Good afternoon, everyone. Thank you for joining us for our monthly HCC Intelligence webinar and virtual office hours. We'll get started in about a minute here. Just want to give time for everybody joining us to get situated, pull up any handouts if you've uploaded them, and make sure that you are ready for an exciting half-hour presentation and then a half-hour virtual office hours. Okay, we are right at 4 o'clock on the dot, so I would like to say hello and welcome to our monthly HCC Intelligence webinar and virtual office hours. Today's webinar is entitled Improving Workflows, Front Office, Back Office, and What it Means for Staffing. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research. I'll 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. He has mentored hundreds of medical students, residents, nurse practitioners, and physician's assistants. Dr. Paul Cheng is HCCI's Senior Medical and Practice Advisor and Medical Director for Home Care Physicians. Personally, Dr. Cheng has made over 30,000 house calls to more than 2,800 patients. He's involved in both local and national efforts to advance quality home-based primary care through teaching, mentoring, and creating curriculum. Brianna Plentsner is Home Center Cared Institute's Manager of Practice Improvement. Brianna has deep knowledge and experience in house call practice management, having focused her career in home medicine and primary care. She is a Certified Coder and Certified Professional Medical Auditor. Prior to joining HCCI, Brianna served as the Practice Manager for Home Care Physicians. In addition to her understanding of practice operations, Brianna excels at developing workflows and efficiencies for home-based primary care practices. If you would like to submit a question, please do so by clicking the questions box located on your screen on the lower right-hand side. We will address all questions during the 30-minute virtual office hours following the webinar. A copy of our presentation is available in the handouts box and can be saved by clicking on the name of the presentation and downloading it. All participants will receive a copy of the slide deck, questions and responses, and a recording of the presentation. At the conclusion of our virtual office hours, which immediately follows our presentation, we will send out a brief survey link via email. We appreciate your feedback, which gives us an opportunity to understand your needs and decide on meaningful future webinar topics. At HCCI, we are committed to advancing home-based primary care to ensure that medically complex patients have access to high-quality care in their home. We provide and support the following, education, consulting, research, and advocacy. Without further ado, I'd like to turn it over to Brianna Plensner. Thank you, Danielle, and thank you everyone for joining us. Our objectives for today is we're going to describe the functions performed by the front and back office within a home-based primary care practice. I want to take a moment to confirm everyone understands the context when we refer to front and back office. When I refer to front office, I'm referring to the administrative staff. They may have various titles, but this is your front office or administrative staff who may help with things such as phone calls, scheduling, or registration. When we refer to back office, we're referring to your clinical support staff, and this could include medical assistants, LPNs, or RNs, and we'll talk more about that. But if you think of a traditional office setting, your front office is the receptionist or the administrative staff you'll see when you walk in, and then the back office might take you back and put you in an exam room or maybe clinical pods that are doing clinical care behind the scenes. Now in a home-based primary care practice, you typically won't see any of the staff besides the providers coming to your home, but we're still using front office to refer to administrative and back office for clinical support staff. We're then going to dig deeper into what types of professionals perform those various functions and roles, and then we've provided various examples of staffing models, and we're going to talk about pros and cons on the different models and different staffing uses. So we're going to start with front office, and on this slide, we have overarching main functions that a front office personnel may perform. Now keep in mind there could be various others. We've tried to focus on just the major buckets. So if you think about incoming and outgoing phone calls and initiating and routing messages appropriately, having a front office or administrative staff that can help perform that for you, they can weed out any unnecessary phone calls. Perhaps you utilize a decision tree guide in your office, and that front office staff is able to understand when a call needs to be given to a nurse or if it's something that they can start the process on and be addressed later or when a provider might need to be immediately involved. Again, making sure that all staff is working together. Insurance verification. This is very important to gather correct registration information up front, especially for elderly patients who may not understand Medicare Advantage plans. Many times they might not even realize they have it. They're going to assume traditional Medicare, and that could really lead to some denials on the back end, or especially if a patient's coming off of hospice, going from a Medicare Advantage plan to traditional Medicare. Having some front office personnel that can obtain the correct insurance information up front to make sure your claims are paid is another very important function. New patient intake and referrals. That can be a very time-consuming process, and you're wanting to make sure that you have some support staff that can help get the information you need, get the patient scheduled, and obtain any forms or necessary enrollment questionnaires you might be utilizing. And that leads into paperwork and form management, especially if you think of all the incoming faxes such as home health orders that they may be able to help process and get signed by the providers. Uniquely important to a home-based primary care practice, geographic scheduling and planning provider daily routes. Efficiency and productivity is so important, and making the most of your provider's time so they can spend most of their time face-to-face providing direct care rather than traveling to and from visits. So the front office or administrative staff may help not only group schedules and on days the provider's going to be in that area, but as well as help them plan the most efficient driving route. An appointment confirmation. I'm sure many of you on this phone call may understand the frustration of no-shows, especially within a home practice. So having staff that can help make sure the patient is expecting the provider and that somebody is home to answer the door when they arrive will really save you a lot of time. You may outsource medical records, but in a smaller practice, having that staff to help with those can