Hi, everyone, and welcome to our monthly HCC Intelligence webinar and virtual office hours. Today's webinar will be presented by Dr. Paul Chang and is entitled, excuse me, Medication Management, Art of Deprescribing Medication in HBPC. My name is Danielle Feinberg, HCCI's coordinator for education and research. I will be your moderator for this event. Before we formally begin, I would like to introduce Dr. Chang and go over a couple of housekeeping items. The first portion of our webinar will be dedicated to a formal presentation. All 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 the topic of the webinar, but can cover any topic that you wish. If you'd like to submit a question, please do so by clicking on the questions box located on the lower right-hand corner 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. All registrants will receive a copy of the slide deck, questions and answers, and a recording of today's presentation. At the conclusion of our virtual office hours, which immediately follows our presentation, we're also going to send out a brief survey link via email. We appreciate your feedback, which gives us an opportunity to understand your needs and decide on a meaningful future webinar topics. Today we're joined by Dr. Paul Chang. Dr. Chang is the Senior Medical and Practice Advisor for HCCI. In addition to his role at HCCI, Dr. Chang is Medical Director for the Home Care Physicians, a suburban Chicago practice focused on delivering care to medically complex patients in their homes. The HCP House Call Program has made more than 111,000 house calls to home-limited patients since its founding in 1997. Personally, Dr. Chang has made nearly 32,000 house calls to more than 2,800 patients over his 19-year career. In October of 2019, Dr. Chang received the House Call Doctor of the Year Award from the American Academy of Home Care Medicine. Without further ado, I'd like to turn it over to Dr. Chang. Thank you, Danielle. Before I get into the formal part of the presentation, I think it is necessary for me to take a pause here and address the COVID-19 outbreak that is spreading across the world and across the United States. As a busy practitioner, like many of you, it is challenging enough to take care of complex homebound patients already, and now we are flooded with emails, text messages, latest statistics from your favorite cable news channel telling us about the severity of this illness, and also all of the guidelines as well as system-in-place protocols on how to address these patients. I recognize this challenge, and certainly I feel the pressure of trying to deal in multiple aspects of this disease as it impacts our office. I want to just say that at ACCI, we understand this. We understand the role and the challenges of making house calls to homebound patients, and we recognize that this COVID-19 adds an additional challenge that we really didn't anticipate. We're not a guideline organization. I encourage you to continue to follow CDC guidelines as well as state and local guidelines as well as your health system guidelines on how to address patients who are potentially infected with COVID-19. What we do at ACCI is that we are staying up-to-date on current information and guidelines, and we look at it through the lens of home-based medical care, and we try to give you information that is geared towards house call providers. What information do you need as you go into the homes? How are you going to keep up with some of the billing and the visits that's necessary, even as some of the visits are being canceled or rescheduled? We're here to help. We are trying to stay current, and I invite you to check back with us regularly. Visit our website for the most updated information on COVID-19 and how your practice can adjust and adapt in difficult times. With that, today we're going to talk about medication management and the art of de-prescribing medication in home-based medical care. Our objectives today, one is to describe the importance of appropriate prescribing and the need to reduce polypharmacy in this population group. Number two, I'm going to go over some evidence-based methods to de-prescribe medication and to reduce polypharmacy and to look at some potential prescribing cascade that we could reduce. Number three, we're going to talk about potential barriers to medication adherence. So we're going to start off with a case. This is a 82-year-old female with severe respiratory problems from chronic obstructive pulmonary disease and congestive heart failure. And here is her problem list and her medication list. This is very common in the patients that we encounter in home-based medical care. Their problem list is extensive, and their medication list is equally long, if not longer. I am not going to take the time to go over every single one of the problems on the list or the medication listed. I just want to give you a moment here to glance at the list on the left and also take a look at the list on the right and just put it in your mind and say, you know, as I look at this patient, what are some of the challenges and where can I make an intervention that could potentially benefit this patient? When I take care of complex geriatric patients in the home, I try to keep a