We'll get started in just a moment here, give everyone some time to come in, get settled. If there's any questions, please feel free to type those in. Can you hear me? Yes. Hi, Dr. Chang. Yes, I can. Okay. All right. Okay. Okay. We are right at the four o'clock hour and absolutely want to be aware of everybody's time. So, hello and welcome to our monthly HCCI Intelligence webinar and virtual office hours. Today's webinar is entitled, Putting Person-Centered Decision-Making into Practice. My name is Danielle Feinberg and I am HCCI's coordinator for education and research. Please read about that. I hope I will be your moderator for this event. Before we begin, I would like to cover just a few housekeeping items with you. All participants are muted, but please use the chat or the questions boxes located on your screen to submit questions and comments. Questions that are submitted as well as comments will be answered when we transition into the virtual office hours portion of the webinar. The recording of the webinar and slide presentation, as well as the transcribed Q&A, will be made available on the HCCI Intelligence page within several days following the webinar. We will also send it out via email. Today, we are joined by Dr. Carol Montgomery, Executive Medical Director and Senior Faculty Consultant for Respecting Choices. The objectives for today's webinar are to describe a process to engage and support individuals in making clinical decisions that align with their goals and values, to examine strategies to create an interprofessional system to ensure person-centered decisions, and to understand the systems and tools important to be able to honor individuals' preferences and decisions. Without further ado, I would like to turn it over to Dr. Carol Montgomery. Thank you. Thank you, Danielle, and thank you to HCCI for hosting this webinar. I'm really excited to be able to share our experiences and the lessons that we've learned about what it takes to put person-centered decision-making into practice and how, when done well, this really can transform the culture of healthcare. Many of you may be familiar with Respecting Choices as part of Gundersen Health System from La Crosse, Wisconsin, which is where the program began. But in 2017, we transitioned out of Gundersen Health System and became a division of CTAC Innovations, which is an independent nonprofit organization and an affiliate of CTAC. Respecting Choices has 25-plus years of history of working with over 300 organizations and communities worldwide to effectively implement and sustain evidence-based systems that provide person-centered care. Throughout my clinical practice, I was witness to patients and families who were thrust into decision-making in a crisis, and some of them seemed better prepared than others, and that made a tremendous difference because those who were caught unprepared, never having discussed their hopes, fears, and beliefs about their healthcare decisions, experienced a grief that was amplified by uncertainty. That uncertainty created by not knowing an individual's values and preferences for their healthcare impacts both the families and the clinicians caring for them. But that uncertainty and the suffering that it causes are avoidable. Fundamentally, the topic that we're talking about is knowing and honoring preferences and decisions, which is the National Academy of Medicine's definition of person-centered care. And so you really can think of the goal for this work is to spread capabilities of person-centered care. I want to spend the next several slides kind of level-setting what the it is that we'll be talking about because we've recognized that as the terms person-centered care, advanced care planning, shared decision-making are increasingly used in medical literature and in healthcare policy, it's impressive how they aren't always used with the same meaning. And so we've learned that it's important to clarify concepts that we'll be talking about. And then I'll move into the more practical and tactical descriptions and examples of implementation and practice. Now, we acknowledge that there are many attributes of person-centered care. But one of the primary attributes, we believe, is person-centered decision-making, which is the active engagement and support of individuals and their families on what really is a decision-making journey. It's a process that begins by preparing for future healthcare decisions, what we know of as advanced care planning. But then when the future becomes the present, when the decision to be made is at hand, shared decision-making focuses on the interaction between the patient and the provider, each one of them contributing important content into the decision-making process so that they end with a decision that's in line with the goals and values of the individual. So as this diagram shows, advanced care planning and shared decision-making in serious illness create an integrated process and a continuum that wraps around the individual. Because especially in serious illness, making one healthcare decision oftentimes begins the process of preparing for the next decision. To achieve the ultimate outcome of person-centered decision-making requires a process to support individuals, discern what matters most to them, to make sure that the outcome of that rich conversation is available across settings and over time so that we can be sure that at the time of medical decisions, which are often made in a crisis setting, that the individual's goals and values can be honored. So advanced care planning is a process of communication. It requires time to reflect on goals, values, and beliefs, which really is a discernment process. It requires an understanding of possible future decisions that one might need to make in the context of their current illness and prognosis and requires discussion to prepare others to honor those preferences, whether that be the healthcare agent or proxy or the healthcare team caring for the individual. A common misperception or maybe lack of awareness is the critical distinction between advanced care planning, as I've just described it, and advanced directives, which are the plans, most often written documents, that communicate an individual's preferences. And