be very beneficial as well. And if they do, you know, have the experience or are able to help with practice billing and coding, or maybe that's your practice manager or an outside billing agency, but they can be a great resource for that as well. And Dr. Cheng has joined us today. Is there anything else you'd like to add about the front office administrative staff and how they support your practice? Thank you, Brianna. In addition to the roles and responsibility that is outlined here, at my office, the front office staff help print out labels that I need for the visits for the day. They can help verify chronic care management status of a patient. They print out medication lists for me to review. They help request medication administration records from the facility that I might be visiting as well as weights or blood sugars on my patients at these facilities. The bottom line to all of this is that an efficient front office staff helps me with being efficient in the field so I can have the maximum clinical impact on my patients at my visits. And they also help me capture revenue that's related to caring for the complex patients at home. Thank you. So I want to switch gears now and talk about some of the back office functions. And again, these are overarching, you know, calling everything out would be too much to put on a slide, but really thinking about your clinical support staff being the support system for your providers. You know, they have the knowledge and experience to be able to ask the right questions. They can help obtain, you know, pertinent information on concerns and symptoms a patient may be having when they're triaging those phone calls, which will help the provider be able to promptly, you know, advise the appropriate treatment and to not have to be taking all of those phone calls themselves. DME, durable medical equipment. I'm sure many of you know the long and challenging process that can take, especially if you have a couple of core staff members that are able to really familiarize themselves with the various requirements for things like oxygen, wheelchair, hospital beds. They can also form relationships with vendor contacts to really help move this patient or move this process along for your patients, excuse me, and also keep them informed on what's a realistic timeframe. Prior authorizations, they're necessary and, you know, there has to be someone that's able to help with that so that patients can get the medications they need. And placing orders and referrals, that as well as being a liaison between the community services and the provider or your practice, I mean, community resources are so important and your clinical staff can help you develop relationships, make sure that you're staying in contact with home health and hospice nurses that may be involved in caring for your patients, which can really help, you know, make sure they know the provider's orders and what's going on as well as give you meaningful information on their assessments and what's going on with your patient when you're not in the home. Prescription refills and care coordination, again, making sure they have the medications they need and making sure that their many psychosocial needs are addressed and that they have the resources necessary to help them. And obtaining and document medical history, although this may seem simple, think about how important it is to have updated immunization records as well as the information that they can help gather and document to meet clinical quality metrics. Having a person that's able to help the provider with that is really meaningful. And then, of course, again, along with supporting the providers, being that additional contact that can call patients with results and relay medical advice as appropriate to help the provider spend more face-to-face time with their patients. And Dr. Cheng, did you have anything to add here about the back office and how they support your practice? Sure. You know, our patients are complex and they have a lot of needs, medical and social needs. And yes, we get involved with a lot of paperwork as well. So again, a team, an efficient team can really help the provider focus their time and attention on clinical care. And the other comment is that with us having a team at our office, we can efficiently and in a timely fashion provide the necessary interventions that our patients need at home. Thank you. So let's think about staffing. We've talked about front and back office roles and responsibilities. We're going to start with this triangle. And the importance of this slide is really just the realization of the importance of having an interdisciplinary team, you know, in home-based primary care, really leveraging your community resources. You might not be able to employ all of these positions, but are you familiar with agencies that you and you have that very strong relationship and communication channels so that your patients have access to the care that they need, as well as on the top left of your screen, these other specialists that may be able to go into the home and also provide needed services for your patients. Have you taken the time to build up your directory so you have this information available for patients? So on this slide, we've outlined some sample positions. We've talked about many of the roles and responsibilities that these have. Medical assistant, you know, again, that or an RN or an LPN, different scopes of practice, but having those different clinical support staff on your team. The patient service representative, now this could be various titles, also known as patient service coordinators, but we're referring to the administrative front office staff that helps with scheduling and all of those other front office duties we spoke about. And before I move on and talk about the care navigator, Dr. Cheng, I know your practice is fortunate enough to have both medical assistants and RNs, and would you just want to speak a little bit about their different roles in your office? Sure. So before I talk about the back office side of the medical assistant, we do have medical assistants that travel with the physician providers to help care for our patients in the field. But when they're back in the office, which I'll talk about in a little bit, they can also help with back office function as well. For example, our nurses, they call our patients with results. They can do triage and offer medical advice. They can order labs for us, imaging that our patients need, ordering of DME that Brianna has talked about, and also order of home health and coordinating care with a home health agency. They can also assist with medication refills as well. When our medical assistants are back working with the providers in the field, they help with the back office function as well. They can help with medication refills. They can call patients with results and deliver scripted answers to our patients. Now if the patients have more questions, it gets more complicated, then the medical assistant can triage those phone calls to the nurse or to the provider. Thank you. And so a care navigator, again, there might