framework in mind as I address their needs in an appropriate fashion. These are the five M's, the framework that I go by, and it's been talked about as we go and attend conferences. The first M is what matters most. What are their goals? What's important to our patient and their family? Number two talks about the M of mind and mentation, whether it's about depression, anxiety, or ways to improve cognition or ways to reduce the risk of delirium. Number three, it's about mobility, strengthening, safety, fall prevention. That's the third M. Fourth is medication, and we're going to talk about that today. And the last is multi-complexity. As you saw in the last slide, our patients are chronically ill and complex, and they have a lot of challenges that we need to address and take care of. Why is this an issue? Polypharmacy in the United States. Elderly patients comprise less than 13% of the U.S. population currently, but they use more than 33% of the prescription medication taken annually. About half of hospitalized patients or ambulatory care patients or nursing home residents receive one or more unnecessary drugs. And adverse drug events occur in at least 15% of older patients, which contributes to ill health, disability, and hospitalization. What are some of the challenges in medication management in the elderly? One, they have multiple chronic conditions, which almost by nature leads to polypharmacy. Remember the two slides ago, the problem list on the left and the medication list on the right. Number two, their physical impairment that comes with age, whether it's cognition, vision issues, dexterity issues, physiological impairment, whether you're talking about kidney function or liver function, that can affect the metabolism and the dosing of appropriate medications. Number three, many of the studies that's talked about or used when we describe the treatment of, say, heart failure or COPD, they are done outside of the population patient that we see. By that, I mean it often exclude elderly, multiple, complex patients. Therefore, we need to be careful when we look at guidelines and interpreting these guidelines and applying it appropriately to our patient population. What are some of the risks of polypharmacy? Number one is adverse drug reaction, whether we're talking about a drug-drug interaction or a dose-related event or an adverse impact on cognition or their mobility. The risk increases with the number of medication. For example, some have cited 13% risk with adverse reaction when you use two medications, 58% risk with five medicines, and over 80% risk when you take seven or more medications. Approximately 5% to 6% of hospital admissions are associated with adverse drug reactions, and some commented that it is the fourth common cause of death in U.S. hospitals. So that's one risk. The other is the prescribing cascade. An example recently was published in JAMA about the use of dihydropyridine calcium channel blockers to control high blood pressure, leading to leg edema, leading to the prescribing cascade of adding a diuretic. So that's an example of a prescribing cascade, a problem that we can find ourselves getting into. As medications become more complex, adherence goes down. Our patients, as discussed before, they may have cognition issues, dexterity issues, vision issues, and also financial constraints, which is in the next bullet point there, that can affect their ability to adhere to the therapy that you recommend. And finally, with a lot of medications, it might not be in the interest of the patient or consistent with their goals of care. So we need to keep that in mind as we review the overall approach and care of our patients. You know, as providers, we want to achieve this balance, right? We want the least amount of medication possible, but then we struggle with the idea of, you know, if everything is okay, maybe we should leave the medications alone. I just want to say that often in our experience that our patients get benefit when we take away medication rather than adding more and more medication. So I just want to have you keep that in mind. And I want you to be comfortable talking about and weaning down off medication that may no longer be needed as you care for your patients in the days ahead. When we have learners come with us and have a ride-along or we teach webinars or live conferences, one of the approach I take in terms of looking at the medication is these four bullet points in my head as I review their pills. One is to reconcile the medication, and that is to verify the list of medication, including prescription over-the-counter herbs and supplements, and clarify the dosage and frequency and the route that the patient is taking. So reconcile the medication is the first step. The other is to justify the use of the medication. Again, going back to the two lists, based on the medical history, determine is there a diagnosis that necessitates a particular drug. Determine the benefit or the harm of medication. And in your opinion, is there evidence to support their use? So that's the second bullet point. The third is optimized. Under-prescribing, over-prescribing, mis-prescribing, based on the patient's condition and also their physiologic status. Again, looking at their