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HCCIntelligence™ Webinar Recording: Clinical Conun ...
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Hello, everyone, and welcome to the July HCC Intelligence Webinar and Virtual Office Hours. Today's webinar is entitled Clinical Conundrums, Three Common Challenges You May Be Facing. My name is Heather Hodge, I'm HCCI's Director of Education and Training, and I will be your moderator for this event. We're joined today by Dr. Thomas Cornwell, the Chief Executive Officer at HCCI. Dr. Cornwell founded Home Care Physicians, a practice focused on delivering care to medically complex patients in their homes in 1997. Home Care Physicians has provided more than 100,000 house calls to home-limited patients, and Dr. Cornwell has personally made over 33,000 house calls. He has mentored hundreds of medical students, residents, nurse practitioners, and physician assistants. Dr. Paul Chang is HCCI's Senior Medical and Practice Advisor and Medical Director for Home Care Physicians. Personally, Dr. Chang has made over 30,000 house calls to more than 2,800 patients. He is involved in both local and national efforts to advance quality home-based primary care through teaching, mentoring, and creating curriculum. Brianna Plentsner is HCCI's Practice Improvement Specialist. Brianna has deep knowledge and experience in house calls practice management, having focused her career in home care medicine and primary care. She is a certified coder and a certified professional medical auditor and holds a diploma in medical insurance billing and coding. Prior to joining HCCI, Brianna served as a practice manager for Home Care Physicians. If you would like to submit a question, please do so by clicking on the questions box located on your screen. We will address all questions during the 30-minute virtual office hours following the webinar. Handouts are available in the handouts box and can be saved by clicking on the name of the handout and downloading it. All participants will receive a copy of the slide deck, questions and responses, and a recording of the presentation. After our presentation, you will also receive a brief survey via email. At HCCI, we are committed to advancing home-based primary care to ensure that chronically ill, chronically complex homebound patients have access to high-quality care in their home. We do all of these things, training, consulting, research, and advocacy. Without further ado, I'd like to turn it over to Dr. Paul Chang. Well, thank you for that introduction. I am really excited to talk to you about how to provide great care to our homebound patients. The objectives this afternoon are discussing the management of systolic heart failure in complex homebound patients with comorbidities, review strategies in caring for homebound patients with advanced COPD, and describe the general consideration and recommendations in the treatment of type 2 diabetes in complex, frail, elderly patients in a home setting. Unfortunately, in 30 minutes, we will not be able to address all of the issues related to management, dosing of medications in patients with systolic heart failure, advanced COPD. What I hope to do is to provide a framework, an approach, in the care of these patients, and to give you some management pearls perhaps you can use tomorrow at your house call visit. Someone once said that you can get information by sitting in a classroom or listening to a webinar, and I certainly hope you can get some information from us today. But the man said that you can get wisdom, not just information, by being part of a community, a brotherhood, if you will. So I invite you, after you're done with this webinar, if you haven't joined us, to join the ACCI community. Be a part of us as we learn together on how to better care for our patients. Let's start with a case, Gertrude, who is 76 years old. You're asked to see her because she's having more shortness of breath, she's coughing, she's wheezing, she's weak, her legs are swollen. Just take a quick glance at the middle panel there, at her other medical conditions. Like Gertrude, it's typical of the patients that we see at home. They're elderly, chronically ill, frail, they're complex medically and often socially as well. For past medical history, you can see here, I'm not going to read all of it. I just want to remind the audience that it is really important to keep in mind the complex medical history our patients have. Because intervention in one area can negatively impact the outcome of another area. Gertrude takes a lot of medications. We have 20 medications listed here. Just give you a moment to read through all of them. A couple of medications that I want to highlight that's particularly relevant to our discussion this afternoon, inhaler, nebulizer, not only the medication, but the delivery system that these two medicines are administered, or three, excuse me. The medications that's used for heart failure and the insulin dose, the fixed dosing insulin that she's currently getting. All of that we need to keep in mind as we develop a care plan for her. Social history, just want to highlight a couple of things that Gertrude cannot go out and get her medications, that she needs help from her husband who's got physical issues himself. Gertrude's diet is not terrific. It could be better. Gertrude is hard of hearing, which can impact the care that we deliver if she does not rightly or correctly hear the information that we want to communicate to her. On physical exam, she's short of breath. She's got