be various titles, but this position could be especially helpful to a smaller practice when you're just starting out. And they can really wear many hats. They can perform both front office and back office functions. Maybe they do travel with the providers to visits, but they're also helping with intake and being that main point of contact for your patients. Typically this position is an LPN or a medical assistant, but really when you're just starting out, rather than bulking up your staff too quickly, a care navigator could be a great position to consider for your practice and your providers. And Brianne, if I can just add one quick thing to what Paul said. What is great with our MAs is they actually have their own computers. And so they're constantly putting in vitals and doing medication reconciliation. They help with quality input for our MIPS indicators, as well as for our ACO. But also, if we happen to be at a patient that is having a long goals of care conversation, they can actually, by having a laptop computer, go into the back office in-basket and literally start doing refills and all that other material that Paul talked about, even when they're in the home. So there really is no downtime for them. Even if you have a long visit, that requires a lot of talking. That's a great point. Thank you. And also, helping with patient and caregiver education, right, and relaying the information as well when they're in the home and helping with that could be a great benefit of having an extra set of hands. Absolutely. So the next few slides, we wanted to give various examples. These are all home-based practices that are currently in existence today. And I want to start by highlighting that there's no one-size-fits-all model. Your staffing model that's right for your practice is going to depend on various factors. You want to take into account your practice's mission, vision, business plan. It matters if you're an independent practice versus a practice that may have the support of a health system. But we wanted to give you some examples so you can, you know, compare how this compares to your team or think about the team that you may want to expand and build. This first slide is an Illinois community hospital home care program. You can see they have a census of approximately 800 patients with some administrative and a practice administrator staff. They have physicians and nurse practitioners, mainly full-time nurse practitioners, as well as the support of an RN and medical assistants. And here we have an Ohio home care program. Now you'll notice with this program, they have a higher census and some unique positions such as a reimbursement specialist and an RN manager. Again, this particular program, larger census and has some support from a institution. And I'm not going to spend too much time per slide. I may be going a little quickly, but this information is included in the handouts for your reference so that you can refer back to it. And if you have any questions, you know, feel free to ask during the virtual office hours or reach out to us after the webinar. But here is a California home care program. Again, this program is unique by employing social workers themselves to help support their patients as well as analytic staff bundled with their administrative support staff. And finally, a New York home care program. Again, they also have social workers involved in their team. Dr. Cheng, did you want to talk just a little bit about how your team works together or anything else to add? Yeah, I will just give some highlights of our practice. Obviously, because of time, I can't get into all the details. As we've already discussed, the physician provider travels to the patient's homes with a medical assistant. We do have mid-level providers, nurse practitioners. When they visit patients in the homes, they go alone without a medical assistant. We have a nurse in the back office doing the triage work and other clinical work, as we've discussed. I have a front office staff, again, helping me be efficient in the field. So I think, yeah, I'll just end it there. Thank you. So we've talked a lot about different positions and staffing models, but how would you think about evaluating your current staffing or deciding what's best for you? I wanted to leave you with some questions and some ways that you could think about evaluating this on your own. So when you think about productivity and supporting the business plan, are you reviewing your fiscal year-end budget and you're comparing the budget and the RVUs to where you need to be, or are you too much in the red? That's one way you could think about that. And then your schedules, understanding, are they full? Are your patients able to schedule timely appointments? Now this could be looked into by working collaboratively with your practice staff. You know, what's your typical new patient wait time? What about transitional care visits? Or are you having problems? You know, make time at monthly staff meetings to be able to explore those kinds of issues so that you have an understanding. And are patients experiencing long hold times or are they complaining about abandoned phone calls? If you do utilize a call center or an answering service, they should be able to give you these kinds of reports where you can have an understanding not only of this, but how many phone calls is your practice receiving during a day? And that can be really helpful information to have when you're trying to make decisions about staffing. Again, patients, you know, that's why we're here, right? Patients first. So are they able to obtain timely prescription refills, prior authorizations, referrals? Is your practice manager, you know, sharing with you the complaints that you get and how often, what they're about so that you can make informed decisions if there are any? Generally, programs have high satisfaction, but there's, you know, everyone can always improve on something. So making sure that you're making time to have those conversations. And then are all team members working to the top of their scope? You know, are your providers able to provide that direct face-to-face care while having others who can support them for administrative tasks? Also thinking about, you know, your clinical staff versus your front office staff and the different roles that they play. Some additional considerations here. Again, we know in the current fee-for-service model how important reimbursement is, but are you also monitoring your revenue cycle reports? ARs to bill, are they within acceptable norms? AR is accounts receivable, but the national average is actually 73 days for a claim to be paid. I would say a good billing process, you want to have a small medium where at least half your claims are paid within about 30 days, and that you're keeping an eye on things that don't exceed 60 to 120 days, claims that don't exceed 60 to 120 days before you're receiving that payment. What about your overall satisfaction? Not, you know, just your staff as well as your patients. We talked a little bit about patients, but your staff as well. Are you doing those annual