the reason the distinction is so important is that the quality or usefulness of the document, of the advanced directive, is very dependent on the quality of the process that went into completing it. So, for example, an advanced directive that states, I don't want life support if there's no hope for meaningful survival, is not really helpful in a crisis situation when we don't really know what the individual meant by life support. What did they really have in mind when they said that? And did they really mean no hope, like they're talking about futile care? And what did they mean by meaningful survival? So a high-quality advanced care planning process would explore all those ambiguous terms and result in an advanced directive that is clear, unambiguous, and useful at the point in which it's required. So I think you could call this maybe pearl number one of our time together, is a recommendation to not focus solely on document completion as the outcome of a program, but to ensure that there's a process that supports individuals to discern and clarify their personal values. And there's an ability to skillfully transfer that into a clear and unambiguous plan so that all you've learned in your unique relationships in a home setting where you know people very holistically can be translated and effectively serve as the patient's voice in a crisis, which is likely to happen in another care setting. So if advanced care planning is preparing for future health care decisions, shared decision-making is used when actively making current decisions where the clinician and the patient work together and the provider is an expert on the clinical information, but the patient is elevated as an expert on their values, goals, and preferences so that together they can make a decision aligned with what matters most to the patient. Our model of shared decision-making that we advocate for recognizes a need to shift from the historical or common approach that oftentimes begins with a clinician offering a treatment option or intervention, providing all the relevant clinical information before asking the patient if that sounds right. Is that aligned? Does that seem like the right thing we should be doing? In contrast, we recommend flipping the order of that conversation because we've learned that patients identify what matters most to them through a discernment process. So therein lies the commonality between advanced care planning and shared decision-making. By starting shared decision-making by discerning what matters most to the individual, you may ultimately uncover other treatment options or interventions that are better aligned with the patient's goals that you might not have thought to elevate had you started in the traditional way. And this is especially important for individuals with serious illness. So perhaps pearl number two might be to help patients find their voice and engage in decision-making by first helping them discern what matters most. And whether that's through advanced care planning or through using this model of shared decision-making, helping them discern that before offering or discussing treatment options is a much more person-centered way of approaching it. In 2017, there was a consensus definition of advanced care planning published that was described as a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. So embedded in this definition, you hear that advanced care planning is appropriate for all adults. And so I think that would maybe be another pearl is to not think of advanced care planning as end-of-life planning because imagine how that undermines the message that advanced care planning is appropriate for all adults. Now, with that said, that doesn't mean that advanced care planning looks the same and the conversation is the same for all individuals. It's not a one-size-fits-all conversation. So this illustration will help unpack what I just said. We know that individuals require different support for planning for future health care decisions depending on where they are in their stage of health because the future decisions you're planning for look very different. For example, so we've described this as the stages of person-centered decision-making. A first-steps ACP conversation really is intended for individuals who large part are healthy, haven't started an advanced care planning process, and is focused on helping them select and prepare an agent or proxy to stand ready to speak for them. But as illness progresses, complications occur, and end-of-life becomes near, advanced steps ACP conversations while still planning for future health care decisions are taking place at a time when there's increased certainty about what those future decisions might look like and entail. And so this conversation adapts and uses the PULSE recommendations. And then in the middle, there's the next steps ACP conversation where the target is for a large segment of population that are actively engaged in disease management. They are not planning for end-of-life. But we in health care can kind of anticipate what their most likely next decision will be. So this is more of a disease-specific advanced care planning. Note on the far right-hand side of the screen the term certified facilitator. Respecting choices has a long history and evidence that demonstrates that a high-quality advanced care planning conversation does not depend on or require the skill set of a physician or an advanced practitioner. And so this would be another pearl, to think of person-centered decision-making as a team sport. So much is written about provider time or lack thereof as a barrier to completing advanced care planning. And so the respecting choices model leverages sort of a top-of-license philosophy that uses an interprofessional team-based care. The vast majority of individuals who have become certified facilitators through respecting choices programs are nurses, social workers, and chaplains. Now, the physician or provider still has a role in ACP, but their role is different. Their role is to introduce ACP to their patients, to recommend and encourage their participation, to make referrals to a facilitator who has the skill set and the time to have the conversation, and then the provider needs to remain available