kidney function, is the dose appropriate given their kidney or liver disease? The next is to demonstrate. And that's, I think, a beauty of home-based medical care. And that is we have an opportunity to be at the home and see how the patient used your medication. Whether it's inhaled medication for their lung disease or insulin for their diabetes, are they injecting this correctly? Are they using it correctly? Do they have technique problems? Recently, I saw a patient who had a skin tear, and there was a bandage on the skin tear. And I asked the son, where did you get this bandage? Oh, I have it right here. As it turned out, the bandage over the skin tear was lidoderm. And obviously, that is not the appropriate use of the medication. We can go through reconciliation and justifying that she is on lidoderm for her post-herpetic neuralgia, but we actually get to see how it is applied. So that is one of the advantages of being at the patient's homes. So what is deprescribing? Deprescribing is the systematic process of identifying and discontinuing medication in instances which existing or potential harms outweigh the existing or potential benefits within the context of a patient's care goals, current level of functioning, life expectancy, values, and preferences. It is not about denying patient care or denying medication. It is an ongoing dialogue. It's a shared decision-making process regarding the benefits and risk of multiple medication, again, within the context of a patient's goal. There are some guidelines for deprescribing. The two commonly used ones are the BEERS criteria and the STOP, and then also there is a STOP and START criteria, but we're going to focus mainly on the STOP side today. The BEERS criteria is available through the American Geriatric Society and includes multiple medication, and it's put into five categories, those potentially inappropriate for use in older adults, those that should typically be avoided, those should be used with caution, certain drug-to-drug interactions, and drug dose based on renal function. The STOP guideline, which stands for Screening Tool of Older Patients Potentially Inappropriate Prescription, comprised of multiple commonly encountered instances of potentially inappropriate prescribing, including drug-to-drug and drug-to-disease interactions, duplicate classes of drugs which can contribute or add to patient's risk of falls. They are categorized by physiologic systems, these medications, whether it's cardiovascular, gastrointestinal, endocrine, musculoskeletal, respiratory, CNS, and so forth. And it includes an explanation as to the reason why a medication can be potentially inappropriate. There's also Deprescribing.org that provides you with some guidelines on reducing proton pump inhibitors, for example, as well as antipsychotics. Choosing Wisely is another available tool as you engage with your patient and try to talk with them about deprescribing. Again, these provide guidelines for potentially inappropriate medication for older adults. It does not mean that these medications should never be prescribed. It gives you a chance to pause and reflect and discuss, again, with your patients and families, given the context of their goals of care, as well as the burden of disease. So what is an approach potentially? So one way I like to do deprescribing is, and it's going to be shown in the next couple of slides here. Number one, I reconcile all the medication and indications paying attention to possible prescribing cascade. Number two, I review the overall risk of the medication, keeping in mind the barriers and stop criteria, as well as the clinical knowledge of the pharmacokinetics of the medication, as well as their renal function, liver function, and so forth. Number three, I take a look at each medicine and its ability to be discontinued. Again, is there an indication for the use of the medication? Do I think that this medication was used as part of a prescribing cascade? We talked about diuretics with calcium channel blockers due to leg swelling. Is this a drug that is used as a preventative drug that is unlikely to confer patient benefit based on their prognosis? Is this a burdensome drug for the patient, whether it is a financial burden, whether it's a monitoring burden, whether it's just simply too complicated to adhere to, and so on. Then I prioritize drug for discontinuation. I look at those drugs with the greatest potential harm. For example, antipsychotics in elderly patients. That's one example. And also the use of a diabetic medication in the elderly with a potential risk of hypoglycemia. And I also look for those that are easiest to continue, minimal withdrawal side effects. And I try to change or stop one medication at a time so I can monitor for any adverse reaction. Again, it's an ongoing discussion with your patient and family. You give anticipatory guidance for what to watch for and the number to call if they have any questions or concerns. You arrange for timely follow-up, whether it's an actual visit or a telephone check-in with a patient and family. There's an example protocol of different prescribing algorithms out there. ACCI has an example protocol that's available for download at ACC Intelligence website. So let's go back