surveys so that they have a chance to express any feedback that they might have? And EHR, you know, there's many pros and cons to this, but one of the pros would be the reporting capabilities that you have. You'll be able to see how many messages are in various in baskets or assigned to various providers throughout the day. Or maybe you want to perhaps have a supervisor keep an eye on certain workflows or certain, you know, teams to see how much they're really addressing and if they need more assistance. Again, in a busy practice, just making sure that there's time to review daily workflows and manage office personnel and address concerns. If you're finding that you just never have time to come up to air, then maybe it's time to consider, you know, if you need some additional staffing that can help let everyone breathe a little bit more. Lab and diagnostic test results. It's very important that patients have that information and the results within a timely matter. Again, so that your clinical support staff and your providers are able to get to that and relay those results to patients within an appropriate amount of time without being overwhelmed. And your average wait time for a new patient. I would say, you know, within seven to 14 days is reasonable, different practices are going to have different metrics. But are you able to schedule new patients? Are you having to put people on a wait list because of lack of availability? That's another thing to consider. As well as think about your post-acute problems. You know, patients may need things in between the time that a provider may typically want to see them, especially if they come out of the hospital. Are your schedules having the flexibility where you can add patients on when they need to be seen? I would say post-hospital best practice would be to see the patient within 48 hours. However, in a busy practice, that may not happen. Maybe it's within a week's time and you can leverage the help of a home health nurse that may be able to get out there and see the patient sooner. Dr. Cornell or Dr. Chang, do you have anything else to add on that? Obviously you're thorough, Brianna. Yeah, no, I think that just all, you know, great information. I look forward to hearing, you know, questions from the group in terms of what other specifics they would like. Okay, so again, we've talked a little bit about data, but don't forget about the importance of data and metrics, you know, so that you're not just going off of, you know, communications, but you actually have some statistics and data to not only show the outcomes of your practice, but to also help you make informed decisions on what's best for your practice. We talked about various, you know, incoming call volumes, adverse messages, productivity, that's a big one. You know, what's your current patient census on average? How many providers individually are, you know, patients per day is each provider seeing as well as your team as a whole? And is that supporting your business plan? And are you monitoring that and taking the time to review that? Referrals, especially when you're trying to grow your practice, are you aware of, you know, the average increased referrals per month and where they're coming from so that you can maintain those meaningful relationships that you have? Another one, you know, days from referral to first visit or to transitional care visit could be another powerful metric to have. We talked about the importance of employee and patient satisfaction surveys. Again, making sure that you gain honest feedback from your patients as well to help you understand how your practice is doing and how patients, you know, how they feel their care is going with your team. And then having the ability to return phone calls same day, especially with these complex needs of these patients. And many of the matters may be urgent. You know, it's not just a runny nose and the sniffles that they're calling in for. You know, is there someone that's able to get back to them, you know, by the end of the day without having to continually make phone calls into the evening. And then timely registration and form management, how quickly you're able to turn things around. And Dr. Cheng, I know you probably have some insight too on just different meaningful metrics for your practice. Anything you'd like to add? So some of the data or metrics that we are following include referral sources, who is or who are referring these patients to us, how many visits are the providers making, time to a new patient visit, time to a post-hospital follow-up, readmission rate, flu and pneumonia shot vaccination status, fall risk assessment, alcohol use screening, depression screening. And going forward, we're hoping to be able to capture some data on cognitive assessment and screening, advanced care planning, and also overall hospitalization rates for our patients. I think these data and metrics are important, whether you are under a fee-for-service model or value-based contract model. Yeah, I would agree with that, especially with MIPS. And I think it's helpful to pick three that you think are important and then really work on those for a time, maybe three to six months and really try to set a program in place to really capture the data as well as improve the metrics. And then once you feel you have those two or three high priority ones, then you can add on others while you continue to watch and follow to make sure that the ones that you had been working on do not drop. We've been doing this now 22 years at Home Care Physicians. And so we didn't start with all the ones that Paul listed all at once. And so it just bite off what you can chew and just start with the important ones and then increase over time. And obviously if there's a MIPS quality indicator where you can get credit for that, that's where you really wanna kind of focus your time where it can also affect your bottom line. Great point. And I think that's a great transition to just thinking about how you can kind of put all of this together, realizing there's no one size fits all, there's no magic staffing model, but there's things that you can do to make sure that you're making informed decisions on what's best for your practice. And also all of those metrics that we just talked about, it's important like Dr. Cornell and Dr. Chang mentioned MIPS, but also with there being more value-based opportunities or potential ACO partnership, you need to have data on the outcomes that you're providing. Some of the metrics we talked about are from a practice standpoint so that you can make informed decisions on staffing, but also that you're able to show the impact that you're making for these complex home limited patients and being able to explore partnership opportunities. I'm not gonna go through each one of these, but again, patient care, monitoring these things to make sure that care gaps aren't there and that patients aren't falling through the cracks. And really that your entire team understands the impact that provider productivity has on reimbursement and what does that mean for your practice and for your budget as well. Are