATCHON. So let me just quickly look at the, so CATCHON is one of our Rush University Medical Center program. It stands for Collaborative Action Team Training for Community Health. It is a HRSA geriatric workforce enhanced program. So they have, if you go to this website, you can find a wonderful educational resources. And it provides a classroom-ready teaching resources, not only for professionals, but also for caregivers, you know, for older adults. So, and you can find information on, you know, chronic conditions or Alzheimer's diseases and dementia. So you can, you know, educate yourself to provide, you know, better care, better health for the population we serve. Next slide. So more on CATCHON. It's a free continuing education that is available for, you know, anybody. Okay. So lastly, next, please. Key takeaways. Homebound patients need a care that integrates health and social needs. In-home supports and services are available for older adults and people with disabilities. The aging network at multiple levels nationwide provides resources and services for people over 60, you know, old and caregivers. Various community resources exist to meet the needs of a homebound patient, such as food, transportation, housing, and utilities. We need to advocate for patients' rights to access the resources, regardless of their background. Excuse me. Okay. So next slide. So I can take any questions or comments at this moment. I know we are, you know, a little bit behind our schedule, but if you have any questions or comments, you can enter them in the chat or, yeah. Thank you so much for listening. And also I want to thank Lizzie for collaborating on this presentation. Thank you so much, Susan and Allie and Lizzie from yesterday for, for helping us with this workshop and for your presentations. This is great information. And I know most of our learners, many of our learners are from the Chicago or Illinois area. And, and, and so those very specific resources for this last session, I know will be extremely helpful. But there, but, but if you're from outside of Illinois there, you can also take some of that guidance. I think other, you know, it can inform how you approach your state to identify resources in your own communities. So we're going to go ahead and head to our break. We have a 30 minute break. So we will be coming back at 1245 central time. So in 30 minutes from now, thank you all very much. And we'll see you soon. We'll be coming back to house call operations, one-on-one budgeting, technology, marketing, and more. Welcome back. So we are ready to go. I'm pleased to welcome back Paul, Amanda, and Brianna. This is kind of a big session for those of you, especially who are starting their practice. I think this is, these are some great places to start when it comes to budgeting and, and choosing your technology and then marketing your practice. And so I'll go ahead and I'll turn it over. I think first to Amanda. Yes. Hi, hi, hi, hi. Hope everybody had a great lunch. Thanks for coming back. So we have a lot to cover in kind of our hour together. We're going to open with budget considerations. We're going to talk about technology and we're going to talk about some marketing approaches. So I'm going to kick us off with budgets. Everybody's very favorite topic. Keep going. Thank you. Well, one thing we like to talk about is not one size fits all their common pitfalls, pitfalls impacting the bottom line. And we talked, I talked about it yesterday. They're really only two major components. There's the revenue, the diversification, the productivity, and then there's the expense. Do we have the right staffing? Are they accomplishing the work we need to? Generally, I would say there's not been rising costs. Like in the last couple of years, when we've been teaching around kind of more fixed expense, we're seeing inflation drive some of that. And we're seeing, you know, more of a move to kind of virtual, but at the same time, and I don't know if your practices are experiencing this, I would say my fixed costs that's increasing has not been physical. We do have a corporate office. It's actually been some technology where now we need to think about technology in new ways. And so now I need a population health module and I need an EHR and I need to think about data in new ways. And we've hired someone just to cut data. So I think there's a couple of areas to kind of keep an eye on, but if anybody's looking for some of the inflation projections as of this morning when I was reading through it, they expect over that 5% inflation through the end of the year, but to return to a pretty normal about 3% next year. So as you think about any fixed expense or any concerns around inflation, that may level off. So give that a little bit more time. And I'm not an economist, so I could be totally wrong. That was a couple of articles I was reading this morning around inflation. And then, you know, most of our work is gonna come from the people and it's gonna come from then the billing of the fee for service. And so really, you know, are your providers, are your staff working on top of scope? How do you use APPs? And I always encourage, APPs have gotten a lot more state-by-state legislation to expand their scope, but at least once a year, it's worth looking at your APP websites, to see if they've made any significant changes or at least having a staff member look at those to see if there are any additional things that APPs can do inside of their scope. And then, you know, have you considered utilizing physicians in different ways? And this could be from an expense side, or as we talked about from a revenue side of medical directorship, partnerships, loaning amount for even hospice on-call. You know, have we thought about different revenue streams? Slide. And then anybody who wants to jump in, just jump in. So here are some variables impacting the bottom line. You know, as we kind of look through this, again, we're going to keep putting on the top, and we're going to talk about productivity models coming up here, but it's the visits per day. And so, you know, that kind of eight to 10 visits per day, you can push it in an assisted living. If you are doing a lot of care coordination, you're in heavy value-based care, that number might go down. So how do you see, how do you see your visits? How do you see your locations? And this is one of the key things here, and Brianna talked about it, is defining that geography very clearly. That's going to, your clear geography will impact, what payers am I working with? Where am I going? Who's going to be in it? Who do I, like, what counties do I need to hire people in? So just kind of to think about those things, too. I'm not going to go into the billing and coding and documentation. We did that with kind of back-end, front-end of the office. Would you add anything on this slide, Brianna? I know there's just so much to kind of take in. Most of this we've- Yeah, I mean, this is, I think we've covered it a lot. And again, this is going to be different if you're fee-for-service and value-based, but I think the majority of us are in fee-for-service models and so we do have to think about, you know, in the hours of the day, this could be a mix of maybe in-person and even telehealth visits now, or maybe I've seen as we've gone away from the visits, like services, you know, all your providers, if they're spending longer time with patients, are they accounting for that in other ways, such as advanced care planning for long services, too? So you can be flexible. It's not like you set a productivity standard and you're saying this is all, you know, patients and visits. You can be creative in how you think about this, but certainly, you know, the reality of the work that we do until we fully see a change to value-based care, things that we need to keep in mind is that we're using the resources we have so we can stay in business and continue providing care to our patients. Absolutely. And that, I mean, that goes really into the next slide. You know, I love the budget busters, but, you know, people are your biggest expenses, number one. Think about the RNs, the LPNs, the MAs. Again, for every scope of license you have, I like to, once a year, look at the state regulation and see, is there anything I'm missing? Is there anything that's been new that's been assigned that I could push that licensure work on? Lower costs are gonna be the physical office space, you know, but you may still need private spaces. I do see probably a rise in getting more creative. When we went remote because of COVID for all of our office staff, you know, we, you know, signed up with the DocuSigns and, you know, so they're creating technologies that don't necessarily require as much physical space or creative ideas on physical space. And then I'll just note one thing on the HR because I know we spend a lot of money on EHR. I would say there were quite a few people in the chat who mentioned they were on Practice Fusion. And so I don't know if you're buying, I believe there's a pay version as well, but you have the opportunity there too. But I would say this on the EHR. There are enough EHRs and they're competitive enough right now. I think it's worth doing it like every other vendor that you do, you know, sign a year, two year contract. And when that year is up, shop it around and get better pricing and come back if you're happy. If you're not happy, shop around because now they're, you know, the EHRs, five years ago, we didn't have this many options for our work, but I saw Athena Health. I didn't see anybody else on GeriMed. We're on GeriMed. I saw Prima. I saw Practice Fusion. I think I saw Accelion and Epic. That's more options than we've ever had before. So it's time to drive prices down. I was reading one of those BuzzFeed articles and it said things that are actually a total scam, but you know, make sense. And one of them was like the fact that you sign an agreement and as a loyal customer at the end of your time, your price goes up, that that's a scam. I'm like, yeah, you know, that's really true if you think about it. Like they are looking to kind of nickel and dime you when your contract comes open. Slide. The only thing I was going to add on EHRs really quick too is, I mean, where we're going from a quality perspective, it really needs to be a certified electronic health record. I mean, if you're going to invest in an EHR, you know, that's the technology standards. Even for CCM, it has to be a certified electronic health record that meets the, you know, 2015 standards and with interoperability. So just make sure you do your research when you are selecting a vendor. If it is a smaller EHR, that's not as known. Alex asks if it's hard to switch from one EMR to another, and there's always a cost to it, but there's also the opportunity costs that you're, you know, that you're incurring if you're on an EMR that's not meeting your needs. So, you know, think about some of those things. It certainly depends on size. So, you know, 500 person organization is going to have a lot easier time. Generally, the CC, is it CCDC, is that? No, that's, isn't that like daycare at Christian schools? Or is that CCDC? It's called CCDA. Help me out. I can't remember. Whatever the, there's a standard- CCDC is where the, Dr. Perry, or CCDA. Well, no. CCDA, thanks. Yeah, I was like, the CCDA is standard documentation that has to go across when it's a certified EHR. So I would say there's customization that takes time, but you're generally going to get the major points that are going to go into an HIE are going to be a major point of your clinical data repository through the CCDA that is the common language all EHRs are talking. Okay. Productivity. So regular, and I'm going to let Brianna take a few of these slides because we don't deal as much in kind of the fee-for-service productivity, but I would say even in value-based care, there's a lot of work you need to, generally, you still need to do quite a bit of fee-for-service work and billing through the 1500. So I would, and we have a slide coming up on how we think about productivity, but think about your budget, your FTE, and your hiring in relation to your productivity. So what point do you hire a new person? Is that, you know, when your last provider is at 50% over staff or over their patient volume, 20%, you know, 25%, what does the on-ramp look like? Getting a really clear budget of how, especially new people are going to fit into it. Otherwise, you're just managing your regular day-to-day. That's really, really key. We talk about geography. We talked about kind of the use of RNs and LPNs and MAs. I would say MAs for sure, and office staff to help with a lot of the work that's not up to your licensure. And I'd add one more thing about monitoring our views. I mentioned it yesterday, but again, you know, about five years ago, it was pretty common to report out kind of de-identified or even identified quality, you know, visits, panel size, stuff like that. And that's really not as common. I believe going forward, that will be looked at more as punitive and not supportive. I think we're moving away from the, you