JVD. She has an S3 gallop. She's wheezing. Her legs are swollen. She has short-term memory impairment, and she's anxious because she's so short of breath. Here are her laboratory studies. These are labs from her last hospital stay about a week ago. What I want you to, again, I'm not going to read all of them. Just review some of the numbers that are listed here. And ask yourself, what are some of the values that are important to keep in mind as we develop a care plan for Gertrude? So what are the conundrums? Before I get into specific conundrums, I want to share some perhaps overarching challenges in caring for patients like Gertrude. Number one, they're complicated. Number two, there's a shortage of formal guideline in the treatment of patients like Gertrude for CHF, for COPD, or diabetes. By this, I mean our type of patients who are complex, multiple comorbidities, who are frail, who are whole-bound. The data is not very robust. The other is that we are often the lone provider caring for these patients who are really complex. And that itself presents a challenge and a conundrum. What I hope to do as you journey with us at ACCI is to eventually help you find a sweet spot in the treatment of these patients that is guideline-based, but patient-centered, and goal-directed. The American Geriatric Society provides us with some guiding principles, which you can see here, when we face complex, elderly patients like Gertrude. These principles are what we are going to highlight throughout the presentation this afternoon. When I see a patient like Gertrude, I ask myself the four following questions. What are the potential diagnosis for her symptoms? She's coughing. She's short of breath. Her legs are swollen. Does she have heart failure? Is this an exacerbation of her COPD? Does she have pneumonia? Could this be a pulmonary embolism or some combination? The other question I ask is, what testing are needed to help me hone in on a diagnosis? What can be done at home? What can be done at the hospital? If we're going to do testing at home, who will do these tests? What is the turnaround time for these tests, for any particular test? Are there limitations to testing at home? For example, if you suspect a patient has a blood clot in the leg or DBT, sometime a D-dimer test can be obtained. But at our institution, a D-dimer test needs to be spun twice and transported in a frozen state. Is that something you're able to do at your institution? There's also talk about using point-of-care CRP-directed antibiotic therapy in patients with exacerbation of COPD. Is that something that your institution is able to support you as you care for these patients at home? Currently, at our practice, we do not have the capability of doing point-of-care CRP testing. The next question is, what is the patient's goal of care? Is it rapid testing, rapid treatment, and more extensive evaluation, as in the hospital or the emergency room? Or is it more comfort-focused, home-based care? And finally, what is the feasibility of the care I'm suggesting? For example, if I make a change in Gertrude's insulin, will she be able to follow my direction, given her dementia? How quickly can her husband pick up the insulin if she happens to have severe hyperglycemia related to, say, a boost in her steroid dose? Let's first consider the challenges in the management of type 2 diabetes. One of the initial considerations is the cost of medication for diabetes. Years ago, we did not have many choices in terms of oral medications in the treatment of type 2 diabetes. First, there were sulfonylureas, then came metformin, and now we have other choices of oral medication for the management of diabetes, such as sodium glucose co-transporter 2 inhibitors or ASGLT2 inhibitors. There are newer injectable medications from different insulins to glucagon-like peptide 1 agonist or GLP-1 agonist. They may look great on television ad, but our patients may not be able to afford them. The other is the complexity of the medications. As we introduce either add-on oral therapy to metformin or consider injectable medication in patients who are failing dual oral agent to control their diabetes, we're adding complexity, whether it's a GLP-1 medication or different types of insulin. We need to also consider the comorbidities which may impact the proper use of these medications, such as vision or hearing impairment or the risk of falling related to low blood sugar or depression, which can lead to medication noncompliance and poor outcome. We also need to think about the burden of blood sugar monitoring in the context of the overall goals of care for our patients. Routine home blood sugar testing may not be necessary for patients whose diabetes are stable and patients not having any symptoms, and we're not making any medication changes. We can talk to our patients and families about lifestyle and diet modification if it is consistent with the overall goals of care and if the patient is physically able to do. Now, let's turn our attention to heart failure and CKD. Again, here we're talking about systolic heart failure or heart failure with reduced ejection fraction in patients with chronic kidney disease. Guideline tells us that ACE inhibitors and beta blockers in maximum tolerated dosing should be used in these patients. Leukodiuretics can be titrated according to patient symptoms, physical exam findings, and laboratory evaluation. The mineral alloporticoid receptor antagonists or MRA agents, such as spironolactone or iplurinone, can be used for additional diuresis. Angiotensin receptor