Hi everyone, welcome to our monthly HCCI webinar and virtual office hours. Today's webinar will be presented by Amanda Tufano and is entitled self care, avoiding burnout and maximizing yourself and your team. My name is Danielle Feinberg, HCCI's coordinator, education and research. I'll be your moderator for this event. Before we formally begin, I would like to cover just a few housekeeping items. The first portion of our webinar will be dedicated to a formal presentation. While participants are welcome to submit questions, please know that we will address these at the end of the presentation and during the open virtual office hours following the webinar. The questions submitted do not need to be directly related to our topic of the webinar, but can cover any topic that you wish. If you would like to submit a question, please do so by clicking on the questions box located on the right hand side of your screen. 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. Please note that all registrants, whether you've attended or are reviewing the archive, will receive a copy of the slide deck, questions and answers, and a recording of today's presentation. After the conclusion of our virtual office hours, which immediately follows our formal presentation, we will send out a brief survey link via email. We appreciate your feedback because it gives us the opportunity to understand your needs and decide on meaningful future webinar topics. Today, we are joined by Amanda Tufano. Amanda Tufano is Chief Executive Officer of Genevieve, a geriatric medical practice and care management organization in Minnesota. Amanda sits on the boards of the Minnesota Chapter of American College of Healthcare Executives and the Minnesota Association of Geriatric Inspired Clinicians. In addition, she sits on the National ACHE LGBT Forum Committee and volunteers as a graduate and undergraduate mentor. Amanda holds additional certifications in Lean Six Sigma and project management. Without further ado, I'd like to turn it over to Amanda Tufano. Great. Thank you, Danielle, and thank you, HCCI, for the opportunity to talk more about burnout and self-care in healthcare. I think it's a really exciting topic for me as I've reviewed this because I view healthcare as the opportunity to continue to get better and do new things and be really innovative. And especially as we think about home-based medical practices, I think there's a real place to be the solution and have a really good and honest conversation about burnout in healthcare. Some of our objectives today are to describe the potential impact of stress on your personal and professional life, define self-care and the importance of maintaining a healthy work-life balance, and discuss ways to develop a self-care plan. And there's certainly no one way to do any of these things. The great part of the world we live in today is you can Google all sorts of different items. You can Google burnout and stress and learn more about it and find the things that are applicable to your teams and then start finding the solutions that are applicable to your teams as well. Hopefully, this is just a way to start thinking about it and will be a launching pad for all the work that we're going to do together in healthcare. So as a grounding, stress is pretty much universally clinically defined as the body's reaction to a change. It can cause physical, mental, or emotional strain or tension. But with burnout, there's really no agreed-upon definition. It's the next level of stress. It's stress for a prolonged period of time. AHRQ says long-term stress reaction marked by emotional exhaustion, depersonalization, lack of sense of personal accomplishment. Burnout's the constellation of symptoms that occur when your energy account has a negative balance. Burnout in the AAFP's definition is literally quantifying how much energy you have and now you're tapping into a negative balance because you're so burnt out. Harvard report says that physician burnout, and I would add in any time you see physician, I would say provider, staff. Burnout is a public health crisis that urgently demands action. As we kind of review this, you'll see a couple of things in here that talk about physicians. And I would just continue to say that it's not just providers. It's not just physicians. It's all workers in the healthcare realm. And you can experience stress and burnout in these spaces. Some common stressors that exist today are family conflicts, especially when you think of the patients that you're working with in home-based medical practice. Around end-of-life, incredibly comorbid, complex, cognitive decline, family complications. As we think about the EHR, a number of articles have been written around the history of EHRs, how they were put into place, how they were financed, how they were legislated. Any changes that occurred around EHRs and those articles don't really drive that the providers were, or don't really say that the providers were in the driving seat around that. Most of that was legislative, financing, and regulatory driven. Financial pressures, certainly both from a practice level of just being one, two, five, ten practices, being a larger practice and trying to figure out how do I balance all of my needs, that my team needs and my providers need, but also on an individual practice level and an individual level. How do I make sure that I hit enough work RVUs or I hit all the things that I need to hit to make sure that I bring home X amount of dollars for my rent and my kids to go to college. Patient adherence, especially around non-compliance. So how do you continue to go into someone's home, emotionally connect with their journey and their supports, and then watch firsthand in their home non-compliance occur? How does that continue to bear on the soul? Scheduling and logistics. A lot of work around HCCI that we do together is talking about how you increase efficiencies, how you maximize time, how you work on resources. Some of the solutions we're going to talk about today are specifically around reducing the burden of scheduling and logistics, but just how do we get it all in in that window shield time? Those are heavy burdens and common stressors. Finally, providers feeling unsupported. Too much in too little amount of time. Too much work without enough of the right supports. So there are a lot of things that go into kind of common stressors. As I evaluate the list, there's a lot of other things that kind of could have made this list. It could be two, three, four slides long. Too much time at work, so not enough work-life balance. Lack of respect from colleagues, administrators, or government regulations. There are a lot of things that come into play as we look at common and top stressors in the workforce. So Medscape in 2019 did a national physician burnout depression suicide report, and it was a