know, it's not uncommon for us to see when the staff starting, you know, paying on, you know, flat visit fees or trying to get contractors or PRN, monitoring our views, I think has certainly gone away. I mean, you still need to understand the visits and the cost, but I've seen more and more practices starting tying bonuses and provider incentives to quality and outcomes. And that's, you know, a much more favorable approach when we start to think differently about productivity. Next slide. And so we did talk about these a little bit already. You saw it in the two graphs ago. I mean, I think it was in the chat. It was a discussion. You know, again, if you're going into a facility, you're going to see that higher average. This is not meant to say your practice has to work at this way. When we, this opening comment I made was, not everybody's budget is the same. And so I'm familiar with a home-based group who the CEO pulls out an incredibly minimal salary every year just to reinvest in their company. And that's the decision, right? And so maybe at that point, you're not at the eight visits a day or the 10 visits a day because you're just in a growth expansion. So, you know, where are you strategically? What makes sense? What's your payer mix? And these are, again, general guidelines on all the research that HCCI has done and everybody submitting information of what we're seeing nationally. Yeah, and to answer the couple of questions in the chat, yeah, this is just from the data we've collected on specifically home-based practices, right? So we know that home-based providers cannot see as many patients in the office. That being said, there is a difference if you're only serving assisted living patients or facility-based patients. You know, generally we've seen those averages go to 10 to 15, you know, more if you're only going to one building and depending on how many patients you have there. So this is specific. The target goal per week, that wasn't just one provider, it was a mix of it. The point with that is I know some practices that are starting to give half admin days or admin days. So, you know, also getting flexible about visit expectations that maybe it's more of a monthly goal or a weekly goal rather than per day and accounting for things like days off was really the point of showing the target per week, right? Was more of, hey, we're talking about visits. We're also talking about visit types and maybe you prefer to work a couple longer days so that you can have your Fridays as your admin day and that's okay. Questions on this slide? We can pause productivity. I know this is always a hot topic. Okay, next slide. So we've talked a little bit about this but I'll throw out some other ideas, you know, other options that are fee-for-service. Are you part of a health system? So there are a number of health systems that are ACOs, whether they're commercial ACOs, they're Medicare ACOs or they're going to be part of the new REACH ACO. You know, one of the things that Brianna will talk about when we talk about marketing at the end of this is, you know, again, if you're saving the system money and you're improving quality, then there's an opportunity to say, who am I saving money? And would they be willing to pay for this part? So think about ACOs. Is there grant funding available? And, you know, think really broadly here. So certainly there was a lot of CARES Act money in play. As far as I know, there hasn't been a federal extension past round four of the draw. And for us, round four was very small but there's all sorts of things. We got grant funding for some of our students. So when Megan was talking about that yesterday, went through the schools, but we got grant funding for our students for a couple of years there and it's straight up now. Does your city have a division on aging? You know, actively engage with them to provide, you know, see if they can provide a community caseworker for team meetings. You know, your target audience is the exact same. So that's not, can you necessarily maximize revenue but can you minimize expense if someone's already doing this or they're focusing in this area? And so by engaging these community resources, you're not paying the expense or you're paying a shorter amount of it or you're, you know, job sharing something. And then review your contracts annually. Are you being paid appropriately? Couple of things on that. Generally fee-for-service contracts read something like this. We'll pay you your fee schedule or the Medicare bill rate, whichever is lower. Yes. So if you are billing under Medicare, so if you have not updated your charge master, you know, and it's worth looking at your charge master every year. If Medicare, you know, if the Medicare charge master is under what your charge master is, the payers will happily pay you under what the Medicare rate is. Some of you have points on top of Medicare rates, certainly continue to push those, especially with inflation. And then our prior authorizations requirements really just too burdensome. And so maybe you find an opportunity to work with the payers on that, to get paid for something inside of that. So, is there a question? Okay. Slide. And then maximize your reimbursement. And so we've talked about some of these, but the non-face-to-face services, the ACP, the CCM, annual wellness visits, transitional care. And I would say on the annual wellness visits, for those who are thinking one day you want to be in value, risk adjusting your patient population today is of great value because you need that historical look back period to say, this is how acute my patients actually are. And that's what the AWV visit is truly doing. It's just capturing all the diagnoses in one true medical record. And so just to note there, we are looking into getting into an MSSP and their catchment period is, it has to be done by the end of September. And so we are risk adjusting a bunch of patients we've really never risk adjusted or paid much attention to because they weren't in our value contract. So for those in fee-for-service who think in the next five years I'm getting into risk adjustment, get the fee-for-service dollars, but there's also great value in maximizing HCCs there. And then think about your alternative payment model. So we don't go into those greatly today, but MIPS and any sort of PMPM care management contracts. And I'll talk a little more about those at the end of the time. We have a couple of slides on alternative payment models. Slide. So here's a couple of samples and budgets. We're not a small practice and we're still on QuickBooks. There are lots of other, Peachtree, there are lots of other books you can use. They're very complicated and you can also get away with pretty not complicated if you're interested. So first of all, I would say this, break out any information that you think you want year over year, month over month, so you can hone down and see what it's looking like. Sometimes it's all employees. Do you really want all employees or do you want providers separate? Do you want in-piece physicians? So just as you start to set up your chart of accounts if you're new, or if you're working inside of an existing chart of accounts, think about sub-accounts that make sense. So you don't want to burden, you don't want to say, well, I go to Kinko's over here for this and I go to Xerox for this and that's two different chart of accounts. That can still be paper supplies, but think about consolidation. So if you have to manage expense or look at revenue in a new way, or you want to blow it out by service line, that you at least have enough categories in your chart of accounts. So just something to think about there. And here you see a lot of the things that we were talking about, different account numbers in your chart of accounts that have descriptions. And so I won't go through each and every one. Slide. Here's some just expense categories that it's good to keep track of. So certainly you want to keep track of kind of the smaller pieces. You may want to, you know, like parking, for example, that might be a little bit smaller. You certainly want to think about how you think about travel, how you think about benefits of CME, how you think about, you know, again, supplies and overhead. And generally I recommend kind of breaking these out into subcategories. So for our practice, we have revenue in subcategories of revenue, the fee for service, the value-based, kind of, and other. And other can be anything over the years, includes medical directorship, stuff like that. And then from an expense, we have our people, and then we have purchase services. So is legal, your EHR, accounting, is that all on a separate line item, other, you know, outside of your... So we have purchase services, admin expenses, and, you know, physical resources and depreciation. And so those are just three buckets. If you don't have that many, line them up in one chart of accounts. Am I seeing any? Nope, no questions. Questions on budget? Okay, Brianna's going to talk us through a productivity grid. These are just some examples. And again, you can use your EMR to do that too. And again, I appreciate Amanda's comments too, of, you know, this isn't to be done in a punitive way or to even publicly do, but it's to measure, you know, is there someone on my team that's struggling? How are we really doing at the end of the month? Especially for new providers, when you're kind of, I would say, thinking about their ramp up, you know, do they need some additional support? You know, do you want them to... You always want to give them a ramp up period. So maybe you start them at like less than half the productivity. Do they have three months? Do they have six months? You know, kind of, what should that look like? And again, this is just because all in all, you need to be there to provide care for your patients and it's a business. So again, there's lots of ways you can be flexible about this, but I would encourage you to think of about some way where you can have a big monthly picture of what kind of care and what kind of volume your practice is producing, just so you can make educated decisions moving forward. Yeah, you know, and one of the things we do on our productivity is we color code it. So if it's below or above something, it kind of pops out because these reports get so monotonous and I know I'm, you know, speaking to the right crowd there. Slide. So here's just a sample house called P&L. If you guys want to throw the workbook in there too, I know there's kind of, this is small and there's a way to look at this, but there's just a couple of things that I draw your attention to. You have your revenues, you have your expense, your direct and indirect expenses, your direct, we've broken it out again, kind of provider and non-provider staff, you know, and again, this one, an example is some non-provider includes people and also things like equipment and stuff like that. You can really get creative. It's, for me, whenever I create a budget or a new ROI or P&L, I always think to myself, what is the thing two or three years from now I want to be able to hone in on? And that's the level of specificity you want to get into. It's always easier in budgeting or P&L work to get less specific and start rolling things up versus get more specific and dig deeper because then you have to go back through old information to try to get more specific. And so I'm not necessarily, again, encouraging create a chart of accounts that's 500 things long. Just ask that question when you put pen to paper of, what's the thing I really need two years from now that I'll ask myself? And this is a multi-year, so you see a five-year P&L. What are the startup costs? You know, and this is the expectation of growth is across the front or the top of the line. And so, you know, this is another way to include productivity in this. Once you capture a year, the other thing that I would say is you build out an ROI like this where it's a forward-looking forward-looking projection. Sometimes we forget. And what I like to do is when a month is over, whether it's my cashflow or my budget or my P&L is go back and put actual next to my budget. So like January, February, March, April, for me have already been filled in as actual in my budget. So I'm not just looking at a budget. I'm actually looking at a trend where it's actual and budget. When you finish year one, put it in, see how you did compare, and then make adjustments if you need for year two. Okay, any questions on budgeting at all? Is it everybody's favorite dealing with P&Ls, talking about dollars? Okay, it's tough. It's tough after lunch, going to budgets. I know, I know. Okay, determining standards. You know, what's my cost versus actual revenue? How many times have we heard nothing in healthcare is actually what it, you know, nothing is actually what it costs. So, you know, figure that piece out, see if you can allocate, and that you may do it by service line, or you may do it by geography, but see if you can start allocating. Once you get your, let's say your, let's see, Y-axis titles in, you know, figure out then what are your X-axis, what are