neprillicin inhibitor or ARNI or class medication can be used as a substitute in patients who have ongoing symptoms despite maximum dose of ACE inhibitors. Remember, Gertrude had a history of non-sustained ventricular tachycardia and low ejection fraction. AICD may be considered in these patients, again, if it's consistent with the goals of care. AICD is an implantable defibrillator. Sorry. Metoprolol, bisoprolol, carbetolol can be continued in these patients with heart failure and COPD or CKD. If ACE inhibitors or angiotensin receptor blockers or ARB are not tolerated, then isosorbidinitrate and hydralazine can be used as an alternative. There's a certain medication that should be avoided in patients with CKD and CHF, and you can see them there. Metformin can increase the risk of lactic acid doses, and you can see the other medications there that could cause adverse outcome. For example, trimethoprim supplement oxazole combination used with lisinopril or spironolactone can lead to hyperkalemia. We need to periodically assess the burden of our intervention in our care versus the benefit if it's consistent with the patient's goal. While we can encourage our patient to follow a heart-healthy diet, this may not always be possible or may not be desirable. Don't forget to assess and treat the patient's anxiety and depression. Studies have shown us that patients with depression and heart failure have a higher risk of medication on adherence, hospitalizations, and mortality. We need to network and think about how to monitor our patients at home with heart failure, such as getting home health involved, getting telemonitoring involved. Is there a community heart failure program from your institution that can be engaged? Perhaps a simple thing as a scale that the patient can weigh themselves on a daily basis to monitor the bottom status. Finally, let's briefly talk about the management of COPD. Medication compliance is critical in improving symptoms, avoiding the hospital, avoiding the trip to the emergency room. Have the patient identify their inhalers, demonstrate their use, and address barriers to their use. And we should do that at our home visits. As in the management of patients with diabetes, be mindful of adding complexity and cost of medication as you consider escalation in the therapy for patients like Gertrude who may be suffering from bad COPD exacerbation. There's an alphabet soup of inhalers, both in medication type and delivery system. Different inhalers, such as a pressurized meter dose inhaler versus a dry powder inhaler or DPIs, or a soft mist inhaler or SMIs may require different techniques. And the medication carried by these inhalers might be different, whether they are a short acting beta agonist or a long acting beta agonist or a long acting muscarinic receptor antagonist. We need to explain to our patients why they're using different inhalers. We may have to use steroids to help Gertrude with her breathing, as I've stated before, that may increase her blood sugar. If she's currently using a fixed dose insulin type, what are some potential problems we may encounter if we need to acutely manage her hyperglycemia? Here are some additional suggestions in the management of shortness of breath in patients with COPD, which you can review here below. Studies have demonstrated the benefits of home-based primary care in the reduction of ER utilization and 30-day readmission. We accomplish this through talking about goals of care, referring to hospice when it's appropriate, having an action plan in case of emergencies, prompt follow-up after a hospital stay or emergency room visit, and you can see some additional strategies there listed. Dr. Cornwell. Thank you, Paul, for detailing, you know, what we see so often in home-based primary care, diabetes, heart failure, and COPD. And I just want to end with just one slide where, as Paul said, when we come into these new patients that, you know, I know our patients average 10 chronic diseases. Most of them, when we first see them, are on over 10 medications. And it can be quite overwhelming when you first meet a lot of these patients. And what I have found is, one, you know, you don't get everything done in one visit. And really what longitudinal chronic care involves is just repeated PDCA cycles. PDCA, probably many of you are aware of, is a form used in quality improvement. But it also, I think, really is a good way of looking at how we treat our patients. We assess them. We make plans. We then make recommendations. But with those recommendations come anticipatory guidance for our patients for what to look for, what to check for. And then if things go well with our tweaking of our patients and our PDCA cycles, well, then we go on to one of their other problems. And so when you approach a patient like this, you prioritize. As Paul said, we really focus on goals of care and help the patient to really fulfill their goals as best we can. And then you prioritize, you start these PDCA cycles. And then over time, you tweak them to hopefully the best quality of life that they can have. And I just wanted to say that as a framework. And so now I'll turn it back to Heather, just to get us going on the next part of our webinar and office hours. That concludes our formal presentation for this afternoon. We will now be answering questions posed during the presentation, as well as any additional questions that you may have during our virtual office hours. As a reminder, if you would like to submit a question, please do so by clicking on the questions box