you sharing that information? It's one thing just to track all of this data and have an understanding, but are you actually sharing and discussing the performance results with the entire team? Not just the leadership team from the front office to your back office, to your providers, to your management, to the leadership if you're involved in a health system. It's really important for everyone to feel connected. And if they feel involved and they understand the impact that they're making, they're gonna be more invested to really be a part of the solution and help to work as everything they can do in their power to improve outcomes and make the biggest impact for your practice and for your patients. And even simple things like Dr. Chang, I know you guys have a few different ways you celebrate staff members and recognition within your practice. A couple of things. There is, at our office, there's a bucket called Caught in the Act. So if we notice that a staff, whether front office, clinical, back office, do something that's notable or extraordinary, we write something down and put it in the Caught in the Act box. And that is shared with the office staff at our monthly staff meeting. And recently, I also started a, what I call a three jar project at our office. Briefly, the first jar is a thankfulness jar. Our work can be very difficult and challenging. And if there's something that I'm thankful for, I wanna write something down and put it in a jar. Again, we can reflect upon this during our staff meeting. The second bucket is what I call the Jedi skills jar. Yes, I'm a Star Wars fan. We all have Jedi skills, skills that help us do our work well and efficient in the field. What can we do to share that information with the rest of the office? Whether you're the clinical, front or back office, we can all share with each other and make us work better. The last jar is what I call the wish jar. These are things that I wish I could have to make my day better, make my care, my patient more efficient. I write these down and as the medical director, I can discuss these wishes with administration and see what we can possibly deliver for our clinical and office staff. So our patients are complex and I'll finish my comments with this. Our patients are complex and not only do I need an efficient office staff, I need an office staff that's really engaged and invested in what they do. Because as Brianna said, it comes down to clinical care. We need a good engaged team to deliver great care at home. Okay, so thank you so much to Brianna, Dr. Cornwell and Dr. Chang for sharing their knowledge and their experiences with us. I love the idea of just kind of the wish jar and the JEDI jar as well. We're going to wrap up our formal presentation portion right now. We did have a couple of questions that came in ahead of time and I would also encourage you as we finish the formal presentation and move into the virtual office hours where you're able to ask questions related to today, other topics or just something in general, please feel free to type those in. But I do want to make sure that we don't miss the questions that came in through the registration. First question is, can you explain some of the pros and cons of having an MA versus providers traveling alone? Yeah, this is Tom. And so when you look at the cost, generally if you do one to one and a half extra patients a day, it covers the cost of the MA. And there are extreme efficiencies in terms of them doing the driving so I can do all my charting. They, as you heard, they do our vitals, they draw blood, they do medication reconciliation, they're looking at the bottles with the med list and then we just confirm it. They give flu vaccines, they call patients on the way, they route the patients. And so the providers aren't doing any of that stuff in terms of working at your highest level. And so there's just so much stuff in house calls, which doesn't require a MD or NP or PA degree or DO degree to do. And so, but there is the cost. And so I think the main disadvantages, yes, there is costs to it, but there are significant advantages. I do find it interesting that a program like VPA, which is for profit, that is their model also in the for-profit world. And so we're in a non-for-profit world and do that. And the other thing that really has come to light is there has been some accusations against home-based primary care providers for inappropriate touching and things like that. And we're dealing with a lot of patients with dementia and you do things like breast exams and such. And there's also both the safety issue, depending on the neighborhoods that you're going into. I used to service the entire Chicago area, including some areas that were not the safest, but also just in terms of, in offices, you would never do like a pelvic exam on a woman without having someone else in the room. And I think there's that aspect to it also. Brianna or Paul, any other thoughts on that? Yeah, I think those are great points. Just to give some other considerations of why, so we can get why a practice might not want to have that MA, you do wanna think about, are you able to provide that MA to your entire team or at least in a way that's fair, or do you need that medical assistant really to be in the back office, assisting through things throughout the day, depending on if you're just a startup. I think it's about making the best decision for you. It's extremely beneficial, as you've heard Dr. Cornwell share for that medical assistant to be with the providers, but also thinking about what that means for your practice. And some providers who prefer a little bit more flexibility, typically, if you have a medical assistant, you would need to start and end your day from that home base. If you're hiring providers just in different areas and they may just commute on their own independently, so they can start and end their days from home, that could be a reason a practice chooses not to. But again, it's about choosing what makes the most sense for you and weighing all of the options and the pros and cons. Excellent, thank you very much. I appreciate that answer and some definite strong insights as to why both sides of that one, pros and cons of having an MA or traveling alone. We did have a question come in, and what I would say is to reach out to us, reach out to the HCC Intelligence. It is help at hccinstitute.org. And then we can route your question directly either to Dr. Cornwell, Dr. Chang, or to Brianna. Another question that had come in, what advice do you have for small practices just starting out? I can start by sharing, and then Dr. Cornwell or Dr. Chang, please feel free to jump in. I think one important consideration, especially for practices that are just starting out, or if you want to start a home-based primary care practice, is just the importance of marketing from day one. While this is such a unmet need, and only about 11.9% of patients that need care in the home are receiving it, especially if you're new and you don't have those relationships with community providers or within your neighborhood, the startup really can be