your top considerations of what you're looking for? You know, again, type of visit, geography, how do you split that out so you can get line of sight to areas, or service lines that are not as profitable, and have opportunity? So it's really easy, and I always say this with my board, and with my staff, I say all the time, if you're in the black, you're not questioning anything. It's when you're not in the black that you start really looking. And I think there's this huge opportunity when you're in the black, and we see it a lot in for-profit, very aggressive, big corporate companies, right? But if you're in the black, keep pushing to challenging yourself and look at your P&L in new ways. So, slide. I wanted to chime in a little here too. So I know it's not totally easy to see this. This was just an example of HHCI has a research platform, excuse me, that has the most recent CMS claims data. And so what they've done is they've looked at all providers that build home and domiciliary visits and just kind of the overall utilization. And this particular graph is 2020, but I do have, I just think it's interesting to compare the most common. So we know, like I said, these patients are complex. So 99349 and 99350 are the two highest level home visit codes. This just gives you something to go off of, but 99349 was 17% overall utilization in 2021 compared to the 99350, which was 8%, which I actually think that 350 is a little low, but keep in mind, this includes specialty providers, palliative, other things like that. This is anyone billing that home visit codes. It's not home-based primary care specific. And then for the assisted living and the group home setting, the 99336 was 29% overall utilization compared to 99347, again, at 8%. Another thing to think about too is looking at your team. So you can use bell curve reports or just look, pull EMR reports on the percentage of utilization of these codes across your team. Because again, a lot of times in audits, I see the providers are undercoding because they're uncomfortable. Maybe they haven't been trained. They don't, you know, they're afraid they're overbilling and they don't wanna get in audit trouble. But again, this isn't encouraging everyone to bill at the highest level. You're not gonna bill at the highest level all the time. But if you have an outlier on your team, that's billing patterns are vastly different than the rest of your team. That could be a compliance concern. It could be an education point. So this is how E&M benchmark data is useful potentially. And then we just wanted to give you some national averages. Again, this is based off on CMS claims data. And Melissa, I know can put in the chat if you're interested. This is a research platform and research services that HSCI offers and is available for demo if you contact the research team, if you are interested. Thanks. And just to wrap up budgets, one more slide here. Just a couple of things, key decisions to optimizing your practice. And we talk through this in, oh, slide please. Some of the marketing work, and we've kind of gone along and talked about this, but thinking about some of these as major areas, these will be either expense or revenue decision makers that may change it. And Melissa said yesterday, if you've seen one home-based primary care practice, you've seen one home-based primary care practice. So again, none of these things are meant to be, you have to do it this way. Everyone else is doing it this way. It truly is. And I believe it starts with identifying your geography, your target population, who you're trying to serve, and that you're filling a gap that's either being underserved, being inappropriately served, or completely not being served, that there's this opportunity to leverage that. And you start there and stay within that as you grow. But these other pieces really play into it as you're growing. And these are the areas we see, I see, as you grow, that can kind of sometimes maybe get out of hand. Sometimes, especially, I'm seeing a lot more home-based primary care practices that are getting private equity infusion. And one of the big things that I think makes us more nimble than bigger, higher infrastructures is our continued ability to be nimble around expense. And when you build really heavy, fixed infrastructure, it's hard to move, because again, 90% of that's gonna be people. And so as you grow, your growth opportunity of keeping that nimbleness in fixed expense is super key. So some areas to look for there. I'm gonna turn it over to Paul to talk about technology. Amanda, before you move on, Alex asked a question about malpractice coverage and if it's different for home visits. And I know Matt, I'll let you answer that one. Um, I'm trying to think. I don't, other people jump in. I don't think so. So you fill out an application and you just need to fill out your site of service. But I don't think within family medicine and internal medicine, because we also do long-term care, I don't think I've ever paid a different premium for those sites of service. If, you know, if you have medical directorship, there's a different premium amount, you know, hospitalists or other services. But I don't think between home and kind of other senior services, I've seen a cost difference. Anybody else? That's on my experience as well. But one thing I had a practice come to me once and they were trying to, the way the form was worded, they were like choosing home health. So just be careful that you understand like what you're, it is different for like home health and hospice. So in my experience, it hasn't been different to you, but also make sure that the coverage or the insurer understands what you do and you're not like misled to select different services than you're actually truly providing. And for the person I'm trying to pull it up who asked about malpractice, malpractice, like become best friends with your malpractice provider. So I don't use a broker. I just manage it directly. So it's my personal relationship and I absolutely love it. I'm on their email listserv for when new stuff comes out. If anything comes out, I keep a file and ready to go to talk to someone about, and they're not that often, I don't think in our line of business, but getting really proactive, knowing who your agent is, being able to call and ask these really great questions or it's a worthwhile relationship to pursue, I think. Amanda, do you recommend any particular company? I do not. Yeah, we work with a Minnesota company, so I don't have a personal recommendation. Well, thank you. And feel free to keep the comments coming from the chat box, really appreciate it. And as we said before, we learn from each other and it's good to engage in conversation. Next slide, please. I think there's a tension as Amanda was talking about budget and so on, and there's the technology. We're all bombarded with ads about technology, getting the next best, greatest, fill in the blank kind of stuff. But the question, and I'll get to at the end, there's some high-level thoughts that I want to leave with you regarding when you're thinking about technology, what should I be considering? Should I really upgrade and pay more? Is that gonna really dig my budget and so on? So regarding technology for home-based medical care, there are just, I listed about six categories of items to consider as you are doing your work in the field, all right? One is the ubiquitous cell phone. And on the cell phone, you can load all kinds of apps, and I've listed some of them there. From clinical app, we talked about personal safety app to GPS, secure text messaging. People talk about Tiger Text is one. Northwest is using Volcero texting, and then internet searches. And hey, mindfulness, I need that after having a hard day and so on. So use your cell phone for multiple different support services as you go about your day. And I'll be happy to share with you as I do with people who rotate through the practice here, I'll be happy to share with you offline or in the chat about what apps that I use that I find helpful, that I use almost on a daily basis to help me with my patient care. Laptop, computer, again, it's very much a necessary thing for what we do here. We have a laptop that's issued here by Northwestern. It has a secured Verizon, oops, sorry, secured cellular broadband connection. So that we have less concern about using a unsecured Wi-Fi at your local coffee shop, right? And we use our laptops for many different things, for internet searches, for televisits, for faxes, and so forth. In the vehicle, some people still use GPS, but I think many of us just pull up our cell phone nowadays. But other things to think about, cables for charging devices, connecting this and that, jumper cables. Yes, it's possible that your car could break down and you need roadside assistance, especially if it's an area that's maybe a little bit concerning. Having an emergency kit, a flashlight, a power converter. We have converters in our vehicles so that when we draw our blood, the serum separator tube commonly, it's usually the yellow top tube, we need to spin the blood down within two hours after collection. So you need different connecting devices, power converter, and a centrifuge if you're gonna be doing blood work as you travel on the road. At the home, there are a lot of technology just coming into the home. We work with a portable x-ray company, portable ultrasound company that's coming to the home. We draw a blood test at home, but there are a lot of point-of-care testing that can be done at home as well. And there's the new wave of POCUS, stands for point-of-care ultrasound. Is that something you want to deploy that you can use at home to help you with diagnostics? The common use, one of the frequent use, I should say, of POCUS is to assess volume. Our patients got CKD, CHF, COPD, and they call you that they're short of breath. You know, what is it? So having a POCUS, having knowledge on how to do that can be very helpful. Just a plug for HCCI, we're gonna have a session on POCUS in one of our advanced application classes later on this year. Please feel free to reach out to us, reach out to Melissa. We'll be happy to get you more information about doing some of the testings at home or management at home, joint injections, G-tube changes, trait changes, and point-of-care ultrasound. Medication management. This is more on a consumer side, if you will. There's a simple pillbox, and then there are these very fancy, you can Google these very fancy electronic pillboxes with automated dispensers and reminders and so on and so forth. Bluetooth, this and that, okay? And then finally, there's a lot of consumer-based monitoring system hardware from weights to blood pressure, temperature, blood sugar, and so on and so forth. Next slide, please. Hey, Paul, a couple of people in the chat were asking about some clinical apps that you use daily in your practice. I don't know if you want to put those in the chat later or if you want to mention a few. Oh, absolutely. I can do that right now. So UpToDate is the one that I use for clinical care. And then other ones that are not as costly are free, Hippocrates. There's a free version. And then Medscape, it's free. I use a antibiotics guide from Johns Hopkins, antibiotics guide to help me decide on which antibiotic to use and what else to consider. There is a anticoagulation. I don't know if you can see this. No, that's not going to work. But there's an anticoagulation software that I use. It's by the University of Michigan to guide me with those difficult conversation of whether I should use warfarin or anticoagulation on grama or not. There's the ChazFast score. It's a very classy app, ChazFast score. And then the reverse side is the HasBlood score. Okay, MedCalc is the one that I talked about before, has a lot of calculators. The one that I use most commonly in there is the creatinine clearance. Doximity, I use that a lot, not only for video visit, but it has a faxing feature. So if I'm out of town or whatnot and there's an urgent fax that needs to be done, I can go ahead and get that done over the internet. And then just a couple of other things real quick. FastFax, FastFax, that's by the University of Wisconsin, Medical College of Wisconsin, I'm sorry. It's really good for treating palliative care symptoms. Intractable fill in the blank, bowel obstruction, hiccups, pruritus, and so on. So that's another one that I use. And finally, there's more than I'll stop. Well, two things. CardioMobile, I don't have the device here, but CardioMobile, there's a CardioMobile 6L. There's a technology, you can Google that, Cardio, that's with a K. CardioMobile 6L, you can get a six lead EKG at home. And that's connected to your app on your phone. And finally, there's an opiate conversion. It's called opioids. We do treat a lot of pain situations and we do convert from one opioid to another, converting from oxycodone to morphine, to fentanyl, going from IV to oral, from short acting to long acting. And I can't keep all the formulas straight in my head. So that is one app that I use to help me convert from A to B and get the appropriate dosing. But