to our case example of our 82-year-old female with severe respiratory problems and lung disease and heart failure. One year before house calls, you can see lots of emergency room visits, lots of hospitalization, multiple rehab stays. Eight months after our intervention, drastic reduction in all of the utilizations in terms of hospital, emergency room, and patient ultimately passed away at home with hospice. We had an opportunity to discuss goals to care with patients and family, avoid hospitalizations, reduce medications, supporting the husband, reducing the need for daughter's help. Telehealth was involved, home health was involved, remote monitoring was engaged, and later on when time came, patient was transferred to hospice care. Part of our success in this patient was frequent touches, phone calls, or house call visits. Now I'm going to give you just some ideas, again, keeping in mind, you know, what the patient had in terms of the problem list and also the medication list. These are suggestions for all of you to consider. I'm not saying that all of these changes happened at one time. I recommend, as I stated before, changing one medication at a time, but these are ideas for you to review as we took care of the patient and what we did for the patient in terms of reducing their medication burden. For example, reducing isosoride mononitrate, she was having no symptoms. Reviewing the CHAT VAS has blood scoring, which is available online or in an app, so you can have an open discussion with the family and the patient regarding the pros and cons of using warfarin versus aspirin therapy. Changing high blood pressure medicine, given the patient's history of constipation and heart disease and heart failure, going from one class of heart blood pressure medicine to a different one to manage multiple conditions with less side effects. Discuss the need of medications, such as medication for her bones, bisphosphonate. Is that still needed, given the overall condition and context of care for the patient? Consider changing, doing blood work and stopping iron, if appropriate, discontinuing tracidone and trying to reduce the use of opiate, since constipation is an issue for the patient. And you can see some of the other suggested interventions for this patient as we care for her through the months. So in summary, patients who are older are commonly on one or more unnecessary medications, which can cause adverse drug reactions. Utilizing guidelines can help providers identify these medications that may not be appropriate or necessary. Drugs should be weaned off or discontinued if no definitive indication is seen or if they are part of a prescribing cascade or if they are used as a preventative measure with little chance of benefit and are potentially burdensome. And finally, it is important to taper medication and they should not be stopped abruptly. And that's the end of the formal presentation. Excellent. Thank you so much, Dr. Cheng. We really appreciate you going through all of the arts of deprescribing and just sharing your knowledge and your expertise with all of us. We're now actually going to move into the virtual office hours portion, where we are also joined by Ms. Brianna Plentschner, CPC, CPMA, who is HCCI's Manager for Practice Improvement. As we move into your questions submitted either during the presentation or ahead of time, we want to remind you that your questions can be related to home-based primary care, medical or practice management, as well as questions related directly to our presentation today and kind of any topics that really come into your mind for questions. So we are also joined by Dr. Thomas Cornwell, HCCI's Executive Chairman. He will be here to partake in our discussion as well and share his knowledge. So some of the questions that we did receive ahead of time are, can you define what multi-complexity is? Yeah, that's a great question. The National Quality Forum defines multi-complexity as two or more chronic conditions collectively and have adverse effect on health status of the patient in terms of function or the quality of life that requires complex health care management, decision-making, or coordination. So it is broadly defined as two or more chronic conditions. Oh, I apologize. Thank you so much, Dr. Chang. Deprescribing guidance for patients who have been on PPI long-term without associated diagnosis. That's one of our additional questions. That's, again, a great question. Formal guidelines, there are a lot of expert opinions, I think, regarding deprescribing. As you can imagine, doing formal studies on deprescribing is difficult for many reasons. But from what I've learned from doing the research in preparation for this talk, if you cannot find a clinical indication why a patient is on a proton pump inhibitor, you can reduce the patient's current proton pump inhibitor by one-half every seven to ten days until they get to the lowest possible dose. And if they continue to do well, to discontinue. Again, I think it's important to make one change medication at a time and also give some advice in terms of anticipatory guidance type question, what they may experience and how they can reach out to you in case they experience an adverse reaction to deprescribing. So to