located on your screen. Okay, we have a question regarding COPD treatment. There is recent literature regarding the effectiveness of combined Labda-Lama inhalers versus combined Labda-ICS inhalers. Can you elaborate on this? Yeah, there was a recent article published, I believe in CHEST, that looked at the combination Labda-Lama. Again, that's long-acting beta-2 agonist and long-acting muscarinic antagonist. Labda-Lama combination seems to be better than the Labda-ICS. ICS is inhaled corticosteroid combination. In clinical practice, I think the summary was in the setting of COPD treatment, the Labda- Lama inhaler appears to be as effective as combined Labda-ICS inhaler in preventing COPD exacerbation, but the Labda-Lama combination may be preferred because it was associated with fewer pneumonias. So that is one thing I learned from reading this article. Okay, our next question is, do you have any tips for how to appropriately manage medications in such complex patients? Yeah, that's a great question. When it comes to taking care of patients like Gertrude, when you are faced with so many different abnormalities or abnormalities in labs or on exams and symptoms, how I prioritize is what is the most acute issue at hand. For Gertrude, it is COPD or CHF exacerbation. What can I do to diagnose this and what are some of the medications that I can intervene immediately to bring her some symptom relief. There are some other abnormalities that I may have to tend to down the line, whether it's her diabetes or her colon polyps, which is really not an acute issue. But my point is to focus on what is really important to the patient and what is the acute symptom that needs relieving. And that's where I'm going to focus my medication management at the first visit. And Heather, I might just comment on that. One of the things that we teach at HCCI, that was actually, you know, Paul kind of developed this, is the four aspects of looking at the medications. Start with reconciliation, which we all do, just trying to figure out, and the home is so ideal, what medicines are they actually taking compared to what the office or hospital thought they were taking. And then after you find out what they're taking with each medicine, you justify. So we call it justification. Do they absolutely need this medicine? Do they still need the PPI? If their leg edema is better, do they still need as much of the furosemide, especially if they're chronic, you know, have chronic kidney disease like this patient. And then after you justify a reason for each of the medicine, well then you optimize the medicine. And oftentimes that does involve deprescribing, trying to see, does a patient need all 15 medicines? This patient was on 20 medicines. And again, you start those PDCA cycles, you start weaning down, you give them recommendations what to call with. And then the final one is demonstration. Here's a COPD patient that might be on multiple inhalers. I think we have all found patients. My worst case was when I had a patient some years back go to demonstrate an inhaler he'd been on for 10 years and he pushed up his nose and started spraying the inhaler into his nose. He thought it was supposed to go through his nose, not through his mouth. And how sad that he'd been doing this for 10 years and no one asked him to demonstrate that he was doing it correctly. And so that's another framework that you can use with the emphasis on really making sure that they need all the medicines that they're on. It's been well described how polypharmacy can be very harming to our patients, both physically as well as financially, as Dr. Cheng discussed. And so again, that's just a framework that you can go by. Reconciliation, justification, optimization, and demonstration. Okay, our next question is a little bit along the same lines. When seeing a complex patient for the first time in the home, how do you even start to develop a clear care plan? It seems overwhelming. Yes, it can definitely be a challenge when you are faced with so many issues. Again, I'm going to go back to what I said earlier. You know, what are the acute issues or symptoms that needs to be addressed? So that's the first thing. And the other is finding out what the patient's goals are. That will really help guide your next steps. As I said before, if the goal is to find out as many possibilities as possible, to get the answers as quickly as possible, and if the family cannot handle the patient's symptoms or decline at home, then perhaps it is a trip to the emergency room that's necessary. However, if the focus is more on palliation of symptoms or if the patient is appropriate or declining to the point that the patient needs hospice care, then we can take on a different trajectory in terms of how we care for our patients. So focusing on what acute symptoms they're having and put that within the context of what the patient's goals of care are, that can at least give me some direction into what my next step ought to be. Okay, now we have some questions for the virtual office hours. What local technology resources have you found in your area? Do you utilize mobile diagnostic and phlebotomy services and how reliable have they been? Also, what about other specialists for the homebound? In Dr. Chang and my area, we actually have competing both x-ray as well as ultrasound services. Our x-rays, it is quite amazing. If we order them, you know, even by early afternoon because they're all digital now, we will usually have the report before the end of office hours or we'll get it on call that night. And