slow. So just don't forget to make sure you get the word out and make sure you're doing those efforts to grow your practice from the very beginning. And also just learn as you go and think about all of these things and continue to evaluate your practice and make the right decisions for yourself. And don't be afraid to change something if it's not working. Yeah, I agree, Brianna. I think there needs to be a constant feedback within the team regarding not only how to make things more efficient, but also defining roles. What am I responsible for? And what are my other team members responsible for? So that we don't overstep each other's boundaries or do duplicate work. And this is Tom Cornwell, and I'm the one that gave all the advantages to having an MA. But I think starting out, the biggest thing to create success is one, what Brianna said, is don't fear the floodgates opening, which a lot of new programs do, thinking that once the word is out that I'm making house calls, the phone is gonna be off the hook. We really haven't found that in the majority of practices that we have helped set up. But then the other thing is keep costs down, keep costs down, keep costs down when you start out. And so starting out, you may not have an MA going out with you just because you aren't seeing nine or 10 patients a day where that volume is covering the cost of the MA. When I started Home Care Physicians in 1997, the office phone was actually one of those old brick mobile phones, if you remember those with the long antenna. And that was in my pocket, and that was the office phone. I had a cubicle in a home health agency that was our office. And that gets in the point too, you don't need to have medical office space. That's the highest per square foot space you can rent. Some people start off in a home or in a strip mall where you're just not paying that same high rent. And so keeping your costs to a minimum, and then as Brianna said, as things get busier, then you can increase that staffing to increase efficiencies. Just to piggyback on Tom's comments about cost, the other side would be capturing revenue. I think it will be very important for a small practice just starting out to make sure that the providers are documenting and coding at an appropriate level, capturing all the revenues related to a house call visit. And we have done a webinar in the past regarding advanced coding opportunities, such as a chart review before the visit, a billing for anticoagulation management or chronic care management services. So cost is the one side and capturing revenue appropriately, I think that's also an important part of a small practice that's starting. Right, and I had a good example today and I'm piggybacking on you, Paul. I had a new patient today that was very, very complicated and I was, I'm proud to say I actually discontinued five medications on the patient, but a very complicated patient that I spent about 45 minutes yesterday reviewing Epic and some outside medical records. She had come from Michigan. That 45 minutes gets me $115 for a new code 99358, and so that was $115 and you have to do a visit with that. The visit was about $200. I did advanced care planning, which is another $85, which now gets me up to $400 for this new patient. And then I also got a bunch of wax out of the patient's right ear, and that's another $450, and so that's $450 for a new patient by capturing what Medicare wants to pay us in order to do this wonderful care. Thank you for sharing that and just hearing the benefits of being able to help a medically complex patient. We have received feedback that the MA discussion is very helpful. A question was raised, do the practices outsource their labs or does someone on the team draw them? I'm looking to increase efficiency in our established HBPC practice. Well, at our practice, the answer is yes and yes. The providers, when we go make a visit, we do draw labs and bring it back to our hospital lab to be processed. The beauty of that is that the results come back directly into our electronic health record where we can easily see a trend or a plot, a graph, looking at their numbers for easier access and visually. We do also use mobile labs that do blood work on our patients when a follow-up is necessary or when a provider cannot get to the patient's home in a timely way. The upside to that is that they're very flexible, they're prompt, and they're responsive. The downside to that is that the result comes back in paper form where we have to review it in a PDF format and it does not auto-populate into our electronic health record. Paul, if I can just piggyback on that, I think that just speaks to the importance of understanding what services you have available to you, having that mobile lab option because you don't want to send the provider out there just for a blood draw. Many times, sometimes, especially if you're exploring a new mobile lab option, make sure you see if there is a way that that can integrate into your EHR because oftentimes they can make that work for you so that it is received right away. Just making sure you're exploring all your options and that mobile lab can be a great support if you don't have someone on your own team that's going with the providers to draw the blood or you don't want to send them out there just for a blood draw. Kind of piggybacking on the MA question that was raised earlier in the discussion, we have a question that's twofold. How do these practices utilize RNs and on average, how many patients per day could a provider see with the assistance of an MA? Our nurses, they do not go in the field with the providers. They are mainly in the back office performing clinical duties as we discussed earlier. As Tom stated previously, when a physician provider goes out into the field to perform clinical visits with an MA, we expect about eight to 10 visits per day from the provider. As I was trying to think of some other examples of how an RN could be used in a practice, thank you, Paul, for all that information. Maybe they're a care manager, kind of care management, the importance of that. Maybe they have certain patients that you assign to them that need a little bit of extra support and they're doing those monthly check-ins with those patients to help capture the work that they're doing that's reimbursable. But again, they have that higher scope of practice, could help with a lot of triage. You could develop some triage protocols if there's common symptoms or complaints that your patients are getting that's within the scope of an RN that your provider team can work with them on to certain workflows to go ahead and just order that urinalysis, get certain things in place without that message having to be sent to the provider for review. I think that would be one benefit of an RN that I could share. And I think a very important comment is that Paul and I are part of Northwestern Medicine that requires the level of an RN licensure to give any kind of advice. The MAs are allowed to read word-for-word comments that we write like on lab results or what to tell the patient. They can read it word-for-word, but if there's