I'll be happy to talk more later on. Next slide, please. When thinking about technology, this is a mnemonic. You can tell I'm into these things to help me memorize and remember things. I think of the term diastole. One, the D stands for the device. How complex and how portable is it to use? Complexity, not only in the initial setup, but also in operations. You know, is it too complex for me to do this on a day-to-day basis? For example, there's the ISTAT machine that can be used to get a point of care blood testing, a basic metabolic, a BMP, and so on. But there are particular setup and maintenance as related to using an ISTAT machine at home for field use. Is that something I want to get involved into, in addition to the cost of the device and each cartridges and so forth, and the complexity of meeting lab requirements and CLIA approval and so on. The I is the interface integration. I don't want, the device should hopefully integrate smoothly with your EHR. I don't want to double entry things. We're all sick and tired of typing twice, right? How is the interface? Is it readily recognizable and user-friendly? And is the integration, if I did use the ISTAT machine, how's that SNA7, how's that going to get into my EPIC? Do I have to manually enter that? Is that going to be a deal breaker for me? So those are just some of the things to consider when you think about a device and how to integrate their interfaces with your other pieces of your work. Accuracy and reliability of information, that's self-explanatory. For example, we need to be good at doing POCUS at home because if you get bad imaging and you get bad interpretation, you can do harm to your patient, right? So not only is there an accuracy on the provider's side in terms of being proficient in doing this, but the machine's got to be accurate and reliable in giving you the right information. Storage and tracking of information, that's about security, right? If it gets lost and so on. Team members, who else is involved in data management and analysis? There is the concern of data fatigue. Brianna talked before about RPMs and so on. Is that going to open the floodgates to a whole host of data that's going to come into your inbox? All of a sudden you have 33 pages of fill in the blank, you know, blood sugar, blood pressure, et cetera. Who's responsible for this? Not only are you getting paid, but you know, analyzing the data so you don't get sued for say, hey, you missed that reading there. Connectivity is an issue. The example I use is I ride the elevator. That's one of the reasons to stay healthy. I take the stairs because when I go into an elevator, often my cell signal gets disconnected and the note that I work really, really hard on is now lost or it becomes a read-only note and I can't document anymore. So I have to recreate the note again. So connectivity, you know, test it out as you drive around your community. Am I connected all the time or do I have a dead spot in multiple places? Liability and cost of device. Again, that's about information, protecting sensitive information, but also the cost of the device. You know, it's not only the financial costs, but also the providers. It's the time involved in learning how to use the device to upgrade it and so on and so forth. We've all, I think, upgraded computers and sometimes I just want to, you know, like good grief, you know, how long, how do I do this and how long is this gonna take? So there's that time cost in addition to the financial cost. And finally, there's the end result of the impact on revenue. Does it make a difference in clinical care? Is the POCUS gonna help me? And can POCUS, using that as an example, help me with my revenue? Will this technology help me with my, help with patient care and make an, hopefully a positive impact with a revenue side as well? Next slide, please. Just a couple of things to keep in mind. Don't buy into the false imperative of technology that since it's there, you know, I just gotta have it. You know, marketing is very sexy and good at getting us to want, you know, the next great thing. And we have to be careful of that. And that flows into the seduction of technology that the latest is always better and it's always the best. It may or may not be the case. You may want to let other people try it first. You may want to test it out first before you really sink a whole chunk of money into this particular piece of technology only to regret it six or 12 months down the road. And finally, don't get over-dependent on technology, right? There is that depersonalization when you depend too much on the technology where, you know, we lose that face time with our patient. We lose that trust. We lose that opportunity to build relationships when I'm on my phone all the time, when I'm on my laptop all the time, not looking at my patient. Again, over-dependency also could cause atrophy of our clinical skills at the bedside and thinking up here, right? We need to be great clinicians, thinking about, you know, like I said, the thing about, you know, whether you've got a Bell's palsy or a Ponting stroke, you know, that is something you need to know and don't let technology overtake that piece. And don't forget that, you know, we're healers and we're not just mere technicians. Next slide, please. Finally, you know, what I want to consider, what I want to think about when I am looking at a piece of technology is portability, connectivity, security. Is it durable? And also, do you have a backup plan for documentation if you lose the connection in your EHR? You know, does your EHR have a safe function? At least part of your documentation was saved rather than, you know, everything being completely lost. Next slide, please. And template building. Oh, this is, I think it's, especially if you're early on in your practice, is we're talking about so many things here. I mean, template building touches on so many aspects of clinical care. We got burnout, we got efficiency, we got maximizing your revenue, seeing as many patients as you can, doing TCMs and so on. Get a sense of like, what are some of the common templates you are using and create a template for history for your screening assessments, whether we're talking about a mini-COG, a PHQ-2 or nine, or a vulnerable elder survey, whatever it is, build a template for those things, build a template for your TCM visits, build a template for your, Megan talked about, not cognition. Oh, Megan, help me. But anyway. Capacity. Capacity, thank you. Capacity and cognition, yeah. Capacity exam. Having a template for those exams really helped cut down on time of documentation, keystrokes, help you stay focused, maximize your time, maximize that face time and also maximize your revenue and visit per day. Next slide, please. All right, Brianna. Thanks, Paul. So, keep the comments in the chat coming. We're going to talk a little bit about marketing for your home-based primary care program, especially for those of you who are newer and trying to build and grow programs. If we can move to the next slide, please. So, here's some examples. And when you're trying to think about where are your patients going to come from? Where are you going to get referrals? We talked about how valuable senior living facilities or group facilities or even just independent buildings that have a lot of senior populations, networking with their local area on aging and other community resources that would be providing to patients potentially in need. I know some providers that are even on certain boards, Parkinson's associations or vulnerable elders, things like that, that get some exposure. If you're part of a hospital, even if you're not, your local ER and hospitals, could you propose a transitional care pilot if they don't already have a partner that goes into the home? Discharge planners know who their frequent flyers are. Care coordination knows who's there and who's not getting to that clinic PCP. So, certainly another option to think about there. And for your outpatient clinic providers in your area, you don't want any patients that could be cared for properly in the office, right? Try networking with them and say, hey, I only want the sickest of the sick. I want the patient that you haven't seen in a year or two that still needs medication repo request or is really a liability for you. Help them understand that you're not trying to take their patients. You're really trying to be a partner. And that can be another great referral opportunity for you. HSCI actually did a study, and by and large, most of home-based primary care referrals were getting it from home health and hospice agencies, home health in particular. So, really think about where your referrals are coming from. Again, if you guys have any other ideas that are not on the slide, please put them in the chat. But next slide. Again, these are very similar programs, but also thinking about, yes, you need these services for your programs, but again, they also need to be aware of you. We also need to do education to the community that home-based primary care even exists and is available so that these other community programs, kind of a nontraditional one to even local faith communities, sometimes people come to them and need care. So, volunteer programs, things like that, other opportunities for networking, and also could be resources for your patient, like we heard from the social worker team earlier. Next slide. So, when you're thinking about your practice website, these are just a couple practices that gave us permission to use their website. But sometimes I'll be working with a new program, and I'm curious, and I'll go to their website, and I really can't tell what they do, right? So, it should be pretty obvious when you go to your website that you're not concierge, that you make house calls. What are you trying to do? What are you trying to refer to? We make house calls in big, bold letters, and then kind of adult primary care and highlighting those chronic conditions that they care for. I would also encourage you, we can go to the next example too, not to spend too much on digital marketing. You need a website. You need information out there. But I have seen some new practices that invest kind of heavily in a marketing firm or things like that. That's really not where your referrals are coming from. So, also, you know, I would put the thought out there too to not invest too much in digital marketing. But it should reflect easily, very clearly what you do and how to contact you and how to refer to you and make it pretty easy. Next slide. And when you think about your partners, again, the key is flexibility and making it easy. There should be lots of ways to refer to you. You should have that elevator speech ready of what's the mission goals and outcomes that people can expect from working with your program. You know, what kind of patients are you specifically looking for and what are you not looking for so that you can be clear and try to avoid those inappropriate referrals. And then, again, flexible. Can they call you? Can they fax you? Can they e-mail you secure e-mail information? Can they fill it out online? Try and have as many options for people to get to you and to, you know, refer to you as easy. And then also set expectations. What's going to make the partnership successful for your referral source and what do you need from them, especially if you're evaluating a new facility? Assisted living facilities, while we've talked about how they can be great from a geography standpoint, also come with their own challenges. So talking with the DON and talking with the administrators and really understanding what you're getting into before you accept that partnership opportunity. Next slide. The other thing, too, is, I mean, just if we think about relationships in general, it's not like a one and done thing, right? You want to stay connected with them, especially your kind of high volume referral sources. Are you tracking where your referrals are coming from? Like Amanda was saying, where is the patient? Where are your patients coming from is from a referral source, too. And how often, you're not going to do this with everyone, but for your key partnerships, how often are you meeting with them? Again, even from a quality perspective, what's going well, what's not going well? Which of our, you know, mutual patients are struggling? They're certainly now, especially if you're in value-based care, are predictive analytics and tools and, you know, part of some of the same models trying to identify high-risk patients. And again, if you're part of a health system, you know, maybe you're looking at clinic patients with high no-show rates or other creative ways to get patients. Next slide. The other thing you have to consider, too, though, is if you're really trying to grow, is what kind of growth can you handle from a staffing perspective? Again, so that we don't lose quality. So thinking about your provider panel sizes, you know, what is full? You know, can you get access? How long are new patients waiting for an appointment? You know, you do need to have referrals coming in because, unfortunately, the