summarize, the recommendation is to reduce by half every seven to ten days until you get to the lowest dose and then discontinue. And when I've had them, this is Dr. Cornell, when I've had them on the lowest dose, I will have them take it every other day for a couple of weeks. And the reason for that is they'll have a hyperacidic response. Since you've been suppressing their acid, they can have a hyperacidic response if you suddenly stop it. And a follow-up question to that that was posed is, how soon do you follow up then with a patient after a change in their medication? Again, that's a great question. I recommend, for me, number one, I think it depends on the medication, depends on the patient's personality and their needs. I would like to hear from them if I want to dose-reduce any medication a week or two after I change their medication. I'd like to know what is going on, any side effects as I make these changes. So weekly or every two-week touches, it doesn't have to be a phone call. I mean, it doesn't have to be an actual visit. A phone call, for me, is sufficient. And, Paul, since you recently, I'm thinking, is it the STOP criteria? I believe when I reviewed that months ago that it did have a lot of guidance on certain medicines that needed to be weaned off. It gave specific guidelines. Do you recall that? You know, Tom, I actually do not recall the specific examples of weaning. Of a weaning schedule of any particular medication, but certainly attendees can Google or link to our presentation and take a look at the guidelines for themselves. To follow up with that, we have a question. How do you deal with the patients and families who seem to have an emotional attachment to certain chronic medications? Many patients literally fear de-prescribing some medications. Paul, do you want to take that or? Yeah, I'm sorry. Yeah, that's a fair question. I have many patients who are very attached to their benzodiazepine. It's probably the one drug that is often very difficult to de-prescribe because they've been on their blank benzo for a long time. It's an ongoing discussion with the patient. I try to ask, with many of my patients, I'm trying to not make statements, but rather ask questions. For example, what do you see as a potential problem related to de-prescribing or reducing? What are your concerns? And ask them open-ended questions and see where their pressure points are, where their concerns are, so then you can ask follow-up questions or ultimately make a decision and a statement. I try not to make statements, but rather to make open-ended questions and to keep the relationship and the dialogue going so I can find an entry point for, if you will, a compromise regarding medication change and so on. There are those patients who are just so attached to their X, Y, Z medication that despite multiple discussions about falls, about habituation, about tolerance, and so on, they just will not budge. And at least you have had a chance to document and address that, that you have taken time to review their medication, to go over with them, and that you're just not clicking the refill button automatically without some thought. Now, so just let them know that it doesn't have to be permanent. I mean, that's this whole issue is you try, but if their heartburn returns, if you lower their furosemide and their swelling worsens, you can always go back up. And I think that's where it's have regular touches with our patients, have a phone number for them to call you and making sure that you are available to address their question. As you de-prescribe, as Dr. Cornwell said appropriately, that this is not a, you know, I'm going to do this and there is no going back. There is going back potentially if your heartburn becomes so bad that I can go back on your proton pump inhibitor. But at least, again, this shows thinking, this shows investigation and thoughtfulness in caring for our complex patients. Excellent. Thank you. There is a question, how's, I'm sorry, why are providers reluctant to de-prescribe? I, well, there could be several challenges in terms of not wanting to de-prescribe. One is that I don't want to rock the boat. Things are good. Why cause a problem? The other is time. De-prescribing, as you can imagine, talking it over with the patient and so forth, it takes time, time to do. And number three, I think there, we are guideline people. We like to follow rules of the road and so forth. I think de-prescribing, there is not like one set guideline for this medicine or that medication for weaning down people on medication. So I think those are just some ideas off the top of my head regarding not wanting to de-prescribe for the sake of time, lack of a clear guideline, and the desire just to leave well enough alone and not cause any more problems. Yeah, and I think it is that if it ain't broke, don't fix it mentality. But I truly believe as good geriatricians, we should make patients prove they need every medicine, oftentimes because they've had multiple hospitalizations, they have multiple specialists that prescribe multiple medications, and no one takes ownership. And I think that's something that we do in home-based primary care. We usually end up being the provider because they oftentimes cannot get