any other requests for further advice, it has to go back to the doctor or an RN. And so that is just rules here at Northwestern. And most private house call programs, LPNs can do a great job of providing this back office function, LPNs. And again, as you just so need to be careful with your cost, it can fill that position very well. Brianna, any comments on that? No, I think that's great. Obviously considering I really appreciate all the feedback, the cost and what makes the most sense for your practice. A lot of smaller practices that I've worked with do tend to go to an LPN or even an MA level of scope, rather than starting with the RN until you kind of grow up in size. Right, because they do document it, and so you can see when the note comes back to you what they told them. And if there's any concerns, you can reach out, but an experienced MA, LPN can really do a great job of filling that role in a more cost-effective way. And to build upon that, the follow-up question is, Dr. Chang had mentioned 8 to 10 visits. Are they in-homes, or are these including ALFs or group homes? When I said 8 to 10 visit sets, in my mind, they are individual homes. We do at our practice, we do visit group homes and assisted living facilities also. Obviously, we can visit more patients when we go to a facility or a group home. So those numbers may fluctuate upward when the majority of your days is spent at a facility. I should just add that Paul and I count a new patient as 2, because that's an hour visit. And so most of our follow-up visits are half an hour. And so if you do 10, obviously that's 5 hours of clinical time, and that does allow for driving time. And we service a relatively small area. It's a densely populated suburban area of 20 by 20 miles. And we divide that up between us, and so we don't ever go into each other's territory. And again, that's just for efficiency. And then you just carve up, like Paul has four days out in the field, you carve up his half of our service area into four areas, and he just goes to one of those smaller areas a day. When you have, we have about 800 patients. We service about 1,000 a year, and when you have that volume, you can really geographically schedule patients relatively close together. Our staff are really good about that. So that driving time is a minimum. And so you're doing about 5 hours of clinical time, some driving time, but it is definitely doable. Yeah, and I was actually just going to piggyback on that. I think when you're thinking about productivity standards and what's right for your team, there's multiple factors in play. Like Dr. Cornwall mentioned, the travel time, as well as if your providers are alone or if they do have the assistance of someone that's driving for them and able to help with visits. What types of visits they are, are they new patients, are they post-discharge patients that may take a lot of time, or are they established patient visits? So I think all of those factors play into what's really going to be reasonable so that you can still provide great care, but also be efficient and have productivity support in all your practice and your revenue. And there is no way I could do 10 patients without an MA. I would say 7 and pushing it 8 patients if you're on your own is a very, very full day. And so that is where the MA again offers me efficiencies to be able to impact more people, but also generate more RVUs. Just a couple of comments. At our practice, new patients are generally seen by the physician provider with the MA. As Tom already said, we count a new patient as two patients because of time involved. And having an MA can really help me capture some of the data and metrics that I spoke about earlier. And the two laptops, they could be doing their things, putting in data in for me, doing some of the screening that's necessary. And I can do the follow-up, or I can have one of my APNs do the follow-up. But a lot of the work of data entry is done at the first visit, and that information is captured into the EHR. Again, that's where MA can be helpful, especially for a new patient and if you want to capture data and help you with metrics. Again, it comes down to, as Tom and Brianna have talked about, in a cost-benefit analysis and what kind of support that you're currently getting from your parent organization. So kind of going off of that, the question is raised, what is the process done for scheduling and routing visits? We have trouble maximizing patient visits and geographic area. I guess this really means who does the work? Yeah, I think that's a great question. Actually, our webinar next month is going to be on geographic scheduling as well. So be sure to stay tuned for that. But I can share a little bit, and then Dr. Cornell and Dr. Chang, I'm sure you'll have more to add. I think it comes down to a couple different things. You want to make sure you have some sort of scheduling guide. Dr. Cornell mentioned provider zones. So are you splitting your zip codes up into the ones that are the closest proximity, and each of your providers have set territories? Beyond that, is there some sort of process for scheduling future appointments on a day when the provider is going to be in that area, whether that be a manual process or maybe you're utilizing technology? In this day and age, there are several options for that. There's technology solutions such as CareLink, which is a practice management software, but also does scheduling and route optimization. There's Road Warrior. As far as a driving route, you can download the free app on your phone that'll do up to eight addresses at a time. I just heard about another one a new practice is using called Maptiv. Or you might be just using Bing or Google Maps to plan your provider routes. But really thinking through the entire process, I've seen it done both ways. Typically the front office staff might be a great candidate for that. Or maybe if you're a smaller practice, that care navigator or that back office is able to help with that function. I think taking that burden off of the providers is really helpful, but they also may have different input. But really just having a start to finish process and so that future visits are being planned geographically already from the start, which will make your life easier as you continue to add patients on and fit new patients in. Yeah, my office knows what days I'm traveling to what areas. So whether they have a call for urgent visit or new patient visit, they know that on Tuesdays I'm going to be here, on Thursdays I'm going to be there, and to schedule the patients accordingly. I also know the schedule in my head as well. So when I get a message in my electronic health record regarding a referral or whatnot, I can think in my head, most likely I'll be able to see this patient on such and such a day because I'm going to be in that area. Having an APN or having APNs in my office is also very helpful. What we've done with our APNs is that we try to schedule opposite visit days during the week. Let me explain that. For example, if I'm in a certain area on Tuesday, my APN may be in that area on Thursday. So if