so we really have good x-ray services, we have good ultrasound. I recently had a 99-year-old who I saw actually on a Saturday at a assisted living facility and we were actually able to get an ultrasound on a swan leg the next day that showed a massive DVT that went up into her iliac veins and so we're able to quickly, actually she went to the hospital, but so we have really good ultrasound and x-ray services. EKGs could actually be a little more difficult just because they pay so poorly, but usually just because we give these x-ray companies a lot of good business. They'll do things if we need something like an EKG done at the home also. We have a separate phlebotomy service that comes to the home and we've had to work with them a little bit, mostly just to make sure that patients didn't fall through the cracks and we do try to keep track of orders that we have done so that we make sure that they are done around the time we wanted them, but have found the service to be very reliable. Paul, would you agree with that or anything else to add? Yeah, I agree. Depending on your practice, at our practice, the providers, we draw blood on our own, I mean at the visit I should say, but we also, as Dr. Cornwell said, use a phlebotomy service. I don't have a lot to add about the x-ray service other than that they're very prompt. There's literature that talks about, you know, the door to, not door to balloon time, but the door to antibiotic time. Sometimes we are very, the x-ray, as Dr. Cornwell said, because it is digital, we can get the report and get the patient if they're able to get to a pharmacy and whatnot from the time of visit or x-ray to time of antibiotic, that's quite an impressive. I think the other part of the question was other professionals at the home. Yeah, I often wish that there were other specialists that made house calls to help us care for our terribly complex patient. There are two ways, I can, there's a way I should say that I compensate or get some of the expertise. Again, depending on your health system and what electronic health record that you use, I communicate by using our EHR with some specialists, asking them to, hey, can you take a look at this blood test? Can you take a look at this medication question or a clinical question? So even if they are not seeing the patient, I can use the EHR to help do what you would consider like a curbside consult to help me take the best care of the patient possible. There are podiatrists that we use that make house calls in the community. There's an optician that we know that can help our patients with vision impairment and they do some vision testing at home. So again, network with the providers in your community and see what kind of services they are willing to provide, either virtual or really hands-on. We also have another, Paul mentioned that, dentists as well as audiologists that will also do house calls in our area. Oftentimes, home health agencies, if you're kind of newer to doing house calls, home health agencies, social workers have actually have often found these services that come to the home as well as your local area agency. An agent can be a great resource in terms of knowing community based services that will go to the home. Okay, our next question is, do you utilize any tools to assess caregiver burden? Yeah, in the past we have, we're no longer using, but in the past and I've also heard of other practices using a particular caregiver burden tool, that's the ZARIT, caregiver burden inventory, and that is one tool that we've used in the past, but for multiple reasons we're no longer using, but I've heard of other practices using that as well. Tom, are you aware of other tools that other practices are using? Well, just that we do, you know, just like the PHQ-2 as a screening tool that will get you to the PHQ-9, we do ask two questions to every patient that is on the ZARIT scale, and that is, this is on a, we send out a five page history form, which is of immense use to all of our patients ahead of time and have a well over 95% return rate, where they do list their things like their past medical problems, allergies, medicine, all those things that you ask, the family history, the social history, tobacco, alcohol, we ask about POA status, advanced directives, do they have them, we ask ADLs and IADLs, and then at the end of the review of systems page, it asks two questions, do you feel you are able to provide the care your relative needs, yes or no, and then they have a place to comment, and then the second question is, do you feel you have time to take care of yourself, so one, do you feel adequate to take care of your loved one, and do you feel, and it really is a wonderful thing when you come in there and you show them, you know, having read these questions, if they do have any concerns, that you discuss it with them, makes them feel so supported, as you know, we really have a dyad when we go into the home most of the time, where we have not only the patient to kind of look after, but obviously our patient will only get the best care is if we do help the caregiver in these oftentimes difficult situations. Okay, before we go on to the next question, just a reminder, if you have any questions, click on the questions box on your screen. The next question is, can you talk a little bit about the environmental assessment in the home? How do you go about this, and how often do you reassess? You know, I think it's one of the beautiful things, many beautiful things about making a house call, one of it is being at the patient's home. I