self-reported confidential report that was created. And when they looked at this, the two I've highlighted in red are internal medicine and family medicine, the majority of the specialties that are going into home-based medical practice. And, again, it was filled out independently by each individual and confidentially, so we hope that they're accurate answers and they're addressing them. But almost 50% of the physicians that are most burnt out are in our practice today and are working in our practice today. And so I'm going to extrapolate that, again, for all providers, and I'm going to extrapolate that to administrators working in those areas. So if we define what stress is, and then we define the prolonged period of time of stress eventually causes burnout, and that burnout piece is a significant problem, as the Harvard report states, then what are the outcomes of burnout? There are individual health outcomes, depression, exhaustion, dissatisfaction, depersonalization, higher rates of addiction, failure, job or career change, suicide rates, and those are all very severe. The Medscape report said that, as they surveyed everyone, 80% of the folks surveyed had never thought of suicide, but 20% were somewhere in the gray zone. So 14% have thought of it, 1% have tried it, and 6% preferred not to answer at all. So if one in five physicians that work with you, and then, again, extrapolate that for the team, one in five have thought of suicide, it's not as uncommon, and it's not uncommon to put it on a slide as a potential outcome. There are also patient outcomes. There's lower patient satisfaction, lower quality of care, and higher risk of malpractice claims when the providers and the support teams providing that care are completely burnt out. And their systems are drawing on that negative balance of energy. And then at the system outcome level, at that macro level, the system just never gets better. Right now we continue to perpetuate the system that is working in a space that's not heading forward anymore, it's stagnant. Students become unprepared and untrained for the real world, and innovation is stalled because new ideas can't flourish inside of a burnt out system. So I offer an opinion that home-based medicine has the potential to be the solution for stress and burnout. Successfully positioning home-based medicine in the healthcare field leads to a number of things. Again, I could have so many more bullet points here. A couple of ones I want to talk about are vocationally rewarding work because it's challenging cases. I worked in primary care prior to this, and the stress was really, can I get more of those level fours that take short amount of time versus, wow, now I'm really contributing to the well-being of an individual over time. And it's really interesting work. It's really why I went into medicine. It requires complex teamwork and community partnerships. So it's really solving that next level problem. It's big problems for the community and with other people, and it's not solo practice on an island. The reimbursement model is lagging, and normally I wouldn't say that that's a good thing. And yet, because of that, many use sustaining and motivating compensation models. Could be salary, could be panel size, but they're not necessarily tied to widget-based work-or-reuse where you're pushing out a certain number of visits, a certain number of level of visits, or seeing a number of patients in a day. The entire team feels value-added as part of the system. Home-based medical practice, when it's split off from an academic medical center, a for-profit or non-for-profit health system, it's looked at by the system and it's looked at by the community as value-added work. It's something where these patients are falling through the cracks, and we've created a home-based practice who's going to go in and really start sorting out some really complex areas of concern for the family and for the patient. And it allows for personal flexibility. Many people in home-based medical practice start to create a work-life balance. Sometimes that work-life balance blends a little bit more into what you'd call kind of the after-5 o'clock personal time that you may have, but again, it creates this personal flexibility. So if I need to be somewhere at my child's event in the morning, I may go a little bit later into the night, but I know that at 6.30, my patient is still going to be there and is still going to be partnering with me for their care. So that personal flexibility of not having to get it all in between 8 and 8 to 5 day can be a solution. So then what are some coping strategies? The next two slides I have are really talking about how do we administratively think about how to support our teens in the field. Joint visits to manage tension and have separate discussions with family members. So there's an opportunity to have visits together with potentially another family member. You could take a colleague out or you can bring in a spouse to really support these separate discussions. Documentation, recognizing the time involved for paperwork to allow for completion during work hours. Our providers do a couple of different models. They make time throughout the day, and so they build that in during the day, and then some create more of an admin half day as kind of a typical primary care practice would have. The financial model inside of home-based medical practice allows for a lower overhead that allows this flexibility for the number of patients that are seen. Because now you don't have the fixed infrastructure of the brick-and-mortar building. And so sometimes, you know, if you're in a bigger organization, you might be put in a small section. Sometimes we have lots of practices all over the United States, one or two people who are still running them out of their homes. But they have that lower overhead piece that can allow for that fixed infrastructure that's not so expensive. A team approach to continually educate patient and family and reinforce the care plan. One nice part about being in home-based medical practice is where a provider ends, then another team member picks up and continues to make sure that everyone has heard everything that was said, feels supported in the plan, and feels like they have someone to call if something were to come up or there were to be a change of condition. And finally, administrative support to manage scheduling and routing. So as we've kind of talked about and I'll continue to touch on, you know, how do we continue to make our providers in the field feel more supported around their schedule, their window shield time? What does that exactly look like? And I think as we have administrative staff to really schedule and do that work, we have a provider on the phone who will be answering questions later out of Northwestern, and they take a scribe with them. So that