reality of this patient population is you have, I think Paul did some research, it's about 30% mortality rate for home-based primary care patients. So you're going to lose patients. So you're going to kind of plan for that and make sure that your community is aware of your services, you have reasonable growth, and then you also are continuing to measure, again, on the outcomes and the success of your practice. And you can do, I know some practices that even do partner surveys. Again, not everybody, but they're key partners, maybe they're key facilities, key home health agencies, just like you do an annual patient and caregiver satisfaction survey, even doing a partnership survey to really evaluate that. Next slide. So, again, you know, home-based primary care is not one size fits all. We can say that over and over again. Every practice is unique. There are certain, you know, key attributes to be successful, but you need to figure out what makes sense for your practice. Definitely take the time for those newer practices to really think about your, you know, do a business plan, think about your model, think about patient identification, think about your limitations, and all of those important things. And then weigh the costs and benefits of technology, like Paul said, and really kind of think about, and I think they expect, we expect the floodgates to open, and that's usually not the case. Usually when you're starting up, you know, you do need to invest some time, because startup is generally slow, but also know your limit so that you're not going too quickly and not overpromising things you can't deliver on. Yeah, there's a question. What is the average wait time for office are seeing to get a new patient scheduled? Well, it depends, right? Part of the protocol, I think, again, work with your front office staff. You get some intake information. You can have them ask them a question, you know, when was your last visit with your PCP? If it was just a week ago, you probably could put that patient maybe a month or two down the line, but also you could ask them, you know, are there issues that you're concerned about that needs perhaps more urgent attention? And then you can have your office staff get that information and send it to the providers and say, hey, you know, this one sounds a little bit urgent. Can you bump maybe a patient off your schedule and get this patient added on? So it depends on not only the location of the patient. Again, we travel by geography, so certain days I go here, other days I go there. So geographic consideration and also the needs of the patient needs should be put in mind as well. And finally, remember, Brianna said, you know, TCM is getting huge reimbursement increases. If at all possible, if it's a hospital referral, say, you know, this guy needs a TCM visit, trying to get to that patient within seven days. Not only it's good for patient care, it's good for revenue as well. Yeah, great points. I don't know a specific, like, if there's really an average around. I mean, I know some practices that will go to waitlist. You know, I would hope you want to try and be able to get a patient in within two weeks if they really need you. And if you're out more than two weeks, then that might be time to kind of assess kind of what your access looks like and if you can continue to grow. Otherwise, I do know practices that will utilize waitlist, although that would be certainly something I'd keep an eye on and evaluate how we're going to solve for that. Great. We're going to talk about staffing and workforce considerations and home-based care. Slide. Okay, factors in developing, growing your team, explore positions and signs that it's time to expand the team and manage productivity standards. So we could talk more about we're going to keep on the productivity. So who is your team today? You know, what positions did you start off with? What's causing you to add more staff? Again, what are those trigger points? How many patients? Do you need a new geography? Do you need so many patients in a new geography? Do you need a new payer? What are your needs for the future? Again, building those kind of steps of budget into place. And then who's going to be doing that work? When you're smaller, everybody kind of does all the work. And then as you grow, you start to silo a little more. And often that makes sense, but continuing to think about what are the needs for the future and do you have the right positions in place? Slide. So a couple of traditional roles. We already talked about social workers, I think, in the chat. It sounds like some people have them, some people don't. Rush has been able to, you know, loan us a number of social workers who are experts in this work, which is fantastic. We see community health workers a little bit. I definitely see nurses, MAs. Some of the pharmacists, again, I think a lot of people are getting that work for free. And then there's these specialized roles. And these are really, again, targeted around where are your biggest pain points? So where do you need some help? Is it coming in and out of the hospital? Is it coming in and out of a MedA state? How's the billing and coding? Are you outsourcing that? But do you need someone inside your organization who's still doing all the intake and prepping that work for them? And so just, you know, I always think about starting with expanding into specialized roles when you have a headache. Yeah. And I mean, I think the other thing to highlight on this slide is with kind of how creative we have to get with workforce right now. We're starting to see, you know, lots of, you know, medical assistants are always the most common. But I've been asked before, well, what about community health workers? What about, you know, paramedics who use more in telehealth or hospital home models? But they're certainly going into the home. And if you're investing in your team, if you have a practice manager that really has a role and you want to try and bring billing and coding in-house, you know, the AAPC, the American Academy of Professional Coders, you can take online training. If you don't want to be certified, you don't have to take the test. You know, there are resources to kind of invest in your team if you did want to bring that function in-house. I don't know if anyone follows the AMA Pro's of the week emails. That's a great way. They have some great topics, but they were talking about the concept of an inboxologist, like assigning a provider just to do inbox work for their team for certain hours and certain days to kind of take that off the other providers. So you could get pretty creative. Brianna and I created this maybe like a year ago because we kept kind of getting questions around licensure. One thing we talked about already is kind of that RN triage is the only one who could do that. Otherwise, LPNs and MA are educating, relaying information, intaking information, gathering information. You can come up with 10 different verbs, but they're not triaging. They're not the gerund of triaging. And so this is not an entire comprehensive list. I'll let Brianna speak to it, too, but I would say know your state's scope of practice laws. So this is the general list that we can aggregate from 50 states. But individually, these could vary. And what I would think more often would happen is there'd be additive things that you could see in there. And that's really what you're looking for is where can I push my individuals to top of licensure? Yeah. And the only comment I'll make about, you know, knowing this is also for those clinical staff, too, right? And not to belabor the point, but your state board of nursing website is where you would look. And even for medical assistance, although they aren't very regulated, there are some states where they can't assist with certain procedures and can't do things that we might want them to do. You know, and again, we're talking about those virtual assistants, too. Another learning I had from a practice is their time can't count as billable CCM time because Medicare, under a federal regulation, doesn't pay for services provided by people outside the U.S. So, again, you could use them, but not counting their time as billable CCM minutes. And then, again, knowing state limitations with medical assistance that may be assisting in procedures or other care, usually more in facility-based work. Brianna put these next two slides together, and I really like them because it's almost a summary of the last, you know, couple of things we've talked about. It's just sometimes it's how do I evaluate that something's not working right? Where do I go look? And these are ideas of places that you can collect data, and we would point you to if there's a staffing issue. We've talked about productivity, but also phone calls and being able to capture those phone calls. How long are they taking? How many are you getting? Where's your phone tree taking them? You know, prior authorizations, the licensure piece of your schedules and the productivity inside your schedules. How quickly could someone get an appointment if they needed to see you? If there was an acute issue, could you actually respond to it? You know, is that where's your staffing being set? So I really like this list as a summary list to, again, evaluate when you're having a problem. Slide. And so, you know, additional staffing considerations, and I'll let Brianna, you know, run most of this slide, but I would just say, again, kind of a summary list of going through your workflow and making sure you address major buckets around, you know, satisfactions, scheduling, getting in and getting results out the door, and making your office the most efficient. Yeah, and I think we talked about most of this, too, but, again, this kind of ties into this next slide, so it's okay to advance here, but, you know, if you're struggling, you know, kind of identifying the problem and doing that cost analysis. Is it really? I feel we're always quick to say, oh, we need to hire, right? You know, is it truly that you need to hire someone, or are you just struggling because you have an inefficient workflow or you haven't investigated the problem fully? The only other comment I'll make on staff and employee satisfaction surveys, I think they can be really valuable when we're talking about retention, but you need to actually assure your team that you're listening and accepting their feedback and doing something about it or acknowledging, you know, the comments that you get in employee satisfaction surveys. But, Amanda, you know, again, we've talked about a lot of this, but really trying to understand, is it a people, you know, concern? Are you overwhelmed, or is there really a process or a workflow, you know, breakdown because you've just been too busy to really invest the time in it? Well, and we're going through this right now. We have a scheduling concern, and I said, is it person-specific, or is it, you know, FTE, or what is the root cause, and the person really couldn't answer me. They were like, I need to go do some digging, and I think that's the other thing, is something's wrong, and it needs to be solved urgently by hiring someone. It's impossible to hire right now, so that can't be the number one solution anyway. And one more thing on surveys, if you are doing surveys, so we take part of a – so a lot of the major newspapers in states run, like, top workplaces surveys or the business journals that you can participate for free, and then you just pay to get the results. So we're not paying kind of twice. We're not paying for the delivery method and the analysis, and so we spend about $27 a person on getting employee data back, and then we create an annual plan based on that data. So just if you're looking for free ways to get surveys, you can do other more free ways, but that's kind of a standardized way. Next slide. So one other thing is kind of as you grow, and you're all in different spots on this, but I just want to highlight, you know, what type of growth are you experiencing, and where is the growth? Is it service area? Is it payer-specific? Is it, you know, provider? Are you trying to grow because you have people interested? You know, I've never had as many people interested to join our practice as I do now, and sometimes I have to say, we don't have the plan yet. You guys got to stop. Are we starting a new venture that requires a different business plan and staffing model? So we just started a wholly-owned subsidiary, and I would say it took six to eight months to fully do the research and move it forward because it really is a different business plan, and it is a different staffing model. We are using a different EHR. So how do you kind of think about those things when you're growing? And so just a couple of notes of where are you growing, and then what's that step growth when you add that service or staff? Really, really key. You don't want to add too late or too early. I had a previous manager who said he only hired when people were crying in his office. Probably want to hire slightly before that in today's market. Slide. These next two slides are really just for examples so that