do, at some point of the visit, what real estate agents talk about is the walk-through. With permission, I say, hey, can I take a look at your bedroom, your bathroom, your kitchen, and etc., and if it's necessary, I can, I ask the patients, hey, can you show me how you get in and out of bed, can you show me how you get to your bathroom, and so forth. This really gives me a sense of what the challenges are, and what the potential interventions may be. I do this on the first visit, and I do it after saying that the patient has had a fall, if the patient has been to the hospital or a rehabilitation center where they might come home in a different condition than when I last saw them, just to get a sense of what the challenges are and what the best interventions may be. Right, and one of the things that we mentioned at our training is in cooperation with the Administration on Aging and the American Occupational Therapy Association, and there's a number of these environmental checklists, but again, the Administration on Aging with the help of the American Occupational Therapy Association put together a two-page, what's called Safe at Home Checklist. You can just Google Safe at Home Checklist or Aging in Place, Safe at Home Checklist, environmentalassessment.pdf is what it is, but it goes through, again, two pages of numerous checklists that you can actually leave with them where they talk about checking entrances, exits, what to check in the bathroom, windows, electrical outlets, the heating system, what to look for in the basement, cracks, and all those different aspects if you want to, in a more formal way, do an environment assessment. But for both Paul and I, it really is more of a gestalt when you go in there, you see the pictures, you see the bathroom, you see the kitchen, usually we'll at least once open up the refrigerator to make sure that there's no surprises, and it just is another reason why house calls can just provide such amazing care for our patients. Okay, our next question is, what kind of care planning tools do your teams use? What elements does it include, and is it a part of the patient's chart? For our practice, we write down the instructions, whether it is a medication change, or whether it's ordering of a particular DME, or home health, we write down the instructions for our patient, and the instruction sheet is on a carbonless copy paper. So we leave one copy at home with our patient, then the other copy we take back to the office to be scanned into the EHR. Obviously, we document in the EHR what we discussed, what the interventions are. We are not slick enough yet to have remote printing to print out an after-visit summary. Maybe that will happen one day, but currently, right now, we are using handwritten instruction sheet, as well as documentation in the EHR. Any other comments, Tom? Yeah, you know, and so again, our patients are quite complicated, and as I mentioned earlier, we send out a five-page, very thorough, I think that is on our website. Heather, you can maybe have that verified, or Brianna, but there's a, and so we get all that information, plus we are in a heavy EPIC area, both our health system, as well as most of the health systems around us, and so these complicated patients have oftentimes been in the hospital, or have other providers that are on EPIC in our area, and so there's usually a wealth of information on these patients, and both Paul and I do review the patient's chart before we go out. There's this newer code, 30, or the first hour before or after a visit, if you spend half of that, 31 minutes reviewing their chart, getting ready for the visit, you can now bill for this 99358. It pays about $115, and that way, you can be so well prepared before the visit, and so I will, on my history of present illness, include all their active problems, and make sure, again, that all the medicines are associated with a diagnosis in that history of present illness, and then determine, obviously, what labs they need for the visit, and then on all initial patients, we also do advanced directives at the first visit. Usually, I will say, between now and turning 100, there's a chance your heart might stop, and oftentimes get a little laughter, like, well, of course, or sometimes I get some threats, like, you're not planning on keeping me alive to 100, I hope, but anyways, you get the point that, in a non-threatening way, I bring up the point that their heart might stop in the next 10, 20 years, depending on their age, our average age patient is 80, 30, or over 85, is our most of yours, and that's another thing, that if I spend 16 minutes doing that at the visit, then you can charge the $85 or so for the advanced care planning code, and this is great care, but it also, we are now being compensated for this very important work, and so from that, it generates some of that history of present illness, I'll actually forward it into my assessment and plan, and then for all those problems, I will create a very thorough assessment and plan for all their medical issues, along with a health maintenance section that will describe the advanced directives, as well as things like any immunizations they need, or any caregiver issues that need to happen, and a lot of providers that do house calls, actually, and this is something that we often do at Home Care Physicians, is print the after-visit summary before you go out, and that way, if there's any, because it usually has their medical problems on it, it has their medicines on it, and then, so you have the after-visit summary