administrative support person is there so they're not alone in their car all day. They have someone else to talk to, right? And they have some support for efficiencies around their workday and scheduling to find the most efficient route. Some administrative strategies that exist are to, you know, and I always say create these proactive operational strategies instead of reactive, right? So how do you start to think about how you handle patient noncompliance? Because it'll happen. A patient is going to hear what you say, and they're not going to do the exact opposite sometimes. And it's easy to see that when you're in their home every day. And so how does the practice handle noncompliance? How long will you go with that patient? How long will you see that every time you prescribe something it's not filled or it's not taken and that results in hospitalizations? What does that look like for your practice? How do you handle patient no-shows? So especially when folks are first starting out and they may be starting in a little bit larger geographical area, which we always try to condense and say, you know, start in an area that feels really reasonable. Because if you go too far out and the patient's not there, they're not ready for you. If they're in an assisted living, sometimes they're difficult to even find. If they're in an independent single-dwelling household, they may not even be at their house. And so it's a lot of work to travel to their location if they're not present. And you don't have sometimes anybody else you can fill in with. So patient no-shows, you have two, three times before you say, nope, we need to stop this. How often do you meet with your colleagues and your team? If you're not in the office every day in the bricks-and-mortar office, again, you're not seeing that socialization, but you're not also talking about the difficult cases. And what's great about the home-based medical practice is if you learn, hey, I have a partner to really bounce ideas off of, that sounds really great. Then you just need to say, what's the right cadence for meeting with the team so everybody feels supported during this time of change? And when really strange things come up, we get to talk about it as a mini case study together. So it's also around creating a culture of support and addressing stress and burnout. I like to believe that even though sometimes I have some stress, I don't experience personally burnout because I feel as though I am a problem solver in the puzzle of health care, in the puzzle of supporting other people, and I'm part of a system that can remove red tape. And I like to empower other people to believe that they are also problem solvers that have put red tape into place and can help be part of the solution that removes it. Burnout, as you read more about it, is really the lack of motivation and the lack of being able to feel like you can really continue to make a difference. You're a cog in a wheel. And as you continue to reiterate that we are in this together and you are a problem solver, it combats that feeling that there's nothing that can be done. It's also important to build a human resources department and policies that are supportive. Again, how do we think proactively and not reactively? Encourage paid time off to promote that balance. Utilize and talk about employee assistance programs. There are lots of companies that offer benefits that will have free EAP programs. And promoting and openly talking about those utilizations help employees know that it's something you care about. Compensate in line with work levels. Could be panel size, could be time if you're a .8 versus a 1.0. But really make sure that you understand and you feel and they feel as though they're being appropriately compensated with the amount of work that they're putting out. A big rub in healthcare is understanding some of the financing pieces. But it extends all the way down to the individual financing piece. If an individual feels as though that they're not being equally compensated for the work they're doing compared to other groups in your area and or compared to other colleagues and or compared to just the amount of effort that they think they should be put out, then there starts to be a divide between administration and the providers or the staff that you're working with. And finally, be proactive. Be forward thinking. Continue to push your HR department to say what are the new things out there that are coming out? One of the things that we are working on is how do we continue to push working from home and remote working? Are there things that we can do that don't cost a lot that allow staff to have some of that flexibility where they can have the energy and space to work from home versus always coming into the office? Especially when you start talking about rural settings and people are traveling pretty far to do that. And it's certainly not a stretch to think about home-based medical practice having that flexibility or home-based medical providers having that flexibility. But how do you think about your office staff? How do you think about your managers? How do you think about every staff member doing that work? Can you monitor their success in a different way other than laying eyes on them every day? And finally, show team appreciation. What motivates people? And what motivates people versus, you know, individually versus the entire team? It can really differ. Some people like public recognition. Some people like food. Some people like all sorts of things. But finding out what individually motivates someone to go to work, to come to work every day and work for you and the cause and your providers and understanding what that looks like individually is a great motivator. In previous jobs, I've had a one-page what motivates you questionnaire. And so it's filled out kind of within the first 90 days of an employee starting. And then it's just something that we keep on file. What's a motivating factor for that individual? I have listed a couple of resources here. There are certainly a number of resources online that can be really, really helpful as we think about all the ways to look at physician burnout. There are a number of videos. It's getting a lot of attention about how we think about stress and burnout and our response to that in health care. I hope that you also believe with me, and I bet you do if you've joined the call, that the home-based medical practice can be a solution to that work. So thank you. Did I do it right? You did. You're totally fine. No worries. All right. Thank you so much, Amanda, for sharing your knowledge and your experience with us. And I apologize. My presentation jumped slides on me. There we go. Okay. As we move into our virtual office hours, and this is going to be more of the open-ended questions, whether it's to do with self-care and burnout or, as I mentioned