you have them in your resources, and we can kind of just go through them, but, like, it's always the burning question. Well, like, what are other people's staffing models? So we can keep advancing here. So, again, these are more just for your reference. I think there's no one-size-fits-all. You know, scribes is kind of a unique position, but typically the way I've seen practices do that if they have a scribe or a virtual scribe, you know, even in your ear listening and dictation is it's not one per provider. It's, like, rotated across the team on different days or things like that. But you can, again, keep going. These slides are really more just for your reference to go back to so you can have some examples of program staffing models. Keep going. I think we talked a lot about productivity. Again, the other thing to think about, though, is it really comes down to access, right? You know, so it should be a partnership. You know, you want it to be not sacrifice quality. I'm not going to belabor this point too much so we can keep going, but what do you need to be there to provide care for your patients? And also just don't forget about panel sizes, right? Like, if you're going to take all these patients on, then how many visits do you really need to be doing to actually see them all? And thinking of you could even analyze your visit frequency to help you kind of answer that question. And Amanda, go ahead. I was going to say advance two slides because these are just ticklers of the two we've talked about. Let's keep going on the panel size. One more. Yeah. So, sorry, did you have anything else to add here on panel size? I kind of already made my point. Again, just reference examples because these are like the biggest, you know, burning questions that we get. So, again, there's no one size fits all. I would say these examples are pretty consistent from what I've seen. This isn't a particular national average. This is just based on specifically home-based medical care practices, but what HCCI is seeing and some other examples that practices were able to give. And other faculty, Megan and Paul, maybe feel free to share in the chat, you know, what you guys think is reasonable for panel size and productivity. And for us, home-based primary care, we're really those same numbers. When we talk about assisted living, they go up. So you might have panel sizes that vary by location that you're going. And so just think about that because we actually pay people on panel size, and so it's kind of a formula that you want to look at, but there's not a flat panel size. If you can do more visits and you can have the aggregation of an IL or an AL or even kind of a senior community, that's going to be a different experience. And every time I have to see a new patient, I drive 30 minutes. Questions for us? I would agree with what Amanda just said. It just depends upon your practice style. It just depends upon your practice style. If you're doing all visits to homes, you can only do so much, even with the best efficiency. But if you're going to ALFs, you may find that you're able to increase that. And, you know, one of the reasons I like paying on panel size versus, you know, work-hour views or even salary is it does allow for some flexibility for those who have increased productivity or are incredibly efficient in their practice, right? And so, you know, it doesn't wholly base your entire salary on work-hour views and these visits you're turning and burning, but it does say how many can I ethically handle on a panel size. So I think it's a good balance of a little bit of volume, but not too much to stress the system out. And I would put one more slide, the next slide. This is what we see in person, and I know we're virtual, but it's really the importance of, no, no, the learning plan is really filling this out. So what we see is you get all these genius ideas or you learn someone's name or, you know, like I want to follow up with them or I have this nugget of an idea, whether it's go research this app or whatever, putting this down here is a place to revisit it because you're not going to ever sit down and rewatch the recording for two full days. So this is kind of the tickler for all the work that you kind of want to do after this. And we find actually people years later coming back and saying, I said I was going to make a note to dig into that quality measure, and I did, and I pulled it out every year and looked at it. So just a plug on the learning plan. And now we're having a break, so we'll see you in 10 minutes. So I have 1.58, and so what, 2.08? Okay. Thanks, guys. All right. Sounds good. Welcome back, everybody. That was our last break of the day. And we have some. We're moving into an exciting session here with. It's called putting it all together. Simulated house calls. Margaret, you were going to share your slides for this part, right? Sure. Okay. Thanks. Okay. All right. Well, welcome back, everybody. This is the putting it all together. This is where Dr. Chang and I and the rest of the staff, we're going to have you kind of walk through and see what a typical day might be like having three patients and trying to plan it all out. Next slide. All right. So we're going to prepare for and conduct three simulated house calls. We're going to discuss the impact of the home-based care on the patient and their outcomes. And we're going to also demonstrate optimal coding. Bran is going to help us with that at the end to make sure we've gotten everything we can out of this and get paid what we should. All right. Next slide. Okay. And we're going to have these three patients. MJ is one. And then we've got Ralph and should be Betty if I remember. We're going to review the patient files. We're going to plan our day based according to the patients, figure out what direction we need to go and who we need to see first. Think about equipment, all the supplies you might need. And Dr. Chang, do you want to also mention how you'd like to plan out your day? Yeah. I chart prep every single one of my patients either the night before or the morning of. Not only do I review the past records, I set up the charts ready to go. Again, using my smart phrases and so forth and see if that's an option in your EHR system that you can pre-populate the chart without actually starting the visit. Again, I also order what I think blood tests are necessary and so on. So that's all loaded in the chart and ready to go. And if I'm going out to do a knee injection, I make sure you can see the supply list. It doesn't mean that you have to have everything on the list there. That's something to think about. Again, Tony talked about, or actually Megan, you too talked about not having a huge bag. So if I know I'm going to be doing a knee injection, I want to make sure that I have my injectable medications and all the supplies that I need for that. If I'm doing a G-tube change, make sure I have the necessary equipment for that. Again, it's about efficiency. It's about maximizing your time, maximizing your revenue. I hope it's coming together for us. As Amanda said, this is the home stretch. We want to help you synthesize and help make sense of all the stuff that we talked about the past day and a half. All right. So we're going to get set up into virtual breakout rooms and we're going to give you 75 minutes. You're going to conduct a simulated visit with each of those three patients, Ralph, Betty, and MJ. And then we'll help guide you through it, kind of what our thoughts would be, how we would approach it. And then if you have any questions, please ask us. We're going to ask that out of each group that somebody kind of be the designated leader. And then when we come back together, we're going to compare notes and talk about some of the ways that we, each of our groups work through these three visits. Any questions? Okay. All right. Good luck. All righty, everyone. This is Sarah Breesue speaking from HCCI. What's going to happen is I'm going to open all three rooms. There will be two of the presenters in each of the rooms. So they will kind of be directing you. I'm going to open the rooms in a minute. If by chance you step away or get disconnected, I will be in the main room. I'll be able to redirect you and you'll always be with the same group. Okay. So enjoy the session. For everyone else still in the breakout or in this room, please make sure to click the button to be assigned into your breakout room. We understand that it sounds more clinical. Please feel free to join that breakout room. This is still part of the session, so we still require everyone to go into their assigned breakout room. Can everybody hear me? Yes. I lost some of my zoom controls, so here we go. All right, and you should be able to see my screen. Sarah, do we have everybody back or are we still waiting? It looks like some people may have stepped away from their computers, but in 10 seconds they should be brought in. Yep, it looks like everyone was brought back in. All right, thank you so much. Big shout out to Sarah for being the breakout organizer. I think I would break out into a cold sweat having to do that, so thank you so much. Okay, so we are back and let's see, Megan and Paul, are you here? Yes. All right, so I know from my group, Amanda and I had a great group and we've got reporters who are going to talk through each of the patients, but who did, let's see, who did you want to start with? Let's see, you want to start with Ralph? Let's do it. Anybody from Paul's group want to be the first to present? Yeah, we had a, Melissa, I think we had a better group than you. No, I don't know. I'll try to stir up some evening conversations. We had good discussions and we'll be happy to contribute what we have. And also, it's great to hear what others, I'm interested in hearing what others have decided to do with each of these three kind of unique cases. And Roseanne was gracious to be kind of our scribe for our team. And I told her that ACCI will be sending her on a trip to the Bahamas. So, she'll be talking with you soon, Melissa, about that. Okay? Paul's writing checks, he can't catch. All right, Roseanne, you want to take it away about MJ? What have we decided to do? What are some of the highlights about his case? Yeah, so are we starting with Ralph? Oh, I'm sorry. I'm sorry. Ralph. Okay, so Ralph. Yeah, so Ralph was the, yeah, he was a guy with the COPD, new onset leg edema. So, we decided to do some further evaluation. I know the first question was whether we have to call 911 or should we look more closely? And so, we thought of doing the focused assessment, definitely look at his oxygen delivery system, check out if the nasal cannula is working, the machine, the connections, do some troubleshooting, check if there are any backups, any concentrators available at home. And then if there's any issues, of course, we have to call the DME company to fix it. And then we would have to increase his oxygen setting to keep his saturation to about 92%. So, for our care plan, so diagnosis and symptoms, definitely. So, first one would be the COPD and CHF. We were thinking that they were probably happening together at the same time. So, maximizing the nebulizer treatments, oxygenation, maybe adjust the diuretics. And then consider some more testing like EKG, echocardiogram, maybe a chest x-ray to check for superimposed pneumonia. And then, of course, also look at the possibility of PE, maybe an ultrasound of the leg or maybe a D-dimer. And then working through the 4M. So, when we talked to Ralph, then we'll see what matters to him. So, of course, it would be to breathe better. So, look at his medication. He was alert, responsive, it was conversant. And then mobility-wise, we wanted to, of course, minimize his risk of falling, see how he's able to get around his home. And then, yeah, so medications really just to really simplify his medication list. And then, of course, adjust as needed. We definitely have to educate the caregiver as to what to do in cases of emergency. And then have a kind of a plan as to what they have to do on a daily basis. So, checking weights, monitoring his oxygen saturations. And then, most importantly, it's really, again, a troubleshooting to make sure that the oxygen equipment is working. And that they have all the necessary contact information available at home. So, that's most of what we have. That's great. So, for my group, for mine and Amanda's group, we had Therese. Therese, did you have anything that you wanted to add for Ralph? They said something about addressing the fact that he's smoking again and using O2. I think she said everything that we came up with that might be in addition. That and also looking at the depression and anxiety. Yeah, thanks. How about in Megan's group? Who's the spokesperson for Ralph there? We had Samantha. Okay. So, we too, you know, we address the medications as well. But we also address the fact that if he's non-compliant, we have to educate him with his medications to see what is going on. That he's not taking the medication. We also decided that we were going to have a home health skill nurse come in for the COPD CHF. And they can monitor