back to other providers. And even one of the hard ones for me is aspirin. The patient doesn't have a previous stroke, heart attack, or diabetes, and they don't know why they're on it. And that one makes me nervous, but again, I'll check the records. And if I don't see any indication, we will get patients off of it. It's been clear that aspirin is not meant for primary prevention, except for with diabetes. And so, yeah, I really make them prove they need every medicine, or I try to reduce. I think there are two other considerations. One is a communication barrier, whether it's a language barrier, whether it's a cognition barrier in terms of trying to get our ideas across to our patient in terms of why we are doing this can be a challenge. The other is many of our patients have a history of multiple providers because they have multiple conditions. So this inhaler may have been prescribed by a pulmonologist, heart medicine by a cardiologist, vitamins or supplements by a nephrologist. Again, who is responsible in terms of taking all of this and start de-prescribing? Should it be the kidney doctor? Should it be the heart doctor, the lung doctor, and so forth? So I think that's an additional barrier for our patients as we try to take care of their multi-complex conditions. Perfect, thank you. We have a question. We know that physician burnout kind of changing our tracks here. We know that physician burnout is incredibly common and damaging, but why do you think it still remains a taboo subject? You know, I think physicians are, or actually we shouldn't just limit to physicians, providers and clinicians here in the office. We are seen as resilient people, hardworking. If things get tough, the tough get going, now we're just going to buckle up and just keep going, taking care of our patients often at the sacrifices of ourselves, because that could be a sign of weakness or a lack of interest in a patient, could be a pride issue. And also, I think there's a concern that if I show or if I discuss my condition, my concerns, my burnout, my mental state with, say, Dr. Quarmell, and that that word might get out and that or people might perceive me as weak or might be reported to the state for concerns or something. So those are just some of the concerns, I think, that are out there as we try to talk with providers about sharing with us their worries, their struggles, and their burnout, because we want to be seen as people who are in control, who are tough, who can take care of business and not be seen as weak and broken. And someone has once said that broken, injure physicians, providers, or make them better providers because perhaps they can identify more closely with the struggles that our patients have. Tom, do you have anything to add? No, I just completely agree. I think it's just a hard, just, I think, you know, safety culture has, you know, we've changed that culture, and I think that being, having a willingness to be human for humanity is something very important for us as providers, and I think that was a great and sensitive question. It was also our last, it was also our last webinar, which was very well received and is on our website. Amanda Tufano did a wonderful talk on provider burnout, if you're interested. Thank you so much. That's definitely a very difficult subject, I think, sometimes. We do have a follow-up questions to a desire to remain on medication. To follow up on the family patient desire to remain on a medication not necessary, what can you offer for guidance on de-prescribing, oh, I'm going to try and say this correctly, rivastamine topical patch in patients with advanced dementia? It is much easier to reduce oral medications. Sure. Again, I think it's important to talk to the family about what the medication is prescribed for and the efficacy that it's going to be meaningful for the patient. Regarding medications for dementia, again, families may have the belief that if we stop the medication for the dementia that the patient will decline rapidly and that we are hastening their deaths. Again, going back to what I stated before, ask the patient what their concerns are, what are the questions regarding reducing the medication, whether it's a pill or a patch. Patch may come in a per milligram smaller dosing, again, weaning those patients off, whether it's pills or patches, over a week or a week's period of time, again, making sure that they have a phone number to contact you, making sure that you give them some anticipatory guidance regarding as they come off of this medication, and again, we can restart them later if necessary. I think it's important to help the patients and family understand that these medications are used, but they are not curative. The patient's dementia, regardless, many forms of dementia are progressive and irreversible, and these medications, whether it's a pill or patch, cannot be used to stop or cure their disease. You can talk about the positive impact of these medications in terms of whether it's activities of daily living or even delayed to placement in a nursing home, but the margins of benefit is modest at best, and it's not a magic medicine that will dramatically, in your opinion, make a huge impact in their lives, but again, asking them what their