to address any clinical questions or prognostic questions. But then when future decisions become current, the clinical expertise of providers is absolutely relevant and required, and this is where shared decision-making can build on the value of prior ACP conversations that prepared patients to actively engage in a decision-making process and become much more efficient, resulting in person-centered care. So I've given a conceptual model of how ACP and shared decision-making integrate, but I want to illustrate it with a story of how this can all come together, and the story is that of my parents. And this took place when my mom was 83 years old. She had progressive dementia, progressive myelodysplastic syndrome, and was running a stable platelet count of about 5,000, which put her at risk for spontaneous and catastrophic bleeding. And my dad wondered aloud, how is all this going to play out? He knew that there would be decisions he would have to make, probably in a crisis at some point, and he was just really unburdened, not knowing how he was going to go about making those decisions when the time came. And so we arranged for a facilitated ACP conversation, and following that, my dad was relieved. He had clarity around what mattered most for my mom's care, and he phrased that as it was important for her to be free from being afraid and free from having things done to her she wouldn't understand by people she didn't know. And that formed the goals upon which to base future decisions, such as avoiding interventions that wouldn't improve her quality of life as she would have defined it, such as surgery or ICU or extensive diagnostic evaluations. So we had prepared for future health care decisions, even though we were unsure what form those decisions would take. And then the future became the present, when about a year later, my dad awoke at two in the morning to my mom slowly regaining consciousness on the bathroom floor. And I want to pause here and recognize that despite the preparation, we have to recognize that the moment when current decisions are made, often in a crisis, and the advanced care plans are put to the test, it's really a moment of vulnerability for patients and families, because it honestly can be comforting when you're in the capable hands of a physician who confidently says, don't worry, I've got it, I know exactly what to do, and the medical machine takes over. Only to realize hours later that so many of the things done automatically were not in line with the goals that we had defined, but nobody had stopped to ask. Fortunately, that was not our experience. Instead, the physician that met my dad in the ED that morning, before presenting any treatment options or entering any tests, started by asking my dad, tell me about your wife. And she met my dad halfway in that decision-making process. She held him up as the equal partner who had the precious and relevant information about mom's goals and priorities, to which she, the doctor, added the clinical information and elevated treatment options. And together, they ultimately decided to obtain a head CT for helpful in prognosis and planning next steps. And it showed a large subdural hematoma with a midline shift. But because of the prior advanced care planning and the way that physician approached the shared decision-making, it was clear what the right decision was for my mom. And we were able to accomplish an under-12-hour hospital stay before she was placed in hospice, with no futile platelet transfusions and no obligatory neurosurgical consult. But most importantly, we were able to avoid an early morning family meeting by phone long distance, agonizing about the right thing to do. So, achieving person-centered decision-making really requires changing the promises we make to those we serve. Changing from promises focused on treatment and cure of disease, to promises focused on healing and caring for the people who have the disease, through promising to initiate and normalize these conversations as a routine part of good health care, to develop the skills and competencies to have unbiased conversations, and then document in clear and unambiguous plans that we commit to keeping updated and stored so that it's available across settings and over time, so that ultimately we can keep the promise of person-centered care. And when you change the promises you make, it changes what you focus on, it changes how you work, and it changes the outcomes that you can achieve. Now, one of the common misperceptions about person-centered decision-making programs is that outcomes can be achieved through large-scale educational rollout. And I will confess that early on, respecting choices also thought that education was the primary lever for change. But then as we worked with more teams, we observed that any changes that were made weren't sustained. And we realized that sustainability and scalability requires implementing these programs as a system of care. So, you've probably heard the saying that systems are perfectly designed to get the results that they get. Then it makes intuitive sense that if we want different results, if we want to be able to keep each one of those five promises, we need to redesign the system to support working differently. We use a framework that defines four elements to create a system, and we work with organizations to adapt how each of those elements is accomplished in their local environments. So, as you can imagine, the adaptations look different when designing systems to support person-centered decision-making in an integrated delivery system than it looks in a health plan and would look yet differently in a home-based primary care practice. So, while there are adaptations for the environment of care, it still is a requirement to create a highly reliable system that all four elements are addressed in some form. Now, you'll notice that all four of the elements rest on a foundation of leadership, and that's because leaders set the vision, they set the expectations for accountabilities, and they play a significant role in removing barriers. And importantly, engaged leaders help to role model the cross-setting collaboration that's really required to build a program that can achieve one patient experience