printed, which also helps you with what used to be meaningful use, but helps you with MIPS now, to print that after-visit summary, and then you can just handwrite changes on the after-visit summary at the visit, and then the last thing I'll say about this is that I really encourage my family members, not so much my patients, to go on Epic's portal, so all electronic medical records have a patient portal associated with them, if they meet what used to, again, be called meaningful use, it was a requirement, and if they do that, you can actually then put in your thorough assessment and plan, or any instructions, into the instructions for the visit, and then it'll be a part of that patient portal after-visit summary, which can be very effective then, also, for them to have that information. Anything you want to add to that, Paul? Yeah, just two comments. One is, in our technology age, and texting, and so on, don't forget the power of a phone call. I think it is so, Tom's already said about treating our patients as dyads. We take care of them in pairs, patient, dad, caregiver, daughter, son, and so forth. If there are concerns, or even just a follow-up after a routine visit, yes, we can write things down on a sheet of paper, and leave it at home, but often, I make that phone call to clarify any nuances or misunderstanding, to answer additional questions that the family members may have, to make that human connection, and to build that relationship, which is so important as we deal with our complicated, sick patients, who often will decline in the future, and then we end up having to talk about end-of-life care. Having that relationship is so important, so don't forget the power of that phone call. The others, since Dr. Cornwell brought up the billing issue, and a few weren't with us last month, when we had the webinar on advanced billing and coding, just take a look at what Gertrude's complexity, and what opportunities there are in terms of getting additional reimbursement. No, we're not talking about doing things extra, or outside of what's permissible. It is about getting reimbursement for things that you are already doing. For example, she is on Warfarin, and we can bill for anticoagulation management. Patient that's complicated, like Gertrude, weak if your health system, if your office has a chronic care management nurse, you can bill for CCM. Tom has talked about billing for reviewing of charts, and often these patients have extensive records that we need to go through. These are opportunities not only to provide great care, but getting reimbursed appropriately for the time that we put in. I don't know if Brianna's on the phone, if she wants to make any comments. I'm here. Yeah, I think all of the opportunities that you highlighted, I mean, in home-based primary care, there's so much care coordination, and time that your providers are spending addressing psychosocial needs. You really need to look out for your practice, and make sure that you can make the most of fee-for-service reimbursement. If you're not in a value-based contract situation, I think like Paul mentioned, chronic care management, that's just 20 minutes per calendar month of combined provider and clinical staff time. That's a really great opportunity. Advanced care planning, that's 16 minutes having that discussion with the patient face-to-face. You're doing those things already. I think it's sometimes just getting into the habit of billing for it. And in the last webinar, like Paul mentioned, we do have on the HCC Intelligence Resource Center, that information as well as some supplemental handouts where you can find additional information on not only those billing opportunities, but also additional services to keep in mind. Along those lines, we have a coding question. For transitional care management, can you still bill if you're unable to reach the patient or caregiver within two business days after multiple failed attempts? That's a great question. So part of the requirements of transitional care management is to have that interactive contact with the patient or caregiver within two business days. I'm sure all of you on the phone know it can sometimes be challenging to reach that patient or that family member before you're actually out there for your face-to-face transitional care management visit. CMS does have published guidance that as long as you have made at least two attempts and those two failed attempts are documented, if all the other transitional care management requirements are met and you do see that patient within seven to 14 calendar days and have your post-discharge visit, then yes, you can still bill for it. You just need to make sure that at least two failed attempts are documented. They do expect you to continue to try and reach the patient until successful, but if your provider visit happens before that time and you've met all the other requirements, you can still bill for it. Thank you, Brianna. One other coding question. Can the cognitive assessment and care planning code be reported in addition to your E&M code? So that is referring to, there's a new CPT code or newer, I believe it was as of 2017, CPT code 99483, and that's a cognitive assessment and care planning visit. It cannot be billed in conjunction with an E&M code because it's for that extensive time spent doing an evaluation, trying to gauge the functional and cognitive capacity of the patient, reviewing high-risk medications, evaluating their symptoms and safety at home and the caregiver's knowledge and support system. So that can be a pretty comprehensive