earlier, any other questions, I want to also welcome today Dr. Thomas Cornwell, who's the founder of Home Care Physicians and also HCCI's CEO, Dr. Paul Chang, HCCI's Senior Medical and Practice Advisor and Medical Director for Home Care Physicians, and Brianna Plentschner, HCCI's Manager for Practice Improvement. We're going to address your questions submitted whether during the presentation and those received ahead of time. If you have any questions as we're going through these or something that we are speaking about sparks a question for you, please feel free to type those in at this time, and we'll answer those as well. As a reminder, if you would like to submit a question, on your screen, there is an area where you can click and drop down and type in your questions, and you can send it to all of us. Okay? We did receive a couple of questions ahead of time from some of our registrants as well as one very profound comment, and we'll go through these and address them. One of the questions that came in was, how do I recognize when stress moves to burnout in my staff? Danielle, thank you for that question. I know stress happens to all of us. It happens, and we feel it viscerally when it occurs, and we understand what spikes that anxiety or stress or that peace. And, again, it's a universal experience. That burnout is the next stage of stress when now we are saying, I've had stress for a prolonged period of time, so much so that I lack motivation to continue forward. The burnout piece around what I'm doing, the type of work I'm doing, where I'm working has set in, and now I no longer find that to be motivating, and I'm starting to separate myself and depersonalize myself from the situation. And it's not always easy to recognize that line. So I really think that as you think about stress and burnout, stress will happen to your staff, and you'll watch it occur. And then the moment you start to recognize that people start having that flat aspect of saying things as fact, where you know that that person otherwise would have thought, hey, I could really make a difference, wow, I'm really frustrated. But as they start to level out and say, hey, this is just fact, it's never going to get better, now you're starting to see early signs of burnout. And so I think it's the right time to address it before it gets to that spot, but you will start to see just a depersonalization and lack of motivation from individuals as it moves along the continuum. But I'd open it up to my colleagues to also answer. I think that's a, this is Brianna, and I think that was a great answer. Amanda, I don't really have anything else to add. I think kind of just recognizing, you know, when staff is no longer kind of showing passion in their work, or kind of those people that used to come to you with solutions and now it feels like, you know, it's just always a mundane or kind of negative spin on conversations when they used to maybe not feel that way, would be the only other consideration I'd add. Great, thank you. Excellent, thank you. And kind of on the flip side of that, what are some stressors that exist within the home-based medical practices that I should know about if I haven't started my practice yet? Yeah, I think that's a really great one, right? Because every stressor that you're going to have, or let me rephrase, every time you think I have a solution for it, you got to trace yourself back to kind of what is the problem and what are some of the major issues. And we talked about some of them. One of them would be compensation. Right away, as you think about your practice, how are you going to compensate people? How do you pay people to manage their appropriate level of work? And how do you assign equity, both for the market, for the individuals in your organization, and for retention? I also think there's just a complexity piece, right? As you move providers, conceptually, you're taking providers from other areas of practice, even if it's from school, and you're going to start putting them into a new structure. And home-based medical practice is inherently more complex than some of the other primary care services, because now you're going into someone's home, you're visualizing someone's home, you're working a lot closer with family members. Sometimes they think of the providers as an extension of the family on long journeys, too. And so how do you really prepare them for this is a really complex practice, and it's not necessarily new medical information you have to know, but you have to recognize there are always a number of factors in play. You're never solving just one earache. There's usually other things that are in play here. One example I would highlight is we had a provider come off of 35 years of primary care bricks-and-mortar family medicine, and really was concerned as he joined our practice around how could he deal with seeing his patients die as frequently as he knew he would? Because in bricks-and-mortar, he was like, I know they pass, and I get notifications when they die, but I don't ever actually have to talk really with the family, usually someone else. It's not bricks-and-mortar primary care. And so just understanding that emotional journey for him, and I had a number of conversations with him over his first year here, and he really started to view the world as I am part of the process, and I am part of the solution with the family to really talk about some of those things. But it's my job as a provider, something he hadn't thought about in 35 years of practice before that. We talked a little bit about it around noncompliance, also really interesting, around how do you deal with noncompliance, so the complexity of noncompliance within patients might be really new if you continually go in their home. And then a financing component, right, a small or low budget. How do you understand and use the resources that you've been given or you've carved out or you've created around those? But it's certainly a stressor in the early years around how do I continue to fund this work? It's not impossible. I never want to be a deterrent for people. It's certainly something that I'm really proud that we do in home-based medical practice, but I wanted to mention the budget, too, and financial considerations. I'd open it to my colleagues if they have other stressors. Yeah, one of the things that we just tell our new providers is when you come into some horrific conditions in the home and just these very complex patients, that one, this didn't happen overnight, and you're not going to change it overnight. And just it's a process. It's a process of trust and things like that, and even I was at some hoarders where I actually was a Sunday school teacher for junior high, and I said, oh, I could have my junior high kids come over here as a project and help clean up your place. And again, just realizing that this is just