concerns are, what can you do to address their concerns, and then, again, going slowly down, having an ongoing dialogue as you engage with them as you bring down the medication, either by patch or by pill. Great, and I'll sometimes, actually, when I'm with the patient and the caregiver, I will actually Google things like discontinuing acetylcholinergistase inhibitors, and usually things will come right up, and you can just literally show them the articles and let them Google it themselves if they want to make an educated decision. Excellent, thank you. What are some strategies? We have a couple more questions. What are some strategies you can recommend or that you have used personally or that your staff has used that you have found to be successful for physician burnout, RN burnout, nurse practitioner burnout, kind of individuals within the medical field? Well, I think there are two approaches here. I think one is a system approach. By that, I mean I think it's important to take a look at your workflow, your EHR, and the work demand that is placed on your staff and yourself by the health system, and work with the health system and the leadership in terms of what can we do to offload some of the system burden that might be in place. The common example I use is that is there any way we can lessen the EHR burden that many of us face when taking care of our patients? So that is one. You can come up with ideas and go to your health system and say, hey, can we make these modifications and so forth. The other is within the office, I think often we feel burned out or one of the things that adds to burned out is being disempowered, having no voice within a very large enterprise. For example, the health system that I work with is having regular meetings and engagement with your providers and in your office, and making sure that they have a chance to voice their concerns and empowering them with an opportunity to share with the whole team their ideas on how they can improve and make the office better and take better care of our patients. There's a system and office level, and then I think there is a personal level that we need to take some ownership of personally. That includes keeping a limit on working. That includes what's commonly called now pajama time at home. Pajama time is still work, even if you are in your pajamas, but we need to keep a limit on that. Make sure you get enough sleep. Make sure you eat a good diet, and make sure you exercise, whether it's walking or some other form of activity, and also finding a way to connect to something bigger. Whether you're talking about faith or medication, that you are doing something that's bigger than just making RVUs, more than just data entry on a computer. You are doing something that's of a bigger calling, taking care of patients, and ministering to them, and taking care of them, and meeting their needs, and supporting the families as they struggle through the difficult times towards the latter stages of their loved one. Also just some ideas that comes to mind in terms of how to address the challenges of burnout and how to empower yourself as well as the staff. And I would just want to add, this is Brianna, I think from the management perspective as well, you just want to make sure everyone on the team feels empowered to do things like use their PTO, and that you're being supportive and responsive to their feedback. If they're bringing barriers or concerns to you, that you're making sure you're communicating and you're taking action as you can and following up with them. And then also just making sure there's time for recognition, and they feel appreciated and their work is valued, and you're making that time to acknowledge and appreciate your staff, everyone from the providers and everyone on your team, but also just making sure you're being that supportive arm for them, encourage them to take their PTO, have that supportive environment where you have someone that can cover a call for them if they have a family obligation they need to get to, and little things like that I think go a long way as well. Yeah, I think Paul's the medical director of Home Care Physicians, our practice, and he does a great job of recognizing employees. He has a system in place where not just he does it, but he encourages everyone to do it, so that it's really a culture of recognizing excellence and caring. Awesome. It really does sound like it takes a team to help everyone not to feel burned out or even to work through if you have those feelings. We have another question. What are the recommendations of deprescribing antipsychotics? Yeah, I recommend you go visit the deprescribing.org website, where it gives you examples on how to deprescribe antipsychotics when a trial period has been used on this patient. Often, it's talked about three to four months of using antipsychotics to control mood disorders in our patients with dementia. But in terms of a protocol, I recommend you go visit that website and get some additional insight into how it is done. Okay, and we've got time. We have about seven minutes left, so we have time for a couple of last-minute questions. I do want to, as we're kind of wrapping up, thank everyone for joining us today, as well as our presenter, Dr. Paul