visit. You would bill that code instead of your E&M code, but it does have a national payment reimbursement rate of $241. So it is a great service to be aware of if you're having those kinds of comprehensive assessments specifically related to, maybe trying to determine their stage of dementia or something similar. Thank you. And one other billing code. Are there any methods you've found helpful to promote documentation efficiency? Yeah, so documentation in the EHR is certainly a challenge for many providers. And we talk about alert fatigue or keystroke fatigue and so forth. And there's the concern about cloning a particular record. There are a couple of ways that I, or a couple of steps that I use to try to improve my efficiency as I see my patients at the home. One's already been mentioned is that reviewing of the chart prior to the visit, that I can update the medication list, I can update their problem list. So that's one way to increase my efficiency. The other is using templates. In Epic, we have a particular template that is set. And there are also these preset buttons that you can press to check off the pertinent negatives, for example, so that you don't have to click each individual review system as a negative negative that will reduce the fatigue and improve the efficiency. The third is a smart phrase. Smart phrase is something that I often use or discuss with patients, such as the use of various type of medications in patients with dementia or behavioral disorder. And I could just type in one or two letters or phrases, and then the smart phrase will automatically populate in my chart. So that is another way that I can improve the efficiency of documentation without cutting corners on the dialogue or counseling time with my patients. Do you have any other suggestions? Yeah, when you talk about smart phrase, that's kind of an Epic term, but it's macros, and so all EMRs that I'm aware of have the capability of doing that. And I think not only can those macros improve efficiency, I think they can also improve care. For instance, I have one for my advanced care planning conversation, and it kind of forces me to make sure I go over all the aspects that I desire to in terms of what's in Illinois is called the Pulse Form. I have one for if I'm gonna deal with their, if they have an alcohol issue. And there's certain parameters that in terms of you can bill for alcohol counseling, but it has certain requirements. And by having a macro, not only does it help you not to have to write the same thing over and over again, but that then it can ensure that you do cover all the aspects that Medicare requires to bill for that service. Yeah, the one final comment is voice recognition. I do have that capability with my laptop, and I do use that on and off, especially at the end of the day when I'm really tired from typing, but it is not perfect. Sometimes it does say or type out words that it's not exactly what I meant. And my nurses are kind enough to send it back to me for revision. So that's another way to help with efficiency with documentation is by using voice. Okay, if there are any questions that we did not get to, we will answer those after the webinar and send you a copy of that at a later date. But as we wrap up our webinar and virtual office hours, we wanna thank our faculty, Dr. Thomas Cornwell, Dr. Paul Chang, and Brianna Plessner. We also want to thank you for joining us. We'll be sending a follow-up email within a few days, which will include a link to the archived recording, handouts, and the questions and responses. Please visit the HCCI website for information on future webinars, e-learning modules, learning events, consulting services, and other resources that we have to offer. The next webinar will take place on August 21st, and it's entitled Improving Workflows, Front Office, Back Office, and What it Means for Staffing. And again, that's August 21st. You can register for that on our website. And that is it. Thank you, and have a pleasant evening.
Video Summary
In this video, the speakers discuss clinical conundrums related to three common challenges: treating systolic heart failure, managing COPD, and treating type 2 diabetes in elderly patients. They provide guidance on how to approach these challenges and the considerations that should be made. They emphasize the importance of prioritizing the acute symptoms and goals of care for each patient. The speakers also discuss the use of technology, such as remote testing and communication, to aid in the management of these complex patients. They also highlight the need for comprehensive medication management and the importance of assessing and addressing caregiver burden. The speakers provide tips for developing clear care plans for complex patients and discuss the benefits of making home visits, where environmental assessments can be performed. They also discuss coding and billing strategies for various services, such as cognitive assessments and care coordination. The speakers stress the importance of documentation efficiency and provide tips on using templates and macros to streamline the documentation process. Overall, the video provides valuable insights and strategies for managing the clinical conundrums commonly faced in home-based primary care.
Keywords
clinical conundrums
systolic heart failure
COPD management
type 2 diabetes in elderly patients
acute symptoms
technology in patient management
comprehensive medication management
caregiver burden
home-based primary care
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