kind of a way that they have come to be, and no one has ever taken me up on that in terms of it was actually more stress than the whole thing about asking what their goals of care are, what matters most to them. And a lot of times that can even relieve stress when they don't necessarily want the condition to be what would make us more comfortable. But I think the big thing is just that it didn't happen overnight, and you can't change things overnight. You just kind of take one step at a time and realize it could be a month, two-year process. Yeah, I mean, would you say, Tom, that it's really a privilege to be able to serve people in this way, but it really pushes you to be really close with the family and emotionally feel quite a lot if you're going into their homes and you're working with those families and the complex issues that you're working with as closely. And so making sure that you monitor those providers during those times, especially during those stressful times. And we've also had it where a provider has gone the entire length of the journey, potentially for a year, two years, three years, and something has come up or someone's flown in from across the United States and now they're really upset and they're getting really mad and threatening and people take it really personally. Hey, I'm really mad, I'm going to threaten a lawsuit or something and it's just devastating for our providers who feel like they've been in the trenches the whole time. So one of the things is that this has been an area of extremely low liability. I know with our practice, I don't even think we've even had like looking into something, let alone a lawsuit in over 20 years. And there's certain things that are challenging, but as you said, that stress is how we react to it. And so I think there are certain things that feed us. And so for me, these challenging patients, these challenging circumstances for the families and caregivers, helping them through these challenging times is kind of what feeds me. So part of it is what feeds providers versus what drains providers. And even end-of-life care, when you talk about kind of becoming part of their family, when I was full-time, I would have five to 10 deaths on average every month. And it's amazing because they see you as caring so much for them, how many funerals you get invited to, and they just don't realize you'd be going to funerals all the time if you actually would. But that's how they feel in terms of the care that you give, that they at least think that this would be something. And I would be interested if there was time, but it brings much more joy to me than stress to me, but that can be very different. I'd be very interested in Paul's comment on that also. Paul, are you muted? Hi. Can people hear me? Sorry, Paul. Yeah. Perfect, Paul. Coming back, Amanda, to what you talked about, I think we can deal with the stress and burnout on three different levels. I totally agree with you. There needs to be a system level. And with Northwestern, we just got an email today sampling physician burnout within our health system, and the number was pretty high. So the system is recognizing that. So I agree, for those of you who has access to HR, to employee assistance, to become involved, to take those courses that's going to be offered on burnout and how to cope with stress. And on a local level, by that I mean our practice, I think it is important for us to come together as a group, either as a staff or staff of providers, to talk about a difficult, challenging scenario or cases, to reflect on our personal struggles with what's going on with our patients and how we can shoulder each other's burden. So I think it's also important on a smaller scale. But Tom, getting to your point about a personal reaction to the demanding nature of our work, this is terribly rewarding work. And I've been doing this for a long time. I thoroughly enjoy making house calls. But there's just something challenging about being home and often home alone. As the sole provider of complicated care to complex social situation in an environment that's what I call organic, you just don't know as you step through those doors what are you going to encounter. It's not the typical office setting or emergency room setting that a doctor face. So how we respond as individuals is also going to be important in terms of how we cope with stress. Over the past year or two, I've gone through some personal coaching in terms of helping me recognize what's talked about as cognitive errors. How I think about the way I think. Am I jumping to conclusions? Am I having black or white thinking? Am I doing catastrophic thinking? Always imagining the worst outcome. That can add to personal stress as well. So having somebody perhaps help coach you through some of those cognitive errors may help you cope with burnout and stress as well. Excellent. Thank you. Dr. Chang, you made a great comment that I think will help segue into our next question. You said it is the demanding nature of your work. And one of the questions we received was kind of keeping in mind the demanding nature of the work, what are some motivating team appreciation events or activities that we can do or that you can do? Amanda, do you want to start with that? Yeah, I certainly can. So I would say we do a lot of things and there's the silly stuff and then there's the bigger stuff. So we certainly in the office, anybody who's in the office space who's here on a regular basis don't take ourselves all that seriously. We like to put money on the lottery. We like to put money into a Super Bowl pool. We like to have monthly lunches recognizing everyone's birthday. I would say I maybe more than others use food as an opportunity, but food is a motivating appreciation. The day before Christmas, anybody who came in for the half day, I bought everybody lunch because I thought, wow, here they are coming in. And some of their colleagues, the majority of their colleagues took the day off. But anybody who showed up, wow, that's great. We also do praise. And so I like to write individual emails or text messages, sometimes cards to say what I really like. HR would tell you if you're going to do those things to make sure that you have a pointed specific thing you're complimenting versus you're just doing a great job. So say, hey, you did a great job on this project. Thank you so much for your help on this project. I also like to do public recognition. So whenever I'm standing in front of a group, I always like to give credit, whether it's the board or it's the entire staff at an all-staff event. I like to make sure that the appropriate credit is due. And then sometimes, you know, as we have team building events, we do an annual team building event for every team. So there's practitioners, the physicians, the office staff, the managers take them out and usually buy them