Chang and Ms. Brianna Plintzner and Dr. Cornwell for their time during our virtual office hours. We definitely want to thank you for joining us. We will be sending out a follow-up email within a few days. It will include the link to the archive recording. It will have any handouts. If you didn't get them from here today or ahead of time, we certainly want to make sure that you get those, as well as all the questions and responses. We do have also our HCC Intelligence Resource Center. This offers you free technical assistance. There's a couple of different ways to reach out to us with any questions that you may have. We have our hotline, as well as our email. It's Monday through Friday, 9 to 5. Our webinars, so as the one that you have attended today, every third Wednesday of the month, each CCI hosts a webinar with topics that are relevant to home-based primary care. As you can see, we cover a gambit from self-care. We've done billing and coding. We've done geographic scheduling, entrepreneurship, today's medication deprescribing. We really try and have a plethora of topics. When you do get that survey today, please make sure that you tell us what topics are relevant to you. That's something that we really do take into account. Immediately after our webinars, we have our virtual office hours. You can see, we don't want just questions for the topic at hand, but any questions that come across your mind. We're fortunate enough to be joined by three subject matter experts who are just a wealth of knowledge and certainly want to share that with you. Then on our HCCI Intelligence page, we have our tools and tip sheets. These are some great one-page, couple-page items that you can download for free. They really will help to give you valuable resources and maybe answer questions that you have or even ask other questions that you might move forward with reaching out to either our consulting or however we can assist you further. We also have our future April webinar coming up and that is April 15th. There will be information in the email going out to everyone, letting you know about that webinar, the topics for it, as well as our presenters. We have a couple of... Oh, thank you. There we go. Our strategies for growing provider and patient referrals for your practice. As I mentioned, that's Wednesday, April 15th from 4 to 5 p.m. We do have an HCCI workshop at the AANP National Conference, June 23rd in New Orleans, and then a pre-conference... Excuse me. Sorry. And a pre-conference at the American Academy of Home Care Medicine in October, and then a pre-conference at CTAC in October in Dallas. We do have one final question before we wrap up today, and it is, which formula do you use to calculate renal dosing of medications? Yeah, that's a great question. It's confusing when it's... Often when our metabolic panel comes back, we see the EGFR, and yet when we look up our favorite apps regarding dosing of medication, it is reported as creatinine clearance. So, two things. The traditional gold standard is the creatinine clearance, and you can... You don't have to write out... Don't take out your calculator or your paper. There's an app for that. Yes, there's an app for that where you can pull up the app, put in the patient's height, weight, date, creat... I'm sorry, height, weight, age, and their creatinine, and it will give you a creatinine clearance based on the formula. So, that's one thing. It is the gold standard when it comes to dosing. However, if you look at a medication such as, say, metformin, which is commonly used for diabetes, it is reported as EGFR, and that is because when the drug company did the studies, it looked at EGFR readings rather than true creatinine clearance. So, there's a caveat there. So, bottom line, use your creatinine clearance as the gold standard, but also reference your favorite apps and see what dosing is recommended from the manufacturer based on their study and how the study was done, whether it was on creatinine clearance or EGFR. And I'll just say Hippocrates is the number one medical app. We try not to single out. There are others, but not only does it give you that renal dosing, but also it has a calculator just as part of its app that you can use for calculating creatinine clearance. Excellent. And in our last minute here, as I mentioned, with some of our resources are HCCI consulting services. They're definitely relationship-focused, and we want to help you achieve the results that you're looking for. So, our consultants do include providers, practice managers, and other professions. And again, you can connect with us via phone or via email, and please feel free to reach out and do so. Thank you to everybody for joining us today. Please be on the lookout for not only the email with the survey link, but also the future email with all of the information. And remember to join us on April 15th at 4 o'clock p.m. Central Time. There will be a direct link in the email for you. Thank you so much to our presenters for sharing your knowledge today, and we wish everyone all the best and stay safe.

deprescribing

medication management

polypharmacy

Beers Criteria

STOP criteria

patient's condition

medication correctness

prioritizing discontinuation

open discussions