across health settings. Now, working across organizations is especially important if you're part of a smaller independent practice that may not have an interprofessional team, because this allows you to develop relationships with others who can support and leverage your work. For example, there are community-based advanced care planning programs who have lay facilitators or may have access to social workers, such as community health workers, or local area agencies on aging are finding an increasing importance in this work. And we also are aware of many faith-based communities that have advanced care planning programs that you could partner with. So, I'll walk through each of these design elements in a little bit more detail and hopefully give you some relevant examples. System redesign can be thought of as hardwiring behavior change. So, embedding patient-centered decision-making into the routines of care requires a team approach that takes into consideration what resources you do have available. It requires defining the roles for the different team members beyond who will be having the conversations and have the training to become certified, because everybody on the team has a role. And it's important to create workflows so that each of those roles understands how they integrate together around the patient. So, for example, workflows could be created to the level of specificity of what target population do we have? Of all of the patients we're caring for, how do we know who stands in need of having an advanced care planning conversation? How will they be flagged? How will we let the patient know that we believe they should be having these conversations? And is that going to be done, like, at an appointment when you're already in an interaction with a patient? Or will they be outreach? And then how will those be scheduled? What appointment type will they be billed for? And if so, how? So, that's the level of detail that workflows can address that make it then easy to do the right thing and achieve significant results. There are also a lot of new tools that are available that fall into system redesign and making it easy to do the right thing. And these include improving documentation templates so that they are integrated across disciplines that may be all contributing to the importance of the conversation. There are increasingly available digital platforms that can help patients and their families sort of contemplate and prepare for a robust conversation. And then lastly, the sharing of documentation and documents that come out of an advanced care plan or planning conversation are critically important. And I'm sure that you in home-based care are uniquely aware of the gaps in communication that occur between settings and between care teams. And so, there are increasing number of ways that documents can be shared, whether it be through creating registries or patient portals, et cetera. So, defining what your program will use and understanding how it can create connectivity are really important. I think this is probably a good time, too, to bring up how workflows and technology have been really helpful to adapt to having virtual ACP conversations in the current circumstances with the pandemic. And so, we've talked with many organizations who are adapting very quickly to have virtual ACP conversations. And so, I'll bring forward some of the themes that we've been hearing. One is to just stay grounded and recognize that the same foundational communication skills and techniques that you are very confident in are still relevant, but to recognize that perhaps they're even more critical when providing remote ACP because you don't have the usual visual cues that we all rely on when interacting with people. And so, to just be more maybe self-aware of the pace, the volume of really being present in the interaction, whether it's over the telephone or with video capabilities. It's also powerful to just express that out loud and acknowledge how you're trying to adapt out loud to the patient and family that you may be talking to, to be able to say something like, it's really hard for me not being able to see you, to know how you're processing what you're talking about. So, I'll be checking in frequently with you through our conversation, things like that. It's also sort of odd to think through, how do I show empathy on a 13-inch screen? And so, again, taking time maybe to practice with a partner, have them on the other end of the video and get feedback on how does it feel to them? How do you look to them? What are they seeing in your background that you may not be aware of is visible to the patient? And sort of the practical run through with that. In preparing for use of technology in these conversations, it's important to practice it ahead of time, but technology snafus will happen. And so, to be patient and persistent when they happen can be really reassuring to patients and families. We've also heard from people who are doing ACP now virtually that it's sort of ironically easier to get healthcare agents and family members to participate in the conversation because you just have a split screen. There aren't those same logistical challenges with trying to get people in the same place at the same time to have a conversation. And then I think the other adaptability that's being required in our current circumstances and with virtual ACP conversations are the challenges in completing documents. And certainly, what is required for a valid document varies state by state. But there are many states now that are invoking either waivers. We're kind of hoping that some of them won't be waivers but may transition to be more permanent changes. But allowing things like e-signatures, e-witnessing, e-notaries. And so, I would encourage you to really research what the current state is in your state as that changes over time. There are also changing billing requirements for advanced care planning. There are current waivers for both telehealth and telephonic advanced care planning billing. And so, to be sure to stay updated and aware of those as they may transition over time. So, moving on to the second design element. And to think of education really as improving team competencies. Often when we begin working