dinner and do an escape room or, you know, top golf or some other way to appreciate everybody. We don't get it right every time. There's so many ways to appreciate and motivate people. And sometimes we catch someone on the wrong day or the wrong year for really feeling like that's there. But I like to spend the time doing that. On a personal level, I always try to remember two facts about every person I meet, one of them at least being a name, not their name, that's a given, remember their name, but a fact about their spouse, their child, and use that name again so people feel like it's a personal interaction with me every time. I'd open it up for others. I just want to echo something that Paul said is I think, you know, those that are drawn to home-based primary care are just amazing, caring individuals and like making such a difference in people's lives. And I think oftentimes, I know this is Paul and I, we don't celebrate all the wonderful impact that we are having. But sometimes when the one out of a hundred is really upset with you or doesn't think you're doing a good job or doesn't think you care, we kind of let that kind of really get under our skin and kind of destroy us where we don't let the 99 out of 100 of wonderful comments to really kind of help lift us up. And so I think really celebrating the impact that we are having is something that I know I could do better. Yeah. Yeah, Tom and Brianna, who used to work with our office here at Home Care Physicians, and she knows what I'm going to talk about here. And it's there are a couple of buckets here in our office. One is something called Caught in the Act. And if you see a staff member, whether it's administrative or clinical, doing an amazing job of something, there's a little slip of paper with a pen. You can fold that paper up and put it in the Caught in the Act box. And at our monthly staff meeting, that box is open and we celebrate what was done. And there might be a little gift card of some kind as a token of our appreciation. The other buckets in our office, the three buckets are the thankful bucket. I encourage my staff here, whatever they're thankful for about it could be their personal life or their professional life here at Home Care Physicians, jot down a little note, put it in a bucket. The other bucket is the what I call the Jedi skill bucket. We all have Jedi skills in terms of what we think we can do and improve how we take care of our patients. For example, how do you get a very, very talkative patient off the phone in a polite way? That's a skill I think we all can learn from each other. And that's the second bucket. And the third bucket is the wish list that I wish my staff or the health system would recognize or help me with such and such. So those are the buckets that we also open up during a staff meeting and say, hey, you know, have you encountered this? And so and so is thankful for what you did on a particular day. So those are some of the ways that we try to to celebrate what we do and keep a family, even as we're trying to exist in a very large health system. The final comment I will want to make is in terms of avoiding burnout and trying to overcome stress is I encourage our listeners. I encourage myself, remind myself that I'm on a bigger mission, having a connection to a bigger mission in life rather than just our views of money. Remind myself of that particular connection can really help me through those challenging and difficult days. Thank you. I would I would also add I'd add just one thing. We're in the practice of or we're in the process of integrating practices. And one of the sister practices that's going to be joining with Genevieve here, they have branded polos and vests and stuff like that. And again, even though it's a thing and it feels like, oh, it's just another thing for them, it specifically means pride in the organization that they work with for early from identification from their colleagues or from being out and about is, hey, I have that on my on my patch of who I work for here. And I'm really proud of that. And it's a unifying look and feel that is comforting. So I thought that was interesting. We haven't we haven't done that, but we are certainly looking into doing something like that to start to bring that unity piece together to to continue to reiterate, even through dress that we're all in this together and we're we're heading towards. The good things together. And Amanda, you kind of spoke to this a little bit, but I know like in HCCI, you know, we did our dots, you know, which kind of show, you know, you know, somewhat about who we are, you know, deep down. And and one of the things we learned from that is is how people like to be recognized. There are some people that are mortified. It's the last thing they would ever want to be put up in front of the team and acknowledge publicly versus, you know, just getting a nice note, like you said. But, you know, you said that you really try to get to know your people in terms of of of, you know, how how they individually like to be recognized because not everyone likes to be put up in front of the whole group. Yeah. And there are those recognition checklists that you can find, you know, or options scorecard kind of things that you can find online that just allow an individual to both say, what are the tangible and intangible things that if I were, you know, if I were to be recognized ways, I like to be recognized. I want a pat on the back. I want a nice email. You know, every nice email that anybody has ever sent me, whether it's someone who worked for me or I worked for them and they sent me, you did this well, I print it out and I save in a file and I take it with me to every job. This is the these are the things that other people have recognized me for because, you know, at the end of the day, like the moment to me feels great when someone says, oh, great job, but it's not something I have great memory of. But if I ever have a down day, I'm like, what are the things I'm really great at? And I pull out that file. So about once a year or so, I pull it out and say, yep, I'm headed in the right track. This feels really good. But again, it's everybody has a different motivating factor. And what are those things? Tom, to your point, you guys did Dots. We took our leadership team, took Insights. So more about how we like to communicate, how we communicate best, how we communicate worst and to understand those things for for each other. And I am an optimistic, enthusiastic, dreamer, bright yellow. You know, and then but if I interact with kind of what they call the cool blue who needs more data, one other way that someone feels recognized is I meet them where they're at. So to bring that much energy to someone who doesn't really want that much energy, you start to, again, develop a little bit more of a rub. So it's that high EQ for