him more closely for us. We're going to have the social worker come in. Because we want to make sure that we address his grieving and depression process. And maybe some home monitoring from the VA. Because he is a patient from there. Where they can monitor his weight, his blood pressure. What we want to do is try to get his chronic diseases under control. Because at this time, he's in exacerbation of both. And we need to also make sure that he knows how to use his inhalers. And so, also making sure that he is safe in the home. And we want to make sure that we can help him get to what really matters to him. And the only way to do that is to make sure that he is aware of his disease process. How to manage it. And to give him the resources that he needs to prevent him from exacerbating and returning into the hospital. Real good. Thanks. Another thing we talked about was bereavement counseling. Because he just had a death in the family. And the VA can possibly supply that. Or maybe if he didn't have it from the VA. Maybe one of the local hospices could help us find a bereavement counselor who can go in and deal with him. Oh, great point. How about Betty? I'm sorry Megan, I'm stepping on you. I know if we kind of go and we let Alex from my group. Did you want to present Betty first? Sure. So, we have Betty. She's a 60-year-old female with multiple medical problems. She's been feeling down, depressed. Mobility has been an issue for her caretaker situation. Her daughter helps out with her. Very verbally abusive. And basically just picks up her medications and helps try to administer it. So, with Betty, she hasn't been able to visit her primary care doctor as well. She's just a case of she's not taking her medication. She's not taking care of herself. She can't take care of herself. And we're trying to bring in the resources for her to try to regain her health. Some of the big issues that we wanted to talk about was her diabetes. Concentrating on her diet, the medication use. Proper education on the checking and what medications to take. Because she doesn't know what medications to take. Her poor hygiene in her legs. So, getting someone to help bathe her if possible. Because her mobility is also, again, an issue. So, she can't do those things herself. Reviewing her meds, she seems like she has a lot of medications that she's supposed to be taking that she doesn't even know she's taking. So, really just bringing in home health, home healthcare nurses, a homemaker, physical therapy to try to regain her mobility. And then just on future visits, try to chip away on her other medical problems. And in the future, address her depression, which is also an issue. But it could all be related to her social situation. Excellent job, Alex. Excellent. And then, Dr. Kaplan, he's our spokesperson for our Betty. Do you want to add to that plan? We agreed we were looking at the abscess and treating it for Betty and the polypharmacy aspects that were concerning for us. We also looked at the social aspect, too, and how a licensed clinical social worker would really be helpful to come in. But we kind of took it a little step further. We talked about calling Adult Protective Services, not because we're trying to necessarily just yet remove her from the home, but at least get them involved and see what maybe that might be helpful or see what could be done from a state standpoint would be a good idea. And we also talked about wanting to make sure the depression screening is completed for her. So those were some of the key things that we took away from that. And then, Dr. Chang, who's from your group as your? Poor Roseanne had the duty for all three. So Roseanne, anything else to add other than what we've heard from the other groups? I think one of the other things that we focused on was a polypharmacy. She had about 27 or 29 medications is what we were counting. So definitely the prescribing. We also really keyed in on those adjustments based on the kidney functions. That's very important to prevent any other side effects. And I think and then additional is maybe ordering for any mobility devices that she may need, like a lift chair, sorry, anything else that she may need at home if she doesn't have. Oh, sorry. And then one more thing, the existential question of her dying. So we also thought that that may be a good time to segue into maybe asking about her goals of care, maybe looking into the polls and just yeah, just so we can have a better idea of what what she wants in general. Absolutely. Thank you, Roseanne. Absolutely. Thank you, Roseanne. OK. And then the final patient for the day was MJ. You want to finish up with MJ, Roseanne, and then circle back around. Sure. So MJ was the Greek speaking patient. So when we when we were deciding on what to the top three things that we wanted to focus on was so definitely we need to be able to communicate well with him. So we we wanted to have some translation services available. We at least in our group, we we were lucky enough to have some phone and translation companies that are available to for our perusal. The second one was the nutritional issues. He was having trouble swallowing. He was losing weight and then his blood sugars are a little bit out of control. So we talked about maybe looking into speech therapy and then imaging if there's there may be some concern about malignancy. And then also we also use that as as a way to kind of focus on what the goals are for the patient. Do they want a comfort that allow us to liberate his diet or are we focused more on treatment than we would have to look further into, again, at this risk for aspiration. So maybe a referral to speech therapy, home health services. And then the third one would be, of course, the patient concerns. Looks like he hasn't been he hasn't seen the cardiologist for two years. So we talked about setting up maybe some telehealth services, working with the cardiologists to manage the warfarin as well. And then just as a side note there, it was brought up to that there are home I and R monitoring companies that we can use that, you know, would help us manage the patients at home better. And then the checking the blood sugars, it seemed like it was too much for for him. So we wanted to reduce the burden, wanted to check more into as to what what's concerning the patient. Is it the frequency of the test? Does he really need to check his blood sugars that frequently? So and then the third one was church. So he wanted to go to church, but he felt also that it was difficult for his knees. So we thought about referring maybe to social services to help with a caregiver burden and then have, again, the appropriate mobility devices that he can use to achieve his goal. So I think those are great. That's a great job. I really you guys address the I and R who's going to monitor the coumadin, his blood sugars. Melissa, who was from your group as a spokesperson? So we had Randy. Randy, can you chime in anything more about MJ? Yes, you pretty much touched on everything. One of our concerns was regarding the safety. We felt that he was at high risk for some safety issues. For falls and then with the dysphagia, possibly aspirating, things of that nature. So we discussed bringing in resources to minimize those risks. For example, maybe a life alert bracelet chain, home health nurse to evaluate the patient in home, DMEs and also the physical therapy. The tremors were worsening and things of that nature. So we thought that those will be beneficial. But everything else you pretty much touched on that we touched on. Yeah, yeah, no, absolutely. Get him to move a little bit more, help with his Parkinson's. And if he's getting up and doing things that might also help with a little bit in the blood sugars. We in our group, we talked about doing some education on hernia reduction, just how to push that back in since he was uncomfortable having family do it. So we really hit that as well as caregiver respite, how to get some relief for the caregiver in there. Those were added on to our list. But, you know, altogether, it looks like, you know, you're really able to recognize that when you have these multi complexity patients that often there's so many aspects that it can be overwhelming and you can't get to all of them in one visit. Sometimes it's just really not possible. But you really want to make sure to approach it with the forums. What matters, you know, their mentation, you know, their mood, their mobility and their medication. You know, is there anything we can do to deprescribe or simplify their medications? Are they taking it? And that way we're then able to address that multi complexity all as one and continue to try to see if we can continue to strive towards improvements in their overall condition. And it gets it gets a little easier with each visit as you get a better handle on each patient. But sometimes it's just you just try to attack what matters the most to that patient so that way they can get them through. OK, Dr. Chang, anything else that you want to add to that? We're going to code the visits now. I think we're going to we're going to call the visits very important to get credit for all the hard work that went into taking care of these complex and sick patients. So I don't have anything else. Brianna. Just notice that Q is the little hand with the dollar sign. I like that. So I'm going to kind of just summarize at a high level and talk through as a group some of the coding options. So let's say Ralph, remember it said it was a post-hospital visit. HPI, you know, he had three unstable or worsening chronic conditions that that showed, you know, maybe you reviewed some hospital records in addition to probably some diagnostic or some lab workup while you were kind of preparing and doing your visit for him. So thoughts in the chat about maybe how you would code Ralph with kind of that in mind and after kind of looking at his case and the activity that we did before. And what's up on the screen here is the Superville worksheet, which you have this in your your workbook, it's kind of some common lists of codes and things for your reference. But post-hospital visit, three worsening or unstable chronic medical problems. You probably had to do some review of diagnosis and labs either from the hospital or maybe you ordered some and follow up thoughts on what we would do there. I just encourage learners to go over what's on the Superville and take the opportunity to capture revenue for everything that you're doing. Tobacco cessation, I heard about Ralph and smoking and cigarettes and oxygen. You know, did you discuss that with with Ralph? Perhaps you can bill for that. We also talk about like I&R monitoring for MJ. If we did take over that, you can get reimbursement for for I&R monitoring, although it's not very much. And of course, advanced care planning discussion for our patients. So finally, and I think the big one is extended services. Often we have, you know, 60, 80 pages of records that we get either electronically or sitting on our desk on patients like, say, Betty. And it takes me time to review 80 pages of records. You should be able to be compensated for the time spent. And I don't know, Brianna, you can you can take us down to that particular code for. Yeah, it's going to be a little too hard to look at the Superville. I think we can jumping around and things. But Paul brought up another good point about smoking cessation. You know, the nine nine four oh six, if you spend four more minutes on smoking cessation counseling. And again, we talked yesterday a little bit about the transitional care management visits. You know, if we think about Ralph being a TCM visit, the reason I was giving you some of those pointers is if I looked at this case in a workbook, we have a comprehensive history, a comprehensive exam, then we can get to the assessment and plan wasn't completely filled in. But we could easily get to a high MDM with three unstable chronic conditions, review of multiple labs or diagnostics. Maybe you talk to the hospital provider or did some record review. All of that would easily get you to that. So that nine nine four nine six for the TCM visit, if you saw him within seven days, would be an option for this visit. The nine nine four six for the smoking cessation counseling, it would support nine nine three five. If you didn't do the the TCM visit, but from a reimbursement standpoint, the CMS national fee schedule is two hundred and eighty one dollars for the high level TCM versus I think it was two twenty or I'm sorry, one seventy eight would only be the nine nine three five because he is an established patient. So thinking about that difference in revenue. And if we think about Betty, to Paul's point, so this was a new patient visit, given the complex social aspects and the depression and her concerns, my thought are you probably be in the house a long time. Right. So maybe I'm starting to think I might be on time for Betty, even for the whole visit itself. If we're if we're trying to think about how long that took or to Dr. Choi Chang's point, if you spent that time before the visit, you have that nine nine three five eight