with a program, they already have pockets of really good educational curriculum. But it's in pockets because it usually takes the form of maybe palliative care physicians who are functioning as mentors. Teaching the way they like to do it to new staff. Maybe physicians or APPs who are taking an online curriculum through CME. And some organizations have homegrown curriculum. The challenge with pockets of good educational curriculum is that they lack a common framework. Common language. And they don't really feel like they fit together. And this creates a challenge when trying to use this across teams and across disciplines. Because it creates really a fragmented experience for patients and families. Because they hear it and see it as different conversations coming from different people. Rather than recognizing it's one conversation that builds over time and across teams. So, perhaps another pearl would be to adopt an educational model that provides context for the program. It's more than just communication skills, but is in a framework for conversations that use common messaging principles. That offers a standardized curriculum. So, there's fidelity to the education for the clinicians. And that it's competency-based. Where there's a chance for interaction and role-playing with a chance for feedback. As well as ongoing mentoring as individuals grow in their competency in having these conversations. The third design element is what we call community engagement. Which is all about creating a message that's aligned and motivating. So, we would recommend looking to build a library of materials. That, again, are based in common language and messaging. But reinforce the same message. Recognizing that you may need to adapt the messaging to be relevant to each target audience. So, for example, the messaging to a patient would be subtly different than the messaging to a family member. And yet different messaging to the healthcare team. But they're all basically the same message, if that makes sense. And in that, you need to acknowledge and respect the diversity across the populations that you serve. So, I want to pause and say a little bit about this work as it applies across diverse populations. We have demonstrated in many areas that a quality advanced care planning conversation that is unbiased and value neutral works well across many populations. Because at its core, starting with exploration, being curious about what matters most to an individual. Before entering into any decision-making actually serves to increase the trust of any individual that you're working with. Now, that said, those common foundational components might need some different strategies and adaptation for different populations. But using that, we have demonstrated that advanced care planning is well-received in populations such as an African-American HIV-infected adolescent population. And then a recently published research study with a largely African-American HIV-infected adult population. We have a relationship with a large community-based advanced care planning program that is really led through a large Jewish community in Manhattan. And their strategy was visible support by their trusted faith leaders. And then the third example I would give is we worked with the Singapore health ministry to implement respecting choices in Singapore. Where initially the health ministry cautioned us that it wasn't going to work, everything would need to be different. Because the decision-making tradition in Singapore is that it's family-based decisions. As a unit, they make decisions. It's not sort of the individuality that we're used to in America. And at its core, the advanced care planning conversation and program remained the same. But it was adapted to accommodate for that family unit making health care decisions. The fourth design element is measuring what matters. Because we all know that what gets measured gets managed. We don't have sort of a preordained set of metrics that we recommend. We do recommend, though, that programs measure things in two different buckets, I'll call them. First would be implementation or process measures to see how the actual implementation is going. These measures would answer the question, are we doing what we said we would do? And those are useful to categorize along the domains of those five promises. So, for example, are we inviting to conversations? Are we having the conversations? Are we documenting? Are they uploaded in a reliable way? And are they being used at the point of care? The second bucket of measures would be outcome measures. And these measures answer the question, what difference is this making? And I'll say more about the outcome measures that have been demonstrated through these programs in a minute. But ultimately, it's the rigor of designing and implementing person-centered decision-making as a system of care that's hard. But that is what creates the long-term successes. Respecting Choices programs, when fully implemented, have achieved outcomes in all domains of the Triple Aim. The third bucket of measures would be outcome measures. So, we have a lot of our partners who do research. And there is a document that I've shared that I think will be shared along with the slides and the recording of this webinar. That is a summary and provides references to publications that demonstrate these outcomes. And then the fourth bucket of measures would be outcome measures. And I'll say more about the outcome measures that have been demonstrated through these programs in a minute. But ultimately, it's the rigor of designing and implementing person-centered decision-making as a system of care that has achieved outcomes in all domains of the Triple Aim. And there is a document that I've shared that I think will be shared along with the slides and the recording of this webinar. And I'm going to pause and say decreasing the cost of care is not the reason for taking up this work. The fact that it is an observed outcome, I think, is an admission that our current healthcare environment is providing unwanted care that happens to cost money. And so, when we really start with what matters most and allow people to select care and avoid unwanted care, the result happens to be a lower cost of