motivating people. But if you don't naturally have it, there are certainly ways to find out more about your staff to just meet them where they're at. Excellent. And great conversation back and forth and just sharing really and truly like how to how to show appreciation and know how to show appreciation for each individual. We did have a question come in kind of geared towards what Dr. Chang had mentioned earlier. And this individual says, I would ask where some more information or counseling on cognitive errors mentioned by Dr. Chang can be found. It would be helpful with my home-based team. Boy, I don't have any particular website that I can refer patients to. I'm thinking patients, my staff. So I will have to get back to you on that. But, yeah, so not on an organizational level, but on a personal level. So I have to get back to you on that. Not a problem. When we send out the question and answers after the conclusion of today's presentation, we'll make sure to include that information in there. And it will also be posted to our HCC intelligence page so that you can upload that information as well. And even Google, Paul, because this is cognitive distortions and we all do this, are errors that people sometimes make in their thinking, which represents inaccurate assumptions that individuals make about themselves, the future and the world. And that was kind of what we were talking about, about even when you get all these people saying, what will we do without you? You guys are so great. Our patient satisfaction scores every year are the highest at Northwestern. And yet, if that one person has this thing, we just assume, oh, we're just terrible, whatever. So that is interesting. And there is a lot of information on Google about that. Yeah, it's kind of interesting. I heard about this cognitive error at a pain conference that I attended a few months back, and that concept was introduced from the podium in terms of helping our patients to overcome some of these cognitive errors. It's all or nothing, jumping to conclusions, magnifying, oh, this will never work. I'm going to have side effects related to this new medicine you're going to try me on. How important that is for our patients, and I was reflecting on that, how important it is for myself not to commit the very same errors that I'm telling my patients not to do. And also the caregiver, because I oftentimes say to my most amazing caregivers, it's the ones that just go so, so above and beyond that feel like they're still not doing enough. And just to really praise them for the amazing work they do, I know, is just so appreciated when it comes from us. Yeah, caregivers is entirely an extension of the conversation, because individuals, when a caregiver steps in, individuals often feel like the weight of the world is on me. Another person completely relies on me, right? How do I take a bath? How do I take in a movie? How do I take a weekend off for these things? And it's 24-7 care. Sometimes it's overwhelming, and sometimes the only conversation, I've certainly had conversations with other caregivers, where the only conversation they're having is with medical professionals, right? And so just to even recognize that that's occurring and that you're such an important part of their life, I would imagine is also motivating. Yeah, I will sometimes, even on our instruction sheets, I'll just write, keep doing the great work you're doing. That's an order. But obviously, it's also meant to make them appropriately feel that they're doing a great job. And I just have one comment, and I'm not sure if others can help with this. I think as providers, it's important to have margins in our lives to keep work, work, and home, home. I should be preaching this to myself. I often bring work home. But in some of the readings that I've done with burnout, they talk about something called compartmentalizing your life. You really need to try your best to compartmentalize work. And one of the presenters talked about charting should be done as much as possible during work. Part of your charting, you're literally bringing your work home when you're trying to finish charting at home, and that doesn't help with stress and burnout. I think there's something, there's a term called pajama time in terms of spending your time at home doing charting and how that pajama time is harmful and adding to the stress and burnout of providers. Any comments from others in the group? I would just comment and say, for me, and as I understand it, these things change, and they change over time, and they can vary by person. When I was earlier in my career, the amount of downtime I needed to reset and to get some perspective from work after a stressful week, a stressful month, was a lot longer than it is today, which is great. It also means, though, that I'm at a pretty active pace all the time, which can sometimes be a challenge, right? I usually say I support people who support people. I care people who care for other people. So it's my job to make sure when they need me that I'm there for them and making sure that I have the ability to be renewed enough at all times, and so my amount of time is shorter. Almost every one of my board members actually uses exercise to think about work and have a lot of work time in their head where they're not sitting at a computer, and I use exercise completely differently. It's the only time I don't think about work actively, and so I try then to work out quite a bit and really enjoy that as my time, too. So everybody is different, and like I said, it changes over time, and you just have to watch for your body and watch for your family life to make sure you can draw those balances really well. Yeah, I would just add, this is Brianna, to piggyback Paul, too, on your point. I think it's really important, especially in home-based medical practices, to realize that you can set boundaries, and it's okay to set boundaries. There's ways to do that, like when you're talking about how things work and how caring for your patients, how they can reach you, working on contingency plans for after-hour emergencies, maybe even using a patient bill of rights, but also knowing that it's okay if something happened or someone treated you badly or a patient or caregiver is asking you to do inappropriate things for you to ask for support from your practice team to address that and set boundaries with those patients and caregivers, because they ask a lot more when they've formed that personal relationship, and maybe you're the only one going into the home. So I think boundary-setting is important, and then my last comment is, Paul, you made the comment about documentation, and I think the time that it takes to document, if you are able to give your providers time during business hours, whether that's deciding how many patients per day would give them at least an hour or two back at