there is a follow-up or urgent need that comes up, if I can't get there on Tuesday, maybe my APN can get there on Thursday. Again, trying to use my staff in a maximally efficient way to take care of our complicated patients at the home. The final comment is this. I love my front office staff. They put up with all of my rescheduling process because I do have a lot of patients, and we do have a lot of patients that come out of the office, out of the hospital that needs a follow-up urgently. So having a good relationship with your front office staff is really important because they are the ones that need to make that phone call and say, hey, Mrs. Smith, we need to cancel your appointment. Is it okay that we reschedule you for another time? And then putting the post-hospital patient into that slot. So flexibility, teamwork, very important in doing what we do. And I would just like to be very clear about what Paul just said, is that what you will hear, which is why all of us went into home-based primary care, is because we are so patient-centered. We want to make such a difference in these people's lives. And we are in no way rigid about these geographic territories each day of the week. That if we are employed by Northwestern, one of our great goals, both for patients as well as for our system, is to prevent readmissions. And so we will definitely go out of our way geographically if it's someone that really urgently needs to be seen. And that's what Paul was talking about in terms of flexibility and changing the schedule, maybe seeing a follow-up that isn't critical in order to see that urgent patient and being willing to go a little bit further in order to really give them the care that they need post-hospital. Okay, as we wrap up here, we have time for one more question. But before we go into that, I just want to let you know about our education and resources. So we have a couple of different conferences as well as live learnings that will be coming up over the course of the remainder of this year. And then our e-learning modules, which are always available. We are presenting October 2nd, a pre-conference at Gapna. And with the American Academy of Home Care Medicine, a pre-conference on October 17th at the Lowe's in Rosemont. We also have our Advanced Applications of Home-Based Primary Care Workshop taking place in December in Schaumburg. And as I mentioned, the e-learning modules. We did have one final question that came in, and I want to make sure that we give time to answer that. For new patients, who assists the new patient paperwork completion process? Is this on paper or is this completed electronically? I think it could go a variety of ways, Tom and Paul, unless you prefer to answer this question. I think the administrative front office staff as far as gathering that paperwork, whether it be downloading it from your website, maybe they're able to fax it or mail it to your office, or maybe you're using a program such as TapCloud that enables you to get it electronically. I think you need to have options to accommodate elderly patients that may not be willing to use technology. Maybe they can send it to you via secure email, but having that administrative staff or even a care navigator that can help get that as soon as possible and process the referral and get them scheduled would be a couple options. I was just going to say that, again, in terms of trying to get everyone to work to the highest scope for advanced practice nurses, doctors to be doing the paperwork that's usually done, as you heard from the beginning of this, the front office people, they have to be the front office people, the back office people, and the provider, is really not only challenging, difficult, but also not a good use of time. Our office is just very good, and again, Brianna did that for three years. If anyone wants to use the HCCI Intelligence Helpline, please give us a call, but we are very good at getting signatures ahead of time, all these forms that need to be filled out, who can we talk to, what their phone numbers are, consent for treatment, consent for billing insurance, HIPAA consent. We get six-page, and this is one of the tools that HCCI has, a six-page medical history form that is very thorough, that has been gone over time and time again over the last 20 years, and most recently took Bruce Leff and Christine's quality work and added a lot of their quality work into it, so it added some questions on caregiver burden and things like that. We really, unless the patient is very urgent and needs to be seen within a couple days because of concern they might be readmitted, we are very good at getting this. It's almost like, and not to this degree, but it's almost like we make it clear that if they want to be seen in a timely manner, we really need this paperwork done in order to provide quality care, and that really helps us to get it when they realize the sooner they get it to us, the sooner we can see them. I hate to interrupt, this is just such a rich conversation and definitely answering so many facets to this question. What we will do is send out, after the conclusion of this, a copy of all of the questions that were posed today, as well as the ones we received via the registration, as well as a copy of the archive link and the handouts from today's presentation. Again, to stress, we will be sending out a survey too, and we really encourage you to fill out that survey. It lets us know how we're doing, what you're looking for, other information that we can really use to help build on what it is we present to you. We have some upcoming webinars, Brianna had mentioned earlier. On Wednesday, September 18th, we'll be touching on geographic scheduling and the impact it has on home-based primary care productivity. On Thursday, October 17th, after our pre-conference with the AAHCM, we will actually have a live office hour, so from 4 to 5 o'clock central time, please feel free to join us and ask questions of our experts. And then in November, on the 20th, we will be doing an entrepreneur presentation with Sandra and Lynn from the National Nurse Practitioner Entrepreneur Network, and they'll be talking about I Want to Start a House Call Program. You can find information on this website, excuse me, on our website for each of these links on our resources page in our resource center. Again, please feel free to reach out to us. I want to thank Brianna and Dr. Cornwell and Dr. Cheng for joining us today. I know we went a little bit over, but sometimes I hate to interrupt rich conversations. I do want to encourage everyone, again, the survey will be going out shortly. Thank you so much for joining us this evening, and we'll see you at our next webinar. And if I could just really thank you, everyone that's on. We live to help you guys, and so we appreciate your questions, appreciate the surveys, and just thanks so much for joining us today. And thanks, Brianna and Paul. Thank you, everyone.

Improving Workflows

Front Office

Back Office

Staffing

Home-based Primary Care Practices

Dr. Thomas Cornwell

Dr. Paul Cheng

Brianna Plensner

Staffing Models

Small Practices