care. So, in summary, attributes of quality programs include leaders that are engaged to ensure plans are created that ensure long-term success. Programs that partner across settings and across organizations are really high quality and recognize that patients receive care across settings. And so, they, therefore, can achieve the greatest impact. Quality programs also recognize that success requires help from beyond the clinical care teams. And so, often, they'll form workgroups. The four most common workgroups that we see and recommend being formed, the first one would be a group focused on standardizing use of the advance directive and optimizing it in some circumstances as well as post documents. The second workgroup focuses on electronic health record functionality, both the documentation capabilities as well as storing, uploading, and sharing across platforms. The third workgroup that's often recommended is a group focused on optimizing and standardizing the patient and community-facing materials. And then, lastly, it really takes a group focused on determining what measures and metrics will be collected, how they'll be collected, and then thoughtfully reviewing them and managing them, which is really the work of quality improvement. Creating highly reliable systems for person-centered decision-making will transform the culture of healthcare from a healthcare culture designed primarily with diseases in mind to a culture driven by person-centered care such that patient values guide all clinical decisions. And over time, almost insidiously, you'll start to see and hear different things as that transformation begins. So with that, I will turn the controls back over to Danielle. Perfect, okay. Thank you so much, Dr. Montgomery. I really appreciate that. What a great presentation. As we transition now into our virtual office hours, this is the portion where you are welcome to share any questions that you have, whether from today's presentation or previously submitted questions. We do have a couple of different questions that I'd like to make sure that we address as we progress into our presentation. The first question says, how do you work to close those gaps between care teams? It was something you had mentioned. Yeah, so the gaps between care teams, and I'm assuming that the question is in reference to across care settings. And patients, especially those with serious illness, are cared for across many settings. And even when they're not hospitalized, they have many care teams and specialists. And I think it's one of those things where it reminds me of the saying that if it's everybody's job to feed the dog, the dog goes hungry. I mean, there needs to be a team that is the primary team. And my guess is that home care can absolutely function and should function. When you guys are in the patient's home, you get to know families in a very unique way, yet needing to build that cross team understanding of what the work is that you're doing in creating the advanced care plans, and how all those other team members really need to build on that and use it as the foundation for how they go about decision, helping patients make decisions. And so that really requires collaboration. Many teams that we work with create steering committees, where you convene with, and I'm trying to translate this to in a home care environment, because I'm sure that many of you practice with patients that may seek care in very different other healthcare organizations. And so it really can be a community wide effort, but to make sure that the patient and family stand ready when they go to see another care team with their care plans, well versed in their mind. And then it probably requires a fair amount of proactive outreach and communication to the other members of the care team that the patient are seeing. But if closing the gap in building a program, my strong recommendation would be to create a steering committee that has key members and stakeholders from the other parts of the organization or from other organizations or care settings that you most frequently interact with, so that there can be a broad understanding of the work that you are doing and trying to elevate that so that others on the team can help to contribute and respect the advanced care plans that are created. Thank you. Another question that came in, what are some of the waivers for ACP billing? So there is, previously advanced care planning was not billable via telehealth or telephonically. And so that was one, and these are waivers by the federal government. So they apply for CMS billing, you would have to check to different health plans to see if they're following the federal waivers or not. And then my understanding too is that there is a waiver. So there are provider rules of what roles can bill for advanced care planning, and previously used the incident to billing requirements. And some of those have also been relaxed. So I don't want to be in a position of doing really anything other than raising awareness and really encouraging you to look at the CMS websites for the most recent and up-to-date policy waivers. And this is Brianna Plensner. I can jump in a little bit here too, as far as the billing. For anyone that hasn't checked out HCCI's COVID-19 Information Hub, we did cover all of the billing regulations in detail and have some helpful articles, but Dr. Montgomery is 100% correct. The big change was that advanced care planning. So that's that CPT code 99497. That's one of the services that could be audio only. And so you could be having a phone conversation with a patient. You still have to meet all the billing requirements. So it still has to be a qualified provider of at least 16 minutes, but you can actually bill for that just being the telephone, whereas other Medicare telehealth services require the video technology as well. But advanced care planning specifically could be just a telephone call. Wonderful, thank you. The story about your mother was very touching. How do you think providers change their thinking so that their focus goes onto their patients and their families? That's a great question. We have, and you saw it in the diagram, our shared decision-making in serious illness, curriculum and teaching that course, I think has helped me understand some of the, I don't know if it's psychology or ego or what that physicians struggle with. We as physicians have been trained to be medical experts and teachers, and we are so tempted to over-teach and come in and problem solve. So it's very important for us to be able to do that. So it's very counterintuitive to pause and think that actually the patient has really, really important information to share that should shape how I then render my medical opinion and thinking. And so I think just being able to tap into whenever there is an opportunity to help elevate that concept for physicians. So for example, I remember one interventional cardiologist that I worked with who was struggling sort of with a moral dilemma within himself because he said, I feel like there's so many things we can do, I don't know what I should do. And he saw this philosophy of approaching decision-making as a solution to that problem for him. And so it really, I think to help physicians understand that it's better for patients and families, but it's also better for us as human beings wanting to do the right thing for people when it's not always clear what the right thing is, have the patient help you define that, and it's freeing. Thank you. Are there differences between palliative care and person-centered care? And if so, what are they? So that's an awesome question. I think that person-centered care is an overarching philosophy of care. Palliative care can be tricky because it's both an attribute of care, but it's also a specialty. And so I will, some organizations we work with bring in our programs as what they call primary palliative care, which is helping all clinicians understand how to deliver palliative care, which has an amazing advantage for the palliative care specialists, because we know there will never be enough of palliative care specialists to deliver all the palliative care that's needed. We all need to up our game in delivering palliative care principles. And so this really helps the entire healthcare team understand those basic principles of palliative care that don't require specialty training, but do require some additional awareness and education. I think person-centered care is a much bigger umbrella. There are many attributes of person-centered care. And I was impressed at a previous organization that I worked with. It felt like there are so many initiatives that you can put under person-centered care. And so I would say that palliative care is one of those, certainly. Thank you. You had mentioned practicing empathy, and this question is for Dr. Montgomery as well as for Dr. Chang, who has joined us today. How do you find that you practice that empathy so it comes through in your telemedicine visits with patients? So I think in telemedicine, and it's probably true in whether it's a video visit or telephonic, it's important to just say it out loud. And that has always been something that I've personally had to focus on and have self-awareness about because I view myself as a very empathetic person. I have all the right facial expressions and hand gestures and body posture. Well, none of that really helps you on the telephone. And so to find the words that feel genuine to me, that they don't feel scripted, but that express it out loud and make it audible, it's because it can't be visible. And so, like I said, things like, this is really hard for me because I wanna be there for you and I can't be there physically for you, or whatever feels genuine to you, but to just put it into words, I guess would be my strategies for that. Anything else to add? Yeah, hi, this is Paul Chang. I think some of the strategies that we use in-person can be still applied through video. As a provider, I often catch myself talking too much and not allowing time for reflection and pause and decompression or expression, I should say, of emotion. And that's even more important now as we go through telemedicine that I need to remind myself to pause and to speak slower and to acknowledge expression as much as you can see, such as, I see that you look sad or you look anxious after I shared that news with you. How are you feeling? Can you share that with me? Again, as Dr. Montgomery has said, acknowledge what you're seeing on the video, allowing them to share their feelings, catching myself, making sure that I slow down and not talk too fast, allowing those pauses, even on video. And again, sharing what you're feeling and what you're sensing, as Dr. Montgomery has said. I wish I could be there. This must be hard news for you. I wish there was a different way that we can manage this. So those are some of the pearls, perhaps, that I've used in engaging my patients through the electronic mean. Perfect, thank you so much. So as we move forward with this, we've got just a couple minutes left. I definitely want to give a special thank you to our presenter, Dr. Montgomery today from Respecting Choices for providing her insight and her expertise on this valuable topic, as well as to Dr. Paul Chang and Brianna Plunstner from HCCI for sharing your expertise on coding and billing and then working with patients. I also want to remind everyone about the HCC Intelligence Resource Center. Here you can find various outlets in which to connect with our subject matter experts. In addition to our monthly webinars and virtual office hours, you can also contact via the hotline, as well as download valuable tools and tip sheets. And then lastly, I want to remind everybody about our upcoming events, our HCC Intelligence webinar. These are the third Wednesday of every month. HCCI hosts a free webinar on a clinical or practice management topic relevant to home-based primary care. Wednesday, June 17th at 4 p.m. Central Time, we will be hosting strategies for growing provider and patient referrals for your practice. And our presenters will be Tammy Browning and Brianna Plunstner. With that, I would like to thank everybody so much for joining us today. Stay safe out there and we wish you all the best. Thank you.

person-centered decision-making

healthcare

transforming healthcare culture

advanced care planning

team-based approach

shared decision-making

documentation

standardized education

measuring outcomes