the office to finish that, or if your providers want to use a drag-and-dictation service, so looking at different strategies so they're not taking that home with them and staying up after hours just to complete their documentation on top of answering messages and never really having time for themselves. Excellent. Great conversation, and it actually answered a couple of questions. One of them was the work-life balance. We do have, just to touch base with everybody, about five minutes left, so I want to remind you as we finish up our question and answer about our HCC Intelligence Resource Center, you can call into the hotline. Every third Wednesday of the month, we do have a webinar, just like the one that you're in now, where you can ask questions related to the topic or go into our open virtual office hours, which immediately follows the webinar. And then we also have tools and tip sheets that you can download, samples and how-to, anything along those lines just to really provide you some starting-off points and then maybe jar a thought or a train of thought and take you there. Additionally, we have some upcoming events. In February 7th and 8th, we are doing our first HCCI and NPAN joint conference in Phoenix, Arizona. We're also doing our Essential Elements of Home-Based Primary Care workshop in March the 26th and the 27th in Schaumburg. Our Advanced Applications of Home-Based Primary Care workshop, which builds upon the Essential Elements, so if you haven't been to one or have been to one and would like to go to the other or come to both, that one takes place April 23rd and 24th. Our next HCCI Intelligence webinar will be what you should know about 2020 coding updates. Definitely, that's always ever-evolving, so that will be Wednesday, February 19th from 4 to 5. And then in March, it's Medication Management, the Art of Deprescribing Medications. And we will just finish up. We have a couple more questions and about three minutes left. One comment that came in that I thought was very interesting. At the Fall UCD Neurology Conference, we had a very enlightening talk by a psychiatrist who heads an anonymous website for medical professionals to help reduce burnout and save lives from suicide. Stanford also has a program online. I didn't know. I opened it up to the subject matter experts if you wanted to provide any insights or feedback or anything. Yeah, Danielle, I'd just say that I love the comment because I think it's really proactive, again, on kind of an administrative policy standpoint to make sure that those resources are provided early. One of the things I think in suicide, especially in depression, that we don't do is we don't talk about it enough. There is a lot of research around after a suicide event has happened and what is the appropriate way in a non-sensationalized way to talk about suicide. I think on the, again, the proactive side, there are a number of resources. I encourage everyone. There's a nice suicide prevention resource, one and a half pages that you sent out. Maybe we could send out. But, you know, there's national, there's local, there's state, nonprofits devoted specifically to suicide prevention. So there's someone to call. Again, EAP programs have opportunities to talk with a therapist at any point or time. Understanding and relaying to people their rights under FMLA and how FMLA works if they were to have any needs. You know, all of those pieces are proactive ways you could start conversations with individuals. Absolutely. I'd be happy to share that resource. And I think that sometimes just that conversation or people knowing there's someone there to listen is huge. We did receive a comment too. Dr. Chang, your comment on compartmentalizing work was really appreciated. It was something that our learners could relate to 100%. And in our last minute, we'll just do one final question from a provider's perspective. And we'll kind of go with the compartmentalizing. What are some tips, specific tips on a work-life balance? Paul, can you answer that? You know, I'm kind of embarrassed to be answering that question because I think I gave it to you. I think I need to preach to myself. So I'm in the journey with all of you. I'll be very honest with you. I struggle with compartmentalizing on a regular daily basis. I do try to finish all my charting at the end of the visit. I do pre-charting prior to visits for multiple reasons, including efficiency, including better communication, better patient interaction, better face time with my patient, and better efficiency in terms of working with my medical assistant who is out with me. I do try to schedule a rational number of patients in my day. And of course, that's going to be variable depending on your practice and depending on your personal abilities. And I do use Dragon Dictation in terms of trying to be efficient with my work and less keystroke. The other comment is I depend on my staff. My staff is amazing. I have an amazing group of providers, and I hope you can work and find a group of providers that's as wonderful as mine in terms of cross-covering. Hey, Tom, I'm going to go see what was the – oh, there's the Star Wars movie, right? Hey, Tom, I'm on call, right? Can you just cover me? And just having that protected time so that I'm not interrupted, that was really precious. So, team, look at your workflow, look at your efficiency, look at how you document, and really try to minimize the pajama time at home. I think it's something that I need to continue to work on, and I encourage all of you to work on that as well. Excellent. So, what we'll do – and I hate to stop this conversation because I think this is so great and definitely something that should be shared, and we will share it. We will get additional comments from Dr. Cornwell and from Brianna and from Amanda and share those with you in our Q&A when we send that out and post that to our website. I do want to be respectful of everybody's time, maintaining that work-life balance. It is after five. So, I want to take a moment and thank our presenter, Amanda, as well as our – Dr. Cornwell and Dr. Chang and Brianna for their time during our virtual office hours. We also want to thank you for joining us. Like I said, we will be sending out a follow-up email. It will have the archive link, the question and answer in the slide deck. And please remember, just take a couple of moments to fill in our survey. It really does provide us valuable information and how we can continue to bring you topics like this and then grow and build our webinars into topics that are what you're looking for specifically. And on that note, thank you, everybody, and have a wonderful evening. Thanks to all. Thanks, everybody.

self-care

avoiding burnout

healthcare

home-based medical practices

stress

work-life balance

self-care plan

team approach

scheduling challenges

recognizing stress