and not for lung services, non face to face code. But where my mind was going was maybe we build a whole thing on time. Right. You know, 70 centuries, a new patient, we could support the night of the highest level new patient, the nine nine three four five with seventy five minutes. Maybe if you really called in all those resources and you were there for a really long time, you know, a hundred and hopefully you weren't. But sometimes it happens. One hundred and five minutes may it would be that new patient press for lung services face to face. Or maybe that follow up was after just arranging all of those services. And then that's when you could think about, you know, the new patient visit plus the prolonged services, not face to face for Betty. So my my mind with Betty is thinking there's probably some time based services that that we want to think about there. And kind of moving on to MJ, MJ was also a post-hospital patient who was a new patient and there seemed like there was some advanced care planning that went on. Remember, he was talking about how he didn't want to go back to the hospital, but he was there frequently. So remember that advanced care planning code, the 99497, that's an additional $85. You know, looking at the progress note that was in the workbook, you know, we could easily, you know, get to a high level of service with MJ2, but probably thinking about the appropriate level of service in addition to that advanced care planning code would be where I would share you with MJ based on the case details that were provided. Other thoughts on coding, anything you didn't agree with that I said, or other considerations or questions? Okay. I'll put some of my favorite coding, like some other resources and websites in the chat while we move on to the next session here. Thanks. I'm just going to spend a couple of minutes talking about the future of value based health care. So slide, please. You've probably all seen some version of this slide, but a couple of key takeaway points here is the least expensive 50% of the population, that bottom 50% is only consuming 3% of the total cost. And conversely, that top 5% consumes 50% of the total cost, and that top 1% is consuming 21% of the total cost. And that top 1% is costing well over $100,000 of cumulative care. And so the spending is concentrated among a small group of community non-institutionalized patients. And this becomes an incredible opportunity. And so as you think about selling yourself and you think about getting into value based care, the patients that you're targeting, you have the opportunity for high quality, which we know you all do, and we keep talking about those things. And now we're saying they're high cost, and does that matter to you in their entire cumulative spend? And so when we think about value based care, and you're talking about it with payers or partners, throw up a slide like this. Take this slide, throw it up there, and just continue to remind people that this is coming and this is here. By 2030, every one of the baby boomer generation will be over the age of 65 and on Medicare. Slide. So here, I think, press the button. There should be a little arrow that says risk, maybe it's a pop in or something. So as you think about kind of continuity or a continuum of value based care, it's going to start at the bottom. We talked about fee for service, but there's also kind of that still 1500 pro fee service of where you're paying for an activity or coordination. You really have low risk, but now you're coordinating maybe for the month, maybe for the year, and sending it through the revenue cycle process. Then you kind of move up as you think about risk and taking on more risk of kind of I'm either paying per performance, so I'm trying to hit quality measures and targets agreed upon or I'm trying to manage a specific event. We often hear about bundled payments or episodic payments tied to the orthopods, cardiology. I think those make a lot of sense when they're not responsible for longitudinal care. When you're responsible for longitudinal care, now we're talking about the managing of a population. And there are other ways to kind of think about it, like shared savings where there is no risk, there's just upside. Usually there's a cap on upside because we've stopped how much you could possibly make because you're not taking risk. Or hey, maybe you're taking risk and you have a floor and a ceiling on that, or maybe it's completely open and you're now negotiating 100% risk. And then kind of the final one that's coming out with some other models, but we see it with the REACH ACO is this global payment capitation where we're still keeping a P&L, a global P&L, but we're paying you a capitation and that's your only regular cash fund until you get to the end. So now you're, again, you're responsible for the entire care of the patient. And when I describe it to employees that work with us, I say, you know, we're responsible if they go to a hospital here, if they go to Florida, if they have home care, if we're paying for pharmacy, doesn't matter who's prescribing that, we're paying the bill for that. And so again, your risk increases. There are other things to think about. You know, this is a little bit of a setup as you, as you think about your practice and then also for the advanced course, because we talk through a lot of the same operations, a lot of the same financing, a lot of the same infrastructure, but in value-based care. And some of these things are really different. The ethics around managing and being responsible for capitation is really important when you, when you're managing that population slide. So there are a couple of key successes to value-based care. I often get asked to speak because we have value-based care contracts. And I always say, that's the least interesting part about us. The, the goal, you know, in our, our dream is to build a really innovative clinical model that solves the problems at the, at the bedside that's, you know, or at the chair side, right. And make sure your organization is ready for that change. It is totally different to take someone on a Friday who's paid on work hard for use, who's only worked in the clinic setting, only work in the hospital setting and say, you're ready for value tomorrow. And everything that you've kind of known about how it works and how we work together and what team looks like and powering it, all that's going to change. Like make sure your organization is coming with you. If you could kind of build the infrastructure where you have a clinical model that's innovative and well-resourced, and you have an operational model that is ready and not holding you back and not screwing up what you just built in that awesome clinical model. Now go out and find a risk partner and build that meaningful relationship to deliver on those results, the quality and cost results. Slide. So I just want to give one DCE revenue example. Now I know DCE is now reach ACO, but it's the same kind of idea. So here's kind of a side by side. If you're at risk under DCE or again, reach ACO, let's say there are a thousand lives in a program and 5% are at home. So you're, you're responsible for a subset of 500 patients. In fee-for-service, here's a list of things you are getting paid for. Maybe you're seeing them on average 10 visits a year, what you're getting paid. You're doing some additional kind of fee-for-service plus billing on these patients. And you're probably collecting around 1.2 million, assuming you're getting all of Medicare allowable, right? When we look at direct contracting and the CMS methodology, now we start to be responsible for the entire patient population. Can I get, could you press the button for the estimated revenue? And so now you're responsible for the historical baseline, your performance going forward. It's a blended regional rate. Any risk adjustment that you do going into it, and then there's a max that you could hit every year on improvement of risk adjustment. And now you're responsible. This is your budget coming in is 16.3 million. So you're responsible for all of it. So your revenue is significantly higher, right, 16 times what it is under fee-for-service. But now you're also responsible for all of the expenses. And how does care look different if you're responsible for all of the expenses related to the entire experience the patient is going to have with healthcare until their end of life? What does that look like? So I think just a couple of things to think about. I think there's this opportunity to build on all of the infrastructure of what we do today. I don't think it takes anything away to talk about value-based care. But I will say this, CMS has issued really to CMMI that by 2030, again, when everybody is 65 or older, the baby boomer generation 65 or older, but by 2030, 100% of Medicare beneficiaries will be in a value-based contract. So that really gives us about eight years to get what is CMMI, what is CMS going to put out there to figure out the right way to incentivize providers to care about the whole patient in a really ethical way. So I think a lot of really exciting things to come. There are a lot of really exciting programs and opportunities, a way to market yourself and think about this. If you've kind of, you know, gotten the basics today, let's keep the conversation going. So I appreciate it. But I take any questions about value-based care. So one of my most favorite topics, so hopefully I will see you in a month or so at the advanced, you know, two-day workshop or maybe even in person at the end of the year at that advanced workshop. Thank you. All right. We're just wrapping up. I want to have Paul come in and kind of give us some closing remarks. And while we're doing that, I'm just sharing with you again a reminder about the other resources that we have through the HCCI learning experience. Yeah. First, I just want to thank everybody for sticking with us for the past two days and often can be the drink from the hydrant analogy. I know we unloaded a lot of information and I hope as we work through Ralph, Betty, and MJ, as we talked about billing and so on, as we talk about even the session before that about revenue and so forth, I hope it's coming together for us in terms of they may seem like separate pieces, but they all tie together. There is a reason for, you know, working the nurses to the top of the license, to streamlining and so on, to have a remote MA and so forth. Not only is for patient care, but also it's for revenue opportunity for the practice. Just a reminder as we finish up here, submit your learning plan and please, we really look forward to hearing from you regarding how we did with this course, what we did that went well and what areas that we need to improve upon for future classes. And then there'll be instructions on claiming your CME. We really want your input. And I always, any comments from anybody before I close for us? Any comments? Just want to say thank you. This was a great experience. Coming in new, I've learned so much. I'm just trying to figure out how to process it all. So I would just like to say thank you for all the shared knowledge that every presenter presented. And then we look forward to continuing the relationship with you guys. It's not like, well, good luck, see you. If you have questions, please reach back to us. We want you to succeed. And as the slide says here, we want you to go out and transform and make better a broken healthcare system that's in this country, especially for our frail and complex seniors. Again, thank you for what you do. And I typically close with a patient story that I introduced on the first day we met. It's about taking care of, I went to the home of this patient who was really declining, and she's cared for by a very loving daughter. I opened the door, like I said already, there were no words, it was just a hug and tears. And as we talk about guiding her, finding the goals of care, guiding her how we're going to do this and what would that look like, and just seeing her, she said to me, it feels like part of me is dying as I'm watching my mom struggle here. And just the power of those words, and how grateful she was, again, it's not about me, it's not about my practice, it's about all what you are all doing. And being at the home, being next to the patient in the moments of pain and struggle, standing in the living room of the bedroom, and my staff has heard me say this before, never, ever underestimate the power of your presence at home. You bring expertise, you bring comfort, you bring security, you bring access to patients who otherwise have zero access to care. So thank you, thank you for being here, thank you for being passionate about your work and wanting to make a difference for these patients. Thank you again. Thank you, everybody. Thank you so much, everyone. We appreciate it. Thank you. Bye. All right. Thanks.

home-based primary care

workshop

cultural competency

medical decision making

workflows

safety

community resources

staffing